SAFETY MANAGEMENT SYSTEMS

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SAFETY MANAGEMENT SYSTEMS

• Management Systems for Pilotage Organisations
• Rory Main
• Fremantle Pilots

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Outline

• Introduction
• Risks and Consequences
• Formal Safety Management System
• AS/NZ 43602004, OHSAH 18002, DNV (OHSMS 1997)
• Management Perspectives
• The organisation in relation to the
  industry/regulations
• Justice Theory
• Some theory to bring it all together
• Human Factors
• Pilot-Information Sharing

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The Risk

• The management of modern pilotage operations
  requires recognition of the risks involved
• Manoeuvering ships in the confined waters of a
  port
• Risk to employees working on the ship, the wharf,
  the mooring boats and the tugs
• Risk to the port infrastructure,
• The financial risk (legal, insurance, reputation
  etc.) and
• The environmental risks.
• To minimise exposure to the consequences of an
  incident requires a systematic approach to
  implementing a Safety Management System.

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The Consequence

• The systemic approach taken by the courts places
  the onus of responsibility on the persons
  responsible for the systems in place that allowed
  the latent failures to occur. Therefore, it is
  incumbent on pilotage organisations to ensure
  that adequate Safety Management Systems are in
  place.
• Where it is possible to guard against a
  foreseeable risk, which though perhaps not great,
  nevertheless cannot be called remote or fanciful,
  by adopting a means, which involves little
  difficulty or expense, the failure to adopt such
  means will in general be negligent.
• Richard Robinson (Risk and Reliability
  Associates) oft uses a quote from Chief Justice
  Gibbs (High Court of Australia)

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Safety Management System

• Safety Management is defined as the systematic
  management of the risks associated with ...
  organisational activities to achieve high
  levels of safety performance. (UK CAA)
• A Safety Management System is an explicit
  element of the corporate management
  responsibility which sets out a companys safety
  policy and defines how it intends to manage
  safety as an integral part of its overall
  business. (UK CAA)
• A Safety Management System is an integrated set
  of work practices, beliefs and procedures for
  monitoring and improving the safety and health of
  all aspects of your operation. It recognizes the
  potential for errors and establishes robust
  defenses to ensure that errors do not result in
  incidents or accidents. (Civil Advisory Safety
  Authority Australia, advisory circular November
  2003).
• The ability of organisations and individuals to
  deal with risks and hazards so as to avoid damage
  or losses and yet still achieve their goals.
  (James Reason)

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Formal SMS

• Australian Standards 1. Policy, 2. Planning,
  3. Implementation Operation, 4. Checking
  Operation, 5. Management Review
• Earl Warner's four P's 1. Principles
  (philosophy) 2. Policies 3. Procedures 4.
  Practices
• James Reason three C's 1. Commitment 2.
  Cognizance 3. Competence

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Organisational Structure
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Organisational Environment
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Implementing a formal SMS

• Policy
• An Organization defines its policy through a
  policy statement appropriate to the organization
  and ensures commitment to its Management System.
• Planning
• An Organization formulates a plan to fulfill its
  policy.
• Implementation and Operation
• For effective implementation, an Organization
  develops the capabilities and support mechanisms
  necessary to achieve its policy, objectives and
  targets.
• Checking and Corrective Action
• An Organization measures, monitors and evaluates
  its performance.
• Management Review
• An Organization reviews and continually improves
  its management system, with the objective of
  improving its overall performance.
• British OHSAS 18002

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James Reason

• Organisational accidents are latent conditions
  that combine adversely with local triggering
  conditions and with active failures to produce an
  accident.
• There is an increasing commercial cost of
  accidents and incidents and their effect on
  company profits and financial viability, as well
  as the social and environmental impact of
  occurrences.
• Consequently prevention and error management
  programs based on system safety and human factors
  concepts, not only improve safety within the
  workforce but are commercially attractive.

