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Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making

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Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making. Kathy Fox, Board Member. System Safety Society Canada Chapter ... – PowerPoint PPT presentation

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Title: Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making


1
Impact of Implementation of Safety Management
Systems (SMS) on Risk Management and
Decision-Making
  • Kathy Fox, Board Member
  • System Safety Society Canada Chapters
    Springtime SymposiumJune 2010

2
Outline
  • Early thoughts about safety
  • TSB Investigation Reports
  • Lessons to be learned
  • Safety Management Systems
  • What works
  • What does not work

3
Early Thoughts on Safety
  • Follow standard operating procedures
  • Pay attention to what youre doing
  • Dont make mistakes or break rules
  • No equipment failure
  • Things are safe

4
  • Safety ? Zero Risk

5
Balancing Competing Priorities
6
Sidney DekkerUnderstanding Human Error
7
Why Focus on Management?
  • Management decisions have a wider sphere of
    influence on operations
  • Management decisions have a longer term effect
  • Managers create the operating environment

8
Drift
  • Drift is generated by normal processes of
    reconciling differential pressures on an
    organization (efficiency, capacity utilization,
    safety) against a background of uncertain
    technology and imperfect knowledge.
  • Dekker (200543)

9
Drifting into Failure(aka Why do safe systems
fail? )
Image by Worth100
10
Organizational Drift
  • MK Air Flight duty times

11

Organizational Drift (contd)
12
Organizational Drift (contd)
  • Source Dekker (2002 18, 26)

13
Safety Management System (SMS)
  • A systematic, explicit, and comprehensive
    process for managing safety risks it becomes
    part of that organizations culture, and part
    of the way people go about their work.
  • Reason (200128)

14
Evolution of SMS
  • Derives from research of
  • High reliability organizations
  • Strong safety culture
  • Organizational resilience

15
Why Change?
  • Traditional approach to safety management based
    on
  • Compliance with regulations
  • Reactive response following accidents
  • Philosophy of blame and re-train
  • This has proven insufficient to reduce accident
    rate

16
TSB Mandate
  • To advance transportation safety in the air,
    marine, rail and pipeline modes of transportation
    that are under federal jurisdiction by
  • conducting independent investigations
  • identifying safety deficiencies
  • making recommendations to address safety
    deficiencies
  • reporting publicly on investigations
  • It is not the function of the TSB to assign
    fault or determine civil or criminal liability.

16
17
TSB Reports
  • Observations
  • Employee adaptations
  • Inadequate risk analysis
  • Goal conflicts
  • Failure to heed weak signals

18
Employee Adaptations
  • Front line operators create locally efficient
    practices
  • Why? To get the job done.
  • Past successes taken as guarantee of future
    safety.

19
Employee Adaptations

20
Aircraft Attitude at Threshold
21
Goal Conflicts

22
Weak Signals
23
Incident Reporting
  • Challenges
  • Determining which incidents are reportable
  • Analyzing near miss incidents to seek
    opportunities to make improvements to system
  • Shortcomings in companies analysis capabilities
    given scarce resources and competing priorities

24
Incident Reporting (contd)
  • Challenges (contd)
  • Performance based on error trends misleading no
    errors or incidents does not mean no risks
  • Voluntary vs. mandatory, confidential vs.
    anonymous
  • Punitive vs. non-punitive systems
  • Who receives incident reports?

24
25
TSB Reports
  • Observations
  • personnel, workload, supervision
  • training, qualifications
  • physical or mental fatigue
  • ineffective sharing of information
  • gaps created by organizational transitions
    affecting roles, responsibilities, workload and
    procedures

26
Implementing SMS What Works?
  • Leadership and commitment from the very top of
    the organization
  • Paperwork reduced to manageable levels
  • Sense of ownership by those actually involved in
    the implementation process
  • Individual and company awareness of the
    importance of managing safety

27
What Doesnt Work?
  • Too much paperwork
  • Irrelevant procedures
  • No feeling of involvement
  • Not enough people or time to undertake the extra
    work involved
  • Inadequate training and motivation
  • No perceived benefit compared to the input
    required

28
Lessons Learned
  • Goal conflicts, local adaptations, and drift
    occur naturally. SMS can help identify these.
  • Organizations can learn from patterns of accident
    precursors.

29
Benefits and Pitfalls
  • There is no panacea
  • But SMS can provide
  • Mindful infrastructure to identify hazards,
    mitigate risks
  • More reports of near misses
  • Help identify safe practices

30
Conclusion
  • Effective SMS depends on culture and process
  • Successful implementation takes unrelenting
    commitment, time, resources, and perseverance
  • There are business benefits and safety benefits
  • Ongoing requirement for strong regulatory
    oversight

31
WATCHLIST
  • Fishing vessel safety
  • Emergency preparedness on ferries
  • Passenger trains colliding with vehicles
  • Operation of longer,heavier trains
  • Risk of collisions on runways
  • Controlled flight into terrain
  • Landing accidents and runway overruns
  • Safety Management Systems
  • Data recorders

32
Questions?
33
References
  • Slide 5 Dekker, S. (2006) The Field Guide to
    Understanding Human Error, Ashgate Publishing
    Ltd.
  • Slide 6 Dekker, S. (2006) The Field Guide to
    Understanding Human Error, Ashgate Publishing
    Ltd.
  • Slide 8 Dekker, S. (2005) Ten Questions About
    Human Failure
  • Slide 12 Dekker, S. (2002) The Field Guide to
    Human Error Investigations. Ashgate Publishing
    Ltd.,18, 26
  • Slide 13 Reason, J. (2001) In Search of
    Resilience, Flight Safety Australia,
    September-October, 25-28
  • Slide 15 Dekker, S. (2007) Just Culture,
    Ashgate Publishing Ltd., p.21
  • Slide 23 Bosk, C. (2003) Forgive and Remember
    Managing Medical Failure, University of Chicago
    Press
  • Slide 24 Dekker, S. Laursen, T. (2007) From
    Punitive Action to Confidential Reporting
    Patient Safety and Quality Healthcare
    September/October 2007

34
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