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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’s Springtime Symposium
June 2010
Outline
• Early thoughts about safety
• TSB Investigation Reports
– Lessons to be learned
• Safety Management Systems
– What works
– What does not work
Early Thoughts on Safety
Follow standard operating procedures
Pay attention to what you’re doing
Don’t make mistakes or break rules
No equipment failure
Things are safe
Safety ≠ Zero Risk
Balancing Competing Priorities
Service
Safety
Sidney Dekker
Understanding Human Error
Tasks
Operating
Environment
Tools
Human
Error
Why Focus on Management?
1. Management decisions have a wider sphere of
influence on operations
2. Management decisions have a longer term
effect
3. Managers create the operating environment
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 (2005:43)
Drifting into Failure
(aka: Why do “safe systems” fail? )
Image by Worth100
Organizational Drift
• MK Air – Flight duty times
Organizational Drift (cont’d)
Organizational Drift (cont’d)
Source: Dekker (2002: 18, 26)
Safety Management System (SMS)
“A systematic, explicit, and comprehensive
process for managing safety risks … it becomes
part of that organization’s culture, and [part] of
the way people go about their work.”
Reason (2001:28)
Evolution of SMS
Derives from research of:
• High reliability organizations
• Strong safety culture
• Organizational resilience
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
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
TSB Reports
• Observations:
•
•
•
•
Employee adaptations
Inadequate risk analysis
Goal conflicts
Failure to heed “weak signals”
Employee Adaptations
• Front line operators create “locally efficient
practices”
– Why? To get the job done.
• Past successes taken as guarantee of future
safety.
Employee Adaptations
Aircraft Attitude at Threshold
Goal Conflicts
Weak Signals
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
Incident Reporting (cont’d)
Challenges (cont’d):
• 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
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
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
What Doesn’t 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
Lessons Learned
• Goal conflicts, local adaptations, and drift occur
naturally. SMS can help identify these.
• Organizations can learn from patterns of
accident precursors.
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
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
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
WATCHLIST
Questions?
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