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Safety Data Sources
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Definition of Justice

• John Rawls describes Justice as a persons
  legitimate expectation of a just
  outcomeThere are definitely many outcomes
  and what makes one of these just is that it has
  been achieved by actually carrying out a just
  scheme of co-operation ... it is the result which
  has arisen when everyone receives that to which
  he is entitled given his and others actions
  guided by their legitimate expectations and their
  obligations to one another.
• (Rawls, 1998, p.52)

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Outline of Justice

• If the outcomes and the inputs fit, the person
  will certainly feel a sense of balance However,
  a discrepancy will lead to perception of
  injustice. (Beugre, 1998, p.xiii).
• Distributive Justice individual rewards and
  company outcomes,
• Procedural Justice voice and the rule-oriented
  climate,
• Interactional Justice dignity and relationship,
  and
• Systemic Justice ethical climate.
• In the study of Justice, Beugre states that what
  is important is not reality itself, but the
  subjects perceptions of reality. (1998, p.60).
  An individuals perception of reality is dependent
  of several factors, including
• The Demographic Variables of gender, tenure,
  level of education and occupational status,
• Cognitive Variables, such as causal attributions
  and self serving bias, and
• Personality Variables like negative affective and
  hostile attributional bias.

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Justice Defined

• Distributive Justice
• There is seldom an objective standard of
  righteousness people render a distributive
  justice judgement on whether they perceive the
  outcome as appropriate, moral or ethical. (Folger
  and Cropanzano, 1998, p.xxi).
• Procedural Justice
• Procedural justice refers to the fairness of
  rules and procedures by which assets and rewards
  are allocated. (Beugre, 1998, p.21).
• A fair organisation is one characterized by
  procedures that ensure such things as voice, due
  process, advance notice and so forth. (Beugre,
  1998, p.23).
• People seek control over decisions because they
  are fundamentally concerned with their outcomes.
  (Lind Tyler, 1988, p.222).
• Interactional Justice
• Interactional justice describes how perceptions
  of individual interactions affect organisational
  justice.
• The focus is on how fairly those in authority
  treat those who are subject to their authority.
  Folger and Cropanzano describe interactional
  justice as separate to procedural justice whilst
  being inextricably interwoven in the joint impact
  of distributive and procedural justice.
• Research has found that individuals will be far
  more tolerant of an unfavourable outcome when an
  adequate justification is provided. (Folger and
  Cropanzano, 1998, p.xxiv).

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Justice Defined (cont).

• Systemic Justice
• Systemic justice represents a global assessment
  of the degree to which the organisation itself is
  fair. (Bies and Tripp, 1995)
• Justice Processes
• Greenberg developed the following list of process
  characteristics that are applied in determining
  the level of perceived procedural justice
• Allow opportunities to select the decision
  making agent,
• Follow consistent rules,
• Are based on accurate information,
• Identify the structure of decision making
  power,
• Employ safeguards against bias,
• Allow for appeals to be heard,
• Provide for opportunities for changes to be
  made in procedures, and
• Are based on prevailing moral and ethical
  standards.
• (1987, p.15)

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Justice Theory
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Implementing the SMS
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References

• CAP 730 Safety Management Systems for Air Traffic
  Management A Guide to Implementation.
  www.caa.co.uk
• James Reason Human Factors Aspects of Safety
  Management Systems. University of Manchester
• Bureau of Air Safety Investigation (UK) An
  Evaluation of the BASI-Indicate Safety Program
• Occupational Health and Safety Management
  Systems-Guidance OHSAS 18002

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Learning is not compulsory but neither is
survival. W. Edwards Deming
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Pilot-Information Management System

• Sharing information between Pilotage Organisations

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AIMS

• Global
• To provide a platform for Pilots to share
  detailed ship information, incidents or near miss
  risk events.
• Port specific
• To provide timely information to pilots in each
  port on ship incidents, hazards and risk events
  related to the Port.
• To allow pilots to record specific details on
  ship handling characteristics for their port.
• To assist pilots create reports for different
  entities from a single data entry point.
• To provide data to support the pilotage
  organisation's Safety Management System.

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Strategic Plan

• To establish a reporting process which sends
  summary reports to specific persons (e.g. monthly
  summaries of risk events to be emailed to pilots
  in the port or region).
• To provide a Microsoft Access database which
  links to the Port specific information on the
  PIMS website.
• To establish a high level of security for the
  site and provide secure data transmission
  protocols.
• To develop a manoeuvre assessment system for
  pilot groups to gather information to share
  between the pilots of the port.
• To keep the costs of implementing the site to a
  minimum.
• To allow access to information for Pilots using
  portable Internet access technology (WAP).

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Customer Focus

• The data stored for the Port can be pulled from
  the site into the PIMS database. This allows the
  Pilotage organisation to analyse data and
  generate reports as part of their Safety
  Management System.
• The site can be customised for each Port. The
  forms and reports can be tailored to the needs of
  each Port.
• Varying levels of access to the site are provided
  to ensure data integrity.

