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System Safety: System Safety: A systematic processesA systematic processes
1. HazardIdentification
2. RiskAssessment
3. Analyze Risk Control
Measures
4. Risk Controls
5. ImplementRisk Controls
6. Follow Through &
Review
1. HazardIdentification
2. RiskAssessment
3. Analyze Risk Control
Measures
4. Risk Controls
5. ImplementRisk Controls
6. Follow Through &
Review
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Making Risk Control DecisionsMaking Risk Control Decisions
1. Identifythe Hazards
2. Assessthe Risks
3. Analyze Risk Control
Measures
4. MakeControl
Decisions
5. ImplementRisk Controls
6. Superviseand Review
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Risk Control Measurement Analysis
Identify controloptions
Determine control effects
Prioritize riskcontrol measures
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Making Risk Control DecisionsMaking Risk Control Decisions
Select RiskControloptions
Make Decision at appropriate level
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The Risk Control Macro Option ListThe Risk Control Macro Option List
• Reject
• Avoid
• Delay
• Transfer
• Spread
• Compensate
• Reduce
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Macro OptionsMacro Options
• REJECT– Risk outweighs benefit
• AVOID– Go around the risk, do it in a different way
• DELAY– Maybe the problem will be resolved by time
• If delay is an acceptable option consider if operation is needed at all
• TRANSFER– Better qualified system, i.e.,“Pro’s From Dover”
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Macro Options (cont)Macro Options (cont)
• SPREAD– Modular or separate Hazardous Operations
• COMPENSATE– Design parallel and redundant systems
• REDUCE– Design for minimum risk– Incorporate Safety Devices– Provide Warning Devices– Develop SOPs & Train
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Providing Management Risk Control Options
• Program Manager looking for optimum combinations– Mission supportive
• Some Risk Controls are incompatible– Evaluate full cost versus full benefit
• Be prepared for numbers game
• Some Controls reinforce one another– Win-Win option
• Redundancy = Robustness– Is it needed?
• Can you afford it? i.e., $$$, #’s, real estate
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Decision Making Considerations
• Make decisions at the right time– Don’t rush – Make them as late as possible without
negative impact on timeline
• Make decisions at the right level– It should be established who makes the tough calls– Use RAC or TREC to quantify who, what, when
• Provide Mission supportive options– Use the Macro Option list as a starting point– Be prepared to offer sound advice
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What Level is “The Right Level”
• Don’t just pass the buck up to the next level• You should help address the operational realities• Decision should be made at the level that has the
best understanding of the risks, opportunity and authority to commit resources
• Be prepared to address dynamic environments such as flight
• What is your span of control
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Preliminary Hazard Analysis in Preliminary Hazard Analysis in system life cyclesystem life cycle
Preliminary Hazard Analysis in Preliminary Hazard Analysis in system life cyclesystem life cycle
System Concept
System Definition
System Development
System Production
System OperationPHA
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SSHA in the system life cycleSSHA in the system life cycleSSHA in the system life cycleSSHA in the system life cycle
System Concept
System Definition
System Development
System Production
System Operation
SSHA
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System Safety OrganizationSystem Safety Organization
PresidentPresident
Division safety administratorDivision safety administrator
Program director vice-presidentProgram director vice-presidentEngineering Vice-PresidentEngineering Vice-President
Program safety
requirements
Program safety
requirements
Program safety
assurance
Program safety
assurance
Special projects safetySpecial projects safetyFlight safetyFlight safety
System safety engineeringSystem safety engineering Nuclear safetyNuclear safety
Safety staff groupSafety staff group
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Determine Risk Control EffectsDetermine Risk Control Effects
• How will this effect probability?• How will this effect severity?• How will this impact other sub-systems?
