Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making

Kathy Fox, Board Member

System Safety Society – Canada Chapter’s Springtime Symposium

June 2010

Outline

• Early thoughts about safety

• TSB Investigation Reports– Lessons to be learned

• Safety Management Systems– What works– What does not work

Early Thoughts on Safety

Follow standard operating procedures

Pay attention to what you’re doingDon’t make mistakes or break

rulesNo equipment failure

Things are safe

Safety ≠ Zero Risk

Balancing Competing Priorities

Service Safety

Sidney DekkerUnderstanding Human Error

Human Error

Tools

Tasks

Operating Environment

Why Focus on Management?

1. Management decisions have a wider sphere of influence on operations

2. Management decisions have a longer term effect

3. Managers create the operating environment

Drift

“Drift is generated by normal processes of reconciling differential pressures on an

organization (efficiency, capacity utilization, safety) against a background of uncertain

technology and imperfect knowledge.”Dekker (2005:43)

Drifting into Failure(aka: Why do “safe systems” fail? )

Image by Worth100

Organizational Drift• MK Air – Flight duty times

Organizational Drift (cont’d)

Organizational Drift (cont’d)

Source: Dekker (2002: 18, 26)

Safety Management System (SMS)

“A systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.”

Reason (2001:28)

Evolution of SMS

Derives from research of:

• High reliability organizations• Strong safety culture• Organizational resilience

Why Change?

• Traditional approach to safety management based on:

• Compliance with regulations• Reactive response following accidents• Philosophy of “blame and re-train”

• This has proven insufficient to reduce accident rate

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TSB Mandate

To advance transportation safety in the air, marine, rail and pipeline modes of transportation that are under federal jurisdiction by:

• conducting independent investigations• identifying safety deficiencies• making recommendations to address safety deficiencies• reporting publicly on investigations

It is not the function of the TSB to assign fault or determine civil or criminal liability.

TSB Reports

• Observations:

• Employee adaptations• Inadequate risk analysis• Goal conflicts• Failure to heed “weak signals”

Employee Adaptations

• Front line operators create “locally efficient practices”– Why? To get the job done.

• Past successes taken as guarantee of future safety.

Employee Adaptations

Aircraft Attitude at Threshold

Goal Conflicts

Weak Signals

Incident Reporting

Challenges:

• Determining which incidents are reportable

• Analyzing ‘near miss’ incidents to seek opportunities to make improvements to system

• Shortcomings in companies’ analysis capabilities given scarce resources and competing priorities

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Incident Reporting (cont’d)

Challenges (cont’d):

• Performance based on error trends misleading: no errors or incidents does not mean no risks

• Voluntary vs. mandatory, confidential vs. anonymous

• Punitive vs. non-punitive systems

• Who receives incident reports?

TSB ReportsObservations:

• personnel, workload, supervision

• training, qualifications

• physical or mental fatigue

• ineffective sharing of information

• gaps created by organizational transitions affecting roles, responsibilities, workload and procedures

Implementing SMS: What Works?

• Leadership and commitment from the very top of the organization

• Paperwork reduced to manageable levels

• Sense of ownership by those actually involved in the implementation process

• Individual and company awareness of the importance of managing safety

What Doesn’t Work?• Too much paperwork

• Irrelevant procedures

• No feeling of involvement

• Not enough people or time to undertake the extra work involved

• Inadequate training and motivation

• No perceived benefit compared to the input required

Lessons Learned

• Goal conflicts, local adaptations, and drift occur naturally. SMS can help identify these.

• Organizations can learn from patterns of accident precursors.

Benefits and Pitfalls

• There is no panacea

• But SMS can provide:+ Mindful infrastructure to identify hazards, mitigate risks+ More reports of “near misses”+ Help identify safe practices

Conclusion

• Effective SMS depends on “culture” and “process”

• Successful implementation takes unrelenting commitment, time, resources, and perseverance

• There are business benefits and safety benefits

• Ongoing requirement for strong regulatory oversight

Fishing vessel safety

Emergency preparedness on ferries

Passenger trains colliding with vehicles

Operation of longer,heavier trains

Risk of collisions on runways

Controlled flight into terrain

Landing accidents and runway overruns

Safety Management Systems

Data recorders

WATCHLIST

Questions?

References Slide # 5: Dekker, S. (2006) The Field Guide to Understanding Human

Error, Ashgate Publishing Ltd. Slide # 6: Dekker, S. (2006) The Field Guide to Understanding Human

Error, Ashgate Publishing Ltd. Slide # 8: Dekker, S. (2005) Ten Questions About Human Failure Slide #12: Dekker, S. (2002) The Field Guide to Human Error Investigations.

Ashgate Publishing Ltd.,18, 26 Slide #13: Reason, J. (2001) In Search of Resilience, Flight Safety

Australia, September-October, 25-28 Slide # 15: Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd., p.21 Slide #23: Bosk, C. (2003) Forgive and Remember: Managing Medical

Failure, University of Chicago Press Slide # 24: Dekker, S. & Laursen, T. (2007) From Punitive Action to

Confidential Reporting : Patient Safety and Quality Healthcare September/October 2007