SMS:
Evolving Approaches to Safety Management
Kathy Fox, Board Member
Canadian Nuclear Safety Commission
Ottawa, Ontario
25 March 2011
1
Outline
• Early thoughts on safety
• Learning Lessons
– Organizational Drift
– Employee Adaptations
– Hazard Identification and Reporting
• Safety Management Systems
– What works
– What doesn’t
– Why
2
Early Thoughts on Safety
Don’t break rules or make mistakes
No equipment failure
Pay attention to what you’re doing
Follow standard operating procedures
Things are safe
3
Safety ≠ Zero Risk
But why not?
4
Reason’s Model (“Swiss cheese”)
Defences
Occurrence
Inadequate
Productive
Activities
Limited Window of
Occurrence Opportunity
Un s afe Act s
Preconditions
P sych o lo g ic al
P recu rso rs o f U n safe
Act s
Line Management
De ficie n cies
Active Failures &
Latent Unsafe Conditions
DecisionMakers
F allib le Dec isio n s
Active Failures
Latent Unsafe Conditions
Latent Unsafe Conditions
Latent Unsafe Conditions
5
Sidney Dekker
Understanding Human Error
• Safety is never the only goal
• People do their best to reconcile different
goals simultaneously
• A system isn’t automatically safe
• Production pressures influence trade-offs
______
Dekker, S. (2006) The Field Guide to Understanding Human Error,
Ashgate Publishing Ltd.
6
Dekker:
Understanding Human Error
Tasks
Operating
Environment
Tools
Human
Error
7
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
8
Balancing Competing Priorities
Service
Safety
9
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)
10
MK Airlines (October 2004)
11
Safety Management System (SMS)
SMS integrates safety into all daily activities.
“It is 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)
12
Why Change?
• The traditional approach to safety management
has been based on:
•
•
•
•
Follow standard operating procedures
Compliance with regulations
Don’t make mistakes
Reactive response following accidents
• This has proven insufficient to reduce accident
rates
13
Elements of SMS
Hazard
Identification
Incident Reporting
and Analysis
Strong Safety
Culture
14
SMS: Hazard Identification
The whole point is to find trouble
before trouble finds you.
However…
It is difficult to predict all possible interactions
between seemingly unrelated systems
(aka: “complex interactions”) 1
_________
1
Perrow, C. (1999) Normal Accidents, Princeton University Press
15
“Requisite Imagination”
16
Risk Analysis
• Challenges:
– Inadequate assessment of risks posed by operational
changes (drift into failure, limited ability to think of
ALL possibilities) 1,2
– Deviations of procedure reinterpreted as the norm 3
_________
1
Dekker, S. (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates
2,3
Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press
17
Employee Adaptations
• Difficult to detect from inside an organization
as incremental changes always occur
• Front-line operators create “locally efficient
practices”
• Why? To get the job done.
• Past successes taken as guarantee of future
safety
18
Fox Harbour
19
Aircraft Attitude at Threshold
20
Goal Conflicts
21
Weak Signals
22
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
23
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?
24
SMS: Organizational Culture
• SMS is only as effective as the organizational culture
that enshrines it
• Work groups create norms, beliefs and procedures
unique to their particular task, thus becoming the work
group culture 1
• Undesirable characteristics may develop: lack of
effective communication, over-reliance on past
successes, lack of integrated management across
organization 2
_________
1 Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press
2 Columbia Accident Investigation Report, Vol. 1, August 2003
25
SMS: Accountability
• To criminalize or not: that is the question
• According to Dekker…
– Safety suffers when operators punished
– Organizations invest in being defensive
rather than improving safety
– Safety-critical information flow stifled for fear
of reprisals
________
Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd.
26
Elements of a “Just Culture”
(Dekker, 2007)
• Encourages openness, compliance, fostering safer
practices, critical self-evaluation
• Willingly shares information without fear of reprisal
• Seeks out multiple accounts and descriptions of events
• Protects safety data from indiscriminate use
• Protects those who report their honest errors from blame
___________
Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd.
27
Elements of a “Just Culture”
(Dekker, 2007) (cont.)
• Distinguishes between technical and normative errors
based on context
• Strives to avoid letting hindsight bias influence the
determination of culpability, but rather tries to see why
people’s actions made sense to them at the time
• Recognizes there is no fixed line between culpable and
blameless error
________
Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd.
28
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
29
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
30
Conclusions
• Old views of safety are changing
• No one can predict the future perfectly
• “Mindful infrastructure”
Effective SMS depends on “culture” and “process”
• Accountability is key
• No panacea. Time + Resources + Perseverance
• Ongoing requirement for strong regulatory help
31
Fishing vessel safety
WATCHLIST
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
32
Questions?
33
References
 Slide # 6: Dekker, S. (2006) The Field Guide to Understanding Human
Error, Ashgate Publishing Ltd.
 Slide # 10: Dekker, S. (2005) Ten Questions About Human Failure
 Slide #12: Reason, J. (2001) In Search of Resilience, Flight Safety
Australia, September-October, 25-28
 Slide #15: Perrow, C. (1999) Normal Accidents.
 Slide #17: Dekker, S. (2005) Ten Questions About Human Failure
 Slide #17: Vaughan, D. (1996) The Challenger Launch Decision
 Slide #25: ibid
 Slide #25: Columbia Accident Investigation report, Vol. 1, August 2003
 Slide #26: Dekker, S. (2007) Just Culture, Ashgate Publishing, Ltd.
 Slides #27, 28: ibid