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Security

• The PIMS website is hosted by a reputable
  company.
• Content Management Via Web Browser
• Storage Management Via Web Browser
• Search Engine Development Integration
• SSL Security Implementation
• Real Time E-commerce Transactional Sites
• Automatically Generated Interactive E-mails
• WAP Applications
• The data will be backed up continually on a RAID
  server and daily on a back-up server.
• Data will be stored off site each day
• Each Port can down Port data at regular intervals

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SSL Security

• PIMS will implement SSL security late 2005 as
  part of the system roll-out if customers require
  SSL level of security
• An SSL Certificate is an electronic file that
  uniquely identifies individuals and Web sites and
  enables encrypted communications. SSL
  Certificates serve as a kind of digital passport
  or credential. Typically, the signer of a SSL
  Certificate is a Certificate Authority.

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Schematic of Pilot-Information site
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Access Levels

• Pilot Group This is the grouping of pilots into
  a Port Group. This sets the access to Port
  Specific information in the drop down tables
  (e.g. Berths, tugs, pilots).
• Pilot allows individual access to read the Port
  Log and Ship pages and then enter an Incident.
  The pilot also will be able to alter the Incident
  report until the Port Administrator locks the
  record.
• Duty Pilot allows a single login for each Port
  to correct, delete and enter new records in the
  Port Log and to enter new Ship records.
• Port Administrator has full access to the Port
  Specific data for correcting and deleting (pilot,
  berth and tug) data. The Port Administrator can
  also correct ship records. The editing and
  locking of reports/records is completed by the
  Port Administrator.
• Site Administrator full site access for data
  verification, correction and deletion when
  required. The Administrator ensures the site is
  managed and utilized appropriately.

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Standard Site Logic

• The site logic shows the initial level of
  functionality. The following description outlines
  the processes available on the standard access.
  The standard access provides for Port specific
  information to be accessed by the Pilots login.
• The Port log displays the berths, tugs, pilots
  for the specific port. There is a specific login
  for each port that allows changes editing of the
  log. Pilots cannot view data for other ports.
• The Ship Information displays data to all pilots.
  Most information can be updated by any pilot
  logged onto the site. The ship information can be
  accessed from the Port Log by clicking on the
  ships name on the log, otherwise the ship can be
  accessed from a search form that looks up the
  ships name (current and past names), IMO number,
  year built etc. The specific ship to view is
  selected from a list of results that meet the
  search criteria.
• The Incident Reports are called from the Ship
  Information form or from a query on critical
  fields on the form (ship name, IMO number,
  incident type, date etc). The specific incident
  to view is selected from a list of results that
  meet the search criteria.
• New vessel movements are entered on a form
  accessed on the Port Log.
• New ships are entered when a ship is entered in
  the database when a search is unsuccessful.
• New incidents are entered from the Ship
  Information form. This ensures the Pilot is
  entering the incident against the correct ship.

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Alternative Site Logic
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Alternative Site Logic

• The following description outlines the process to
  review ship information and review incident/risk
  event reports.
• The ship detail can be accessed from a search
  form that looks up the ships name (current and
  past names), IMO number, ship type and year
  built. The specific ship to view is selected from
  a list of results that meet the search criteria.
  The incident/risk event reports are called from
  the Ship Information form. The Ship Information
  displays data to all pilots.
• The Risk Event reports will be accessed from a
  list that is generated from a search page. The
  search will set the criteria on which the Pilot
  wishes to search the database.
• The specific report to view is selected from a
  list of results that meet the search criteria.
• New ships can be entered onto the database when a
  ship search is unsuccessful.
• New reports can be entered from the Risk
  Event/Ship Defect report form.

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Review

• The site will allow access to Pilots from various
  Pilot Groups to review the tables as detailed
  above.
• The Port Log will display Port specific detail to
  which the group belongs with all the drop down
  lists showing specific data for the port group.
• The Ship form will be fully visible to all
  Pilots.
• The Incident form will be totally visible to all
  pilots in the Pilot Group that initiates the
  report.
• However Pilots from other groups will only view
  the data down to the short note, as shown on the
  table below.
• This ensures that sensitive detail which the
  pilot group wishes to remain confidential will
  not be viewed by other Pilot Groups.
• The site administrator will review all incident
  reports to ensure the information posted for
  review is written in an appropriate language.

Pilot-Information dBase
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