““And now for something And now for something completely different”completely different”

Terry KellyTerry Kelly

SSECC SSECC

January 27, 2006January 27, 2006

In the beginning – “the list”In the beginning – “the list”

• acceptable level of riskacceptable level of risk• ‘‘accountable executive’accountable executive’• confused use of definitionsconfused use of definitions• fuzzy thinking (as opposed to fuzzy logic) fuzzy thinking (as opposed to fuzzy logic) • human factorshuman factors• non-punitive reportingnon-punitive reporting• performance-based approachperformance-based approach• quality management “versus” safety managementquality management “versus” safety management• regulating an SMSregulating an SMS• safety culture safety culture • safety measurement safety measurement • target levels of safetytarget levels of safety• tools to measure safetytools to measure safety

The Short ListThe Short List

• Performance-based approachPerformance-based approach• Regulating an SMSRegulating an SMS• Safety measurementSafety measurement

SMS DefinedSMS Defined

• ““A systematic, explicit and A systematic, explicit and comprehensive process for the comprehensive process for the management of safety-risks that management of safety-risks that integrates operations and technical integrates operations and technical systems with financial and human systems with financial and human resource management …”.resource management …”.

- TP13881 (2002) - TP13881 (2002)

REASON’S MODEL

Defences

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident

Windowof Opportunity

Unsafe Actsand LatentUnsafe Conditions

Latent Unsafe Conditions

Defences

Safe Acts

Preconditions

Line Management

Decision Makers

System Hazard

AccidentAccident

Defences

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident

Risk ManagementHazards

Breaches inthe Defences

AccidentAccident

Performance-basedPerformance-based

• Variation in meaning & Variation in meaning & understandingunderstanding

• PrerequisitesPrerequisites• Evolution from performance-based Evolution from performance-based

to process-basedto process-based

Regulating an SMSRegulating an SMS

• Focus is on complianceFocus is on compliance• Need measures of complianceNeed measures of compliance• Management systems that are Management systems that are

process-process-drivendriven become process- become process-basedbased

Safety MeasurementSafety Measurement

• Mired in our past best practicesMired in our past best practices– Events —> lagging, descriptiveEvents —> lagging, descriptive

• Misapplication of quality and risk Misapplication of quality and risk assessment processesassessment processes

• Require explicit and appropriate Require explicit and appropriate measures of safety performancemeasures of safety performance

Summary: Current ProgramsSummary: Current Programs

• They do not account for current understanding They do not account for current understanding of accident causationof accident causation

• They are not adequate for current prevention They are not adequate for current prevention initiatives (e.g. SMS)initiatives (e.g. SMS)

• A known problem (by some): but not being A known problem (by some): but not being addressed (seriously) by mostaddressed (seriously) by most

• Measurement attention is on technical fixes Measurement attention is on technical fixes (new and more software, new and more (new and more software, new and more databases), not on essential determination of databases), not on essential determination of what needs to be measuredwhat needs to be measured

““We have met the enemy …We have met the enemy …

… … and they are us”!and they are us”!

- Pogo- Pogo

ConclusionConclusion

Last Concluding ThoughtLast Concluding Thought

““If we are to retain any command … If we are to retain any command … over our own future, the ablest over our own future, the ablest people we have in every field … people we have in every field … have to come out of the trenches have to come out of the trenches of their own specialty and look at of their own specialty and look at the whole battlefield”.the whole battlefield”.

- John Gardner- John Gardner