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Safety Culture and Safety Culture and Safety ManagementSafety Management
Jim ReasonJim Reason
Professor EmeritusProfessor Emeritus
University of Manchester, UKUniversity of Manchester, UK
Rail & Aviation Rail & Aviation ConferenceConference
RAeS 21RAeS 21stst May 2009 May 2009
OverviewOverview
Organizational accidentsOrganizational accidents The two faces of safetyThe two faces of safety Safety cultureSafety culture Proactive process measuresProactive process measures Error managementError management
Hazards, losses & Hazards, losses & defencesdefences
LossesHazards
Defences
The ‘Swiss cheese’ modelThe ‘Swiss cheese’ modelof system accidentsof system accidents
Some holes dueto active failures
Other holes due tolatent conditions
(resident ‘pathogens’)
Successive layers of defences, barriers, & safeguards
Hazards
Losses
How and why defences failHow and why defences fail
LossesHazards
Defences
HOW?
Unsafe acts
Local workplace factors
Organisational factors
Latentconditionpathway
s
Causes
Investigation
WHY?
The two faces of safetyThe two faces of safety
Negative face as revealed by Negative face as revealed by accidents, incidents, near misses accidents, incidents, near misses and the like.and the like.
Positive face = system’s intrinsic Positive face = system’s intrinsic resistance to its operational hazards.resistance to its operational hazards.
Intrinsic safetyIntrinsic safety
Vulnerable system
Average system
Resistant
system
The safety spaceThe safety space
Increasing vulnerabilityIncreasing resistance
Organisations
Navigating the safety Navigating the safety spacespace
Increasing vulnerabilityIncreasing resistance
Cultural drivers
CommitmentCognizanceCompetence
Navigational aids
Reactiveoutcomemeasures
Proactiveprocess
measures
Target zone
Negative outcome Negative outcome measuresmeasures
Exceedances (SPADs) Exceedances (SPADs) Near misses & incidentsNear misses & incidents AccidentsAccidents
Proactive process Proactive process measuresmeasures
No single definitive measure.No single definitive measure. Involves regular sampling of a subset of a Involves regular sampling of a subset of a
much larger population of organisational much larger population of organisational processes (somewhere between 8-16).processes (somewhere between 8-16).
Identify those 2-3 processes most in need of Identify those 2-3 processes most in need of remediation.remediation.
Track progress of remedial measures.Track progress of remedial measures. Safety mgt. = long-term fitness programme Safety mgt. = long-term fitness programme
(not a zero production game).(not a zero production game).
REVIEW:REVIEW:Railway Problem FactorsRailway Problem Factors
Tools & equipmentTools & equipment MaterialsMaterials SupervisionSupervision Working environmentWorking environment Staff attitudesStaff attitudes HousekeepingHousekeeping ContractorsContractors DesignDesign
Staff CommunicationStaff Communication Departmental comm’nDepartmental comm’n Staffing & rosteringStaffing & rostering TrainingTraining PlanningPlanning RulesRules ManagementManagement MaintenanceMaintenance
RAIT: Railway AccidentRAIT: Railway AccidentInvestigation Tool Investigation Tool
What defences failed?What defences failed? How did they fail?How did they fail? Why did they fail?Why did they fail? Which of the RFTs was most Which of the RFTs was most
implicated?implicated? Errors and violationsErrors and violations Local situational factorsLocal situational factors
Three C’s: Excellence Three C’s: Excellence driversdrivers
CommitmentCommitment: In the face of ever-increasing : In the face of ever-increasing production pressures, do you have the will production pressures, do you have the will to make your safety management tools to make your safety management tools work effectively? work effectively?
CognizanceCognizance: Do you understand the nature : Do you understand the nature of the ‘safety war’—particularly with regard of the ‘safety war’—particularly with regard to human and organisational factors?to human and organisational factors?
CompetenceCompetence: Are your safety management : Are your safety management techniques understood, appropriate and techniques understood, appropriate and properly utilised?properly utilised?
The importance of cultureThe importance of culture
Only culture can reach all parts of the system.Only culture can exert a consistent influence,
for good or ill.
Though it has the definitional precisionof a cloud
Culture: A workable Culture: A workable definitiondefinition
Shared values (Shared values (what is importantwhat is important) and) andbeliefs (beliefs (how things workhow things work) that interact) that interactwith an organization’s structure and with an organization’s structure and control systems to produce behaviouralcontrol systems to produce behaviouralnorms (norms (the way we do things around herethe way we do things around here).).
A safe culture: Interlocking A safe culture: Interlocking elementselements
Learningculture
Justculture
Reportingculture
Cultural ‘strata’ Cultural ‘strata’
PATHOLOGICALBlame, denial and the blinkered pursuit ofexcellence (Vulnerable System Syndrome).Financial targets prevail: cheaper/faster.
REACTIVESafety given attention after an event.Concern about adverse publicity. Establishes an incident reporting system.
CALCULATIVESystems to manage safety, often in response to external pressures. Dataharvested rather than used. ‘By the book’.
PROACTIVEAware that ‘latent pathogens’ and ‘error traps’ lurk in system. Seeks to eliminatethem beforehand. Listens to ‘sharp enders’.
GENERATIVERespects, anticipates and responds to risks.A just, learning, flexible, adaptive, prepared& informed culture. Strives for resilience.
Error Management (EM)Error Management (EM)
Three main elements:Three main elements:• Error reduction• Error containment• Management of EM
And the hardest of these is And the hardest of these is effective management.effective management.
More management hoops?More management hoops?
Quality management systemsQuality management systems Safety management systemsSafety management systems Error management: what’s Error management: what’s
new?new? Need to sort out differences Need to sort out differences
and overlapsand overlaps
Quality Management Quality Management SystemSystem
(industrial origins)(industrial origins)
TQM had its origins in Statistical Process TQM had its origins in Statistical Process Control (1920s). Deming—Japan—USA Control (1920s). Deming—Japan—USA
Quality measurements at point of originQuality measurements at point of origin Quality assurance (QA) not quality controlQuality assurance (QA) not quality control QA documents the way things should be QA documents the way things should be
done and audits against these standardsdone and audits against these standards Discrepancies are fed back Discrepancies are fed back continuous continuous
improvementimprovement
Safety Management Safety Management SystemSystem
(regulatory origins)(regulatory origins) HSW Act 1974 (Robens). HSW Act 1974 (Robens). Piper Alpha, Piper Alpha, 19881988, ,
Cullen Report (1990). Safety Case.Cullen Report (1990). Safety Case. Modelled on ISO 9000 quality assurance.Modelled on ISO 9000 quality assurance. SMS includes a formal safety assessment of SMS includes a formal safety assessment of
major hazards—steps documentedmajor hazards—steps documented• Hazard identification• Risk assessment• Defences and safeguards• Recovery
QMS & SMS: Common QMS & SMS: Common featuresfeatures
Neither quality nor safety can be ad hoc. Neither quality nor safety can be ad hoc. Both need planning and management.Both need planning and management.
Both rely heavily on measuring, monitoring Both rely heavily on measuring, monitoring and documentation.and documentation.
Both involve the whole organisation.Both involve the whole organisation. Both strive for small continuous Both strive for small continuous
improvements—kaizen not home runs.improvements—kaizen not home runs.
QMS & SMS: ProblemsQMS & SMS: Problems
A strong temptation to put form before A strong temptation to put form before substance—to believe that what’s on paper substance—to believe that what’s on paper matches the reality.matches the reality.
‘‘Quality-assured’ accidentsQuality-assured’ accidents• BAC One-Eleven (1990)• A320 (1993)• Boeing 737-400 (1995)
Neither driven by human factors knowledge; Neither driven by human factors knowledge; neither starts from the fact that human and neither starts from the fact that human and organizational factors dominate the risks.organizational factors dominate the risks.
Why EM is necessaryWhy EM is necessary(Human Factors origins)(Human Factors origins)
Effective EM derives more from a Effective EM derives more from a mindset than a set of ring binders. mindset than a set of ring binders.
EM is not a ‘system’ as such, though it EM is not a ‘system’ as such, though it should be systematic.should be systematic.
EM requires an understanding of the EM requires an understanding of the varieties of error and their provoking varieties of error and their provoking conditions. conditions.
EM takes Murphy’s Law as its starting EM takes Murphy’s Law as its starting point. Errors are inevitable. point. Errors are inevitable.
More about EMMore about EM
Effective EM needs an informed and wary Effective EM needs an informed and wary culture—this depends on establishing: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 EM must play a major part in both QM and SM systems.systems.
QMS and SMS are top-down and normative. QMS and SMS are top-down and normative. EM is bottom-up and descriptive. It says how EM is bottom-up and descriptive. It says how the world is, not how it ought to be.the world is, not how it ought to be.
Some EM principlesSome EM principles
The best people can make the worst The best people can make the worst errors.errors.
Errors fall into recurrent patterns—error Errors fall into recurrent patterns—error traps.traps.
There is no one best way of doing EM.There is no one best way of doing EM. EM is about system reform rather than EM is about system reform rather than
local fixes—it’s about greater resilience.local fixes—it’s about greater resilience.
Error can’t be Error can’t be eliminated, but it can be eliminated, but it can be
managedmanaged Fallibility is part of the human Fallibility is part of the human
condition.condition. We are not going to change the We are not going to change the
human condition.human condition. But we can change the conditions But we can change the conditions
under which people work.under which people work.
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