– Some controls support other sub-systems– Some controls may hinder other sub-systems
• What are the costs vs. benefits? – Direct Costs– Indirect Costs
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Elements of a Sound Decision Making System
• Accurate information delivered to the various levels of decision maker(s)
• Concise and understandable Paper Trail• Progressive line of accountability to the top• Standardized process -- Like decisions made
consistently at Like levels• Process allows timely decision, capable of
responding to fast-pace and dynamic operations
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11 22 66 88 1212
33 44 77 1111 1515
55 99 1010 1414 1616
1313 1717 1818 1919 2020
THE THE “ENHANCED” “ENHANCED” RISK ASSESSMENT RISK ASSESSMENT MATRIXMATRIX
- Numeric Code is used to prioritize hazards and determine their acceptability using a quantitative methodology
ProbabilityFrequent Likely Occasional Seldom Unlikely
I
II
III
IV
Catastrophic
Critical
Moderate
Negligible
A B C D E
S
E
V
E
R
I
T
Y
Risk Levels
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Decision Making GuidelineDecision Making Guideline
• RISK LEVEL– Extremely High– High– Medium– LowLow
• DECISION LEVEL– Senior Executive– Managing Director– Program Manager– Any person in a Any person in a
leadership positionleadership position
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When you have finished your analysis and When you have finished your analysis and prepare to make your decision, ask yourself prepare to make your decision, ask yourself
the following questions;the following questions;
• If I accept this risk do the total benefits outweigh the total costs…or…
• Do the total costs outweigh the total benefits
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When you have finished your When you have finished your analysis and prepare to make your analysis and prepare to make your
decision, ask yourself the following decision, ask yourself the following questions:questions:
“If I accept this risk do the total benefits outweigh the total costs…or…do the costs outweigh the total
benefit?”
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Cost of Mishap vs. Risk ManagementCost of Mishap vs. Risk ManagementM
ish
ap C
os
ts
Risk Reduction Effort
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Cost of Hazard MitigationCost of Hazard Mitigation
Mis
hap
Co
sts
Co
st
of
co
un
term
eas
ure
s
Risk Reduction Effort
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““Balanced” Risk ManagementBalanced” Risk Management
Mis
hap
Co
sts
Co
st
of
co
un
term
eas
ure
s
Risk Reduction Effort
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Implementing Risk ControlsImplementing Risk Controls
1. Identifythe Hazards
2. Assessthe Risks
3. Analyze Risk Control
Measures
4. MakeControl
Decisions
6. Superviseand Review
5. ImplementRisk Controls
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LatentConditions
LatentConditions
UnsafeActs
UnsafeActs
HazardHazard
Occurrence
Layers of Risk Control
Defences can be Breached
Detect and EliminateDetect and Eliminate
Reason ModelReason Model
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Risk Control ROT’sRisk Control ROT’s
• Use the System Safety Precedence order
• Choose the most mission supportive combinations
• Use Integrated Product Teams
• Look for synergistic enhancements– Man – Machine – Medium – Mission - Management
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System Safety PrecedenceSystem Safety PrecedenceA systematic approach to Hazard ID – Risk Assess and ControlA systematic approach to Hazard ID – Risk Assess and Control
• Design to minimize hazards• Robust & Redundant systems, assemblies,
components, etc
• Install physical barriers• Isolate known threatening conditions or environments
• Use Warning devices • Alerts to prevent or reduce unwanted event
• Develop Procedures and Training• Most commonly used & abused hazard control
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Accept hazard or dispose of the System
Design to
eliminate
hazardDesign to
reduce
hazard
Provide Safety Devices
Provide special
procedures, or training
Eliminated?
Hazard Reduction PrecedenceHazard Reduction Precedence
Reduced?
Provided?
Provided?
Provided?
