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Rail & Aviation Conference RAeS 21 st May 2009. Safety Culture and Safety Management. Jim Reason Professor Emeritus University of Manchester, UK. Overview. Organizational accidents The two faces of safety Safety culture Proactive process measures Error management.

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safety culture and safety management

Rail & Aviation Conference

RAeS 21st May 2009

Safety Culture and Safety Management

Jim Reason

Professor Emeritus

University of Manchester, UK

overview
Overview
  • Organizational accidents
  • The two faces of safety
  • Safety culture
  • Proactive process measures
  • Error management
hazards losses defences
Hazards, losses & defences

Defences

Losses

Hazards

the swiss cheese model of system accidents
The ‘Swiss cheese’ modelof system accidents

Some holes due

to active failures

Hazards

Other holes due to

latent conditions

(resident ‘pathogens’)

Losses

Successive layers of defences, barriers, & safeguards

how and why defences fail

Defences

HOW?

Losses

Hazards

Latent

condition

pathways

Causes

Unsafe acts

Investigation

Local workplace factors

WHY?

Organisational factors

How and why defences fail
the two faces of safety
The two faces of safety
  • Negative face as revealed by accidents, incidents, near misses and the like.
  • Positive face = system’s intrinsic resistance to its operational hazards.
intrinsic safety

Vulnerable

system

Average

system

Intrinsic safety

Resistant

system

the safety space
The safety space

Increasing resistance

Increasing vulnerability

Organisations

navigating the safety space
Navigating the safety space

Increasing resistance

Increasing vulnerability

Cultural drivers

Target

zone

Commitment

Cognizance

Competence

Navigational aids

Reactive

outcome

measures

Proactive

process

measures

negative outcome measures
Negative outcome measures
  • Exceedances (SPADs)
  • Near misses & incidents
  • Accidents
proactive process measures
Proactive process measures
  • No single definitive measure.
  • Involves regular sampling of a subset of a much larger population of organisational processes (somewhere between 8-16).
  • Identify those 2-3 processes most in need of remediation.
  • Track progress of remedial measures.
  • Safety mgt. = long-term fitness programme (not a zero production game).
review railway problem factors
Tools & equipment

Materials

Supervision

Working environment

Staff attitudes

Housekeeping

Contractors

Design

Staff Communication

Departmental comm’n

Staffing & rostering

Training

Planning

Rules

Management

Maintenance

REVIEW:Railway Problem Factors
rait railway accident investigation tool
RAIT: Railway AccidentInvestigation Tool
  • What defences failed?
  • How did they fail?
  • Why did they fail?
  • Which of the RFTs was most implicated?
  • Errors and violations
  • Local situational factors
three c s excellence drivers
Three C’s: Excellence drivers
  • Commitment: In the face of ever-increasing production pressures, do you have the will to make your safety management tools work effectively?
  • Cognizance: Do you understand the nature of the ‘safety war’—particularly with regard to human and organisational factors?
  • Competence: Are your safety management techniques understood, appropriate and properly utilised?
the importance of culture

Though it has the

definitional precision

of a cloud

The importance of culture

Only culture can reach all parts of the system.

Only culture can exert a consistent influence,

for good or ill.

culture a workable definition
Culture: A workable definition

Shared values (what is important) and

beliefs (how things work) that interact

with an organization’s structure and

control systems to produce behavioural

norms (the way we do things around here).

a safe culture interlocking elements

Just

culture

Reporting

culture

Learning

culture

A safe culture: Interlocking elements
cultural strata

GENERATIVE

Respects, anticipates and responds to risks.

A just, learning, flexible, adaptive, prepared

& informed culture. Strives for resilience.

PROACTIVE

Aware that ‘latent pathogens’ and ‘error

traps’ lurk in system. Seeks to eliminate

them beforehand. Listens to ‘sharp enders’.

CALCULATIVE

Systems to manage safety, often in

response to external pressures. Data

harvested rather than used. ‘By the book’.

REACTIVE

Safety given attention after an event.

Concern about adverse publicity.

Establishes an incident reporting system.

PATHOLOGICAL

Blame, denial and the blinkered pursuit of

excellence (Vulnerable System Syndrome).

Financial targets prevail: cheaper/faster.

Cultural ‘strata’
error management em
Error Management (EM)
  • Three main elements:
    • Error reduction
    • Error containment
    • Management of EM
  • And the hardest of these is effective management.
more management hoops
More management hoops?
  • Quality management systems
  • Safety management systems
  • Error management: what’s new?
  • Need to sort out differences and overlaps
quality management system industrial origins
Quality Management System(industrial origins)
  • TQM had its origins in Statistical Process Control (1920s). Deming—Japan—USA
  • Quality measurements at point of origin
  • Quality assurance (QA) not quality control
  • QA documents the way things should be done and audits against these standards
  • Discrepancies are fed back  continuous improvement
safety management system regulatory origins
Safety Management System(regulatory origins)
  • HSW Act 1974 (Robens). Piper Alpha, 1988, Cullen Report (1990). Safety Case.
  • Modelled on ISO 9000 quality assurance.
  • SMS includes a formal safety assessment of major hazards—steps documented
    • Hazard identification
    • Risk assessment
    • Defences and safeguards
    • Recovery
qms sms common features
QMS & SMS: Common features
  • Neither quality nor safety can be ad hoc. Both need planning and management.
  • Both rely heavily on measuring, monitoring and documentation.
  • Both involve the whole organisation.
  • Both strive for small continuous improvements—kaizen not home runs.
qms sms problems
QMS & SMS: Problems
  • A strong temptation to put form before substance—to believe that what’s on paper matches the reality.
  • ‘Quality-assured’ accidents
    • BAC One-Eleven (1990)
    • A320 (1993)
    • Boeing 737-400 (1995)
  • Neither driven by human factors knowledge; neither starts from the fact that human and organizational factors dominate the risks.
why em is necessary human factors origins
Why EM is necessary(Human Factors origins)
  • Effective EM derives more from a mindset than a set of ring binders.
  • EM is not a ‘system’ as such, though it should be systematic.
  • EM requires an understanding of the varieties of error and their provoking conditions.
  • EM takes Murphy’s Law as its starting point. Errors are inevitable.
more about em
More about EM
  • Effective EM needs an informed and wary culture—this depends on establishing:
    • A just culture
    • A reporting culture
    • A learning culture
  • EM must play a major part in both QM and SM systems.
  • QMS and SMS are top-down and normative. EM is bottom-up and descriptive. It says how the world is, not how it ought to be.
some em principles
Some EM principles
  • The best people can make the worst errors.
  • Errors fall into recurrent patterns—error traps.
  • There is no one best way of doing EM.
  • EM is about system reform rather than local fixes—it’s about greater resilience.
error can t be eliminated but it can be managed
Error can’t be eliminated, but it can be managed
  • Fallibility is part of the human condition.
  • We are not going to change the human condition.
  • But we can change the conditions under which people work.