Safety Culture and Safety Management

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Safety Culture and Safety Management
Rail Aviation Conference RAeS 21st May 2009

• Jim Reason
• Professor Emeritus
• University of Manchester, UK

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Overview

• Organizational accidents
• The two faces of safety
• Safety culture
• Proactive process measures
• Error management

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Hazards, losses defences
Defences
Losses
Hazards
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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
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How and why defences fail
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The two faces of safety

• Negative face as revealed by accidents,
  incidents, near misses and the like.
• Positive face systems intrinsic resistance to
  its operational hazards.

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Intrinsic safety
Resistant system
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The safety space
Increasing vulnerability
Increasing resistance
Organisations
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Navigating the safety space
Increasing vulnerability
Increasing resistance
Cultural drivers
Target zone
Commitment Cognizance Competence
Navigational aids
Reactive outcome measures
Proactive process measures
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Negative outcome measures

• Exceedances (SPADs)
• Near misses incidents
• Accidents

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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).

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REVIEWRailway Problem Factors

• Tools equipment
• Materials
• Supervision
• Working environment
• Staff attitudes
• Housekeeping
• Contractors
• Design

• Staff Communication
• Departmental commn
• Staffing rostering
• Training
• Planning
• Rules
• Management
• Maintenance

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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

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Three Cs 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 warparticularly with regard to human
  and organisational factors?
• Competence Are your safety management techniques
  understood, appropriate and properly utilised?

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The importance of culture
Only culture can reach all parts of the
system. Only culture can exert a consistent
influence, for good or ill.
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Culture A workable definition
Shared values (what is important) and beliefs
(how things work) that interact with an
organizations structure and control systems to
produce behavioural norms (the way we do things
around here).
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A safe culture Interlocking elements
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Cultural strata
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Error Management (EM)

• Three main elements
• Error reduction
• Error containment
• Management of EM
• And the hardest of these is effective management.

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More management hoops?

• Quality management systems
• Safety management systems
• Error management whats new?
• Need to sort out differences and overlaps

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Quality Management System(industrial origins)

• TQM had its origins in Statistical Process
  Control (1920s). DemingJapanUSA
• 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

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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
  hazardssteps documented
• Hazard identification
• Risk assessment
• Defences and safeguards
• Recovery

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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
  improvementskaizen not home runs.

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QMS SMS Problems

• A strong temptation to put form before
  substanceto believe that whats 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.

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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 Murphys Law as its starting point.
  Errors are inevitable.

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More about EM

• Effective EM needs an informed and wary
  culturethis 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.

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Some EM principles

• The best people can make the worst errors.
• Errors fall into recurrent patternserror traps.
• There is no one best way of doing EM.
• EM is about system reform rather than local
  fixesits about greater resilience.

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Error cant 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.