Provide
Warning DevicesProvide hazard
risk
assessment
package for
management
Conclude hazard
analysis
yes
yes
yes
yes
yes
no
no
no
no
no
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Implementing Risk ControlsImplementing Risk Controls
Clear ImplementationPlan
Establish Accountability
ProvideSupport
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Risk Controls Risk Controls MUSTMUST be an be an Integrated EffortIntegrated Effort
• Risk controls should be integrated within plans, processes, and operations which they support
• Risk controls should compete for resources e.g. (time/money/people) relative to their significance to the mission
• Risk controls should be compatible with the “system” (System safety management & engineering)
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Why Integration?Why Integration?• Compels a “balance” of mission needs• Force Multiplies the knowledge of designers,
experience of manufacturers and operators • Standardizes references (common language)• Reduces unforeseen needs• Eliminates redundancy • Strengthens accountability throughout the
organizational chart
• Bottom Line: Reduces $$$$ and work effortBottom Line: Reduces $$$$ and work effort
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Clarify ImplementationClarify Implementation
• Fully involve operational personnel
• Provide specific task-oriented guidance
• Test your intervening strategies (Verify & Validate)
• Coordinate – Coordinate – Coordinate– Use SSWG’s to proliferate throughout the
orgainzation
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How Implementation Breaks DownHow Implementation Breaks Down
• Operators dislike it• Management dislikes it• Wrong control selected for right reason• Too costly (cost vs. benefit)• Out weighed by other priorities (mission need)• It is misunderstood (poorly defined problem
statement) • Can’t establish a need (Poor performance metrics)
“Can’t prove the accident about to happen”
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“Buy-In Continuum
• USER OWNERSHIP STRONGESTSTRONGEST• CO-OWNERSHIP• TEAM MEMBER• INPUT• COORDINATION• COMMENT AND FEEDBACK• BLIND ALLIGENCE WEAKESTWEAKEST
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Top Down CommitmentTop Down Commitment
• The Bosses commitment is second to no safety program
• Signed policies and directives by CEO• Genuine management support
– Sustained and consistent behavior throughout org chart
– Resources match verbal commitment
– Accountability reflected in performance reports
• Follow up and review (self assessments)
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LeadershipLeadership
• Use the power of command and the influence of organizational leaders
• Use motivation models
• Create positive incentives
• Insure vertical accountability throughout the organization
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THE WELL SUPPORTED RISK THE WELL SUPPORTED RISK CONTROLCONTROL
THE WELL SUPPORTED
CONTROL
A TRAINING PACKAGE
JOB AIDSCOMMAND SUPPORTPACKAGE
A MOTIVATIONALPACKAGE
A MEASUREMENTPACKAGE
A POLICYPILLAR
TOOL KIT PACKAGE
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1. Identifythe Hazards
2. Assessthe Risks
3. Analyze Risk Control
Measures
4. MakeControl
Decisions
5. ImplementRisk Controls
6. Superviseand Review
SUPERVISE AND REVIEWSUPERVISE AND REVIEW
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Supervise and ReviewSupervise and Review
Supervise Review Feedback
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SupervisionSupervision
Nothing new here…just like any supervisory process
Insure controls are effective and in place
Monitor progress through schedules
Correct ineffective control measures
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Quality Management Tools
• Performance metrics are a challenge• Can’t prove the accident that didn’t happen• Find Q & Q methods to measure control
effectiveness e.g. (Resources expended)• Data Information Knowledge • Trend and Analyze
– Pareto Charts– Bell Curve
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Use Quantitative Analysis (Rates Use Quantitative Analysis (Rates and Numbers) when:and Numbers) when:
• You have statistically significant data base
• You need to “Drill Down” to find root causes
• You seek to proactively prove future risk based on historical data
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Support trends and analyses with scientific Support trends and analyses with scientific
understandings of accident root causal factorsunderstandings of accident root causal factors
• Critical behaviors & attitudes (Man)• Critical conditions (Medium)• Critical mechanics (Machine)• Critical oversight (Management) • Critical tasking (Mission)
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Developing Meaningful Developing Meaningful Performance MetricsPerformance Metrics
• Locate or collect supportive data– Be careful what you ask for
• Select critical indicators
• Establish practical performance measures– Keep them simple
• Trend and Analyze– Use what you collect
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Performance Feedback
• Are costs within budget
• Are cost vs. benefit trends favorable
• Are benefits exceeding costs
• Are indirect and direct costs included in the assessments
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Factors for ConsiderationFactors for Consideration
• Lessons learned input to databases– Avoid repeating history and expensive lessons
“re-learned”
• Cross-tell between units, departments and divisions (potentially all interested parties)
• Feedback throughout the organization (CEO to new hire)
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1. Identifythe Hazards
2. Assessthe Risks
3. Analyze Risk Control
Measures
4. MakeControl
Decisions
5. ImplementRisk Controls
6. Superviseand Review
Questions?Questions?