Human Factors in a Safety Management System - Breaking the Chain
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Speaker : Werner Schierschmidt
Title : Human Factors in a Safety Management System –
Breaking the Chain
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High risk products
High cost products
Safety is a must
Quality is not negotiable
Failure is not an option
Tightly controlled requirements
SMS in Aerospace and Defence
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SAA Boeing 707 (Namibia) 1968
Tenerife Disaster (KLM 747 – PanAm 747) 1977
JAL Boeing 747 1980
Aloha Airlines Boeing 737 1988
British Airways Flight 5390 1990
Examples of Accidents
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Why are there still Accidents?
60
40
20
30
20
10
1960 1970 1980 1990 2000 2010
Traffic Growth
Accidents per year
Traffic Growth
Accidents per year
Accid
en
ts p
er y
ear
Mil
lio
ns o
f d
ep
art
ure
s
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Wicken’s Information Processing
Receptors
and
Sensory
Memory
Stores
Attentional
MechanismPerception
Working
MemoryResponse
Long-term
Memory
Motor
Programmes
Ignore it
Respond to it
Consider it
Remember it
Activate other processing
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Stages of Skill Acquisition
Cognitive
Stage
Associative
Stage
Autonomous
Stage
Knowledge
Based
Rule
Based
Skill
Based
Practice Time
||
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Rasmussen’s Generic Error Modelling Framework
ActivityMode of Control
Focus of Attention
Error Forms
Skill-based slips & lapses
Routine actions Mainly automatic processes
(Rules)
On something other than the
task at hand
Largely predictable
“strong-but-wrong” error forms
(Rules)
Rule-based mistakes
“Trained for” problem solving
Directed at problem related
issuesKnowledge-based mistakes
Novel problem solving
Resource limited consciousprocesses
Variable
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Competence
Skills Knowledge
Attitude
Error Mistake
Violation
Competence
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Error Modelling Flowchart
Unsafe
Acts
Unintended
Action
Intended
Action
Slips
Lapses
Mistakes
Violations
Attentional Failures
Memory Failures
Rule/Knowledge
based mistakes
Intentional deviation
from procedures/rules
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Routine Violations
Situational Violations
Optimising Violations (for “kicks or a laugh”, i.e. personal gain)
Types of Violations
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Interventions
Errors Mistakes
Violations
Highly Routine TasksProblem solving /
Misapplying Rules
Intentional Rule Breaking
• Job Awareness• Job Rotation
• Job Knowledge• Improve Data
Remove the need to Violate
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Organizational Factors
Situational Factors
People Factors
Performance Shaping Factors
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Dirty Dozen
• Lack of Communication • Lack of Resources
• Complacency • Pressure
• Lack of Knowledge • Lack of Assertiveness
• Distractions • Stress
• Lack of Teamwork • Lack of Awareness
• Fatigue • Norms
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Hazard Management
Hazard
OwnersOk to Go
Control
Owners
EventHazard
ReportsDatabase
SAG
SRB
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James Reason Model
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Incidents / Accidents
600 Unsafe
Acts
1 Fatal Accident
10 Non-fatal Accidents
30 Reportable Incidences
In Aviation:
Human Factors
contributes to
80 - 85%
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Blame
Loosing face
Do not think the event is significant, i.e.: near miss – no outcome
Always been like this in the past – status quo
Too hard to get things changed – learned helplessness
Why do we not report?
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Beliefs:
Professionals will make mistakes
Professionals will develop unhealthy norms
Expectation that system safety will improve
Duties:
To raise your hand and say: “I made a mistake”
To resist the growth of “at-risk” behaviour
To absolutely avoid reckless conduct
Just Culture (not a “Blame-Free Culture”)
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Reactive Safety Management
Investigation of accidents and incidents
Based upon the notion of waiting until something breaks to fix it
Most appropriate for:
o Situations involving failures in technology
o Unusual events
Types of Safety Management Systems
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Proactive Safety Management
Mandatory and voluntary reporting systems, safety audits and surveys
Based upon the notion that system failures can be minimised by:
o Identifying safety risks within the system before it fails
o Taking the necessary actions to reduce such safety risks
Types of Safety Management Systems (cont.)
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Predictive Safety Management
Confidential reporting, data analysis, normal operations monitoring
Based upon the notion that Safety Management is best accomplished by
looking for trouble
Aggressively seek information from a variety of resources
Types of Safety Management Systems (cont.)
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Basic Error Management System
CF
CF CF
CF
E
R
R
O
R
EVENT
REPORT
INVESTIGATION
INTERVENTION
FEEDBACK
D
A
T
A
B
A
S
E
REVIEW
BOARD
JUST
CULTURE
Re-active
Pro-active
Predictive
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Roadmap
Pathological
(un-controllable)
Reactive
Calculative
Pro-active
Generative
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Navigating SMS through a Safety Culture
Just Culture
Reporting Culture
Informed Culture
Learning Culture
1. Understanding / Initiating
2. Planning / Enabling
3. Engaging / Implementing
4. Managing & Measuring
5. Benefits Realisation
6. Continual
Improvement
Wo
rld
-Cla
ss
Safe
ty M
an
ag
em
en
t P
erf
orm
an
ce
Point A
Point B
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Humans are the strongest Link
Humans want to stick to their
Habits and Norms, they do not
like to break links in chains
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Breaking the Chain
A successful Human Factors and SMS
programme is all about breaking links
in future accident chains
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Thank you for your attention !
Safety is a Journey
Enjoy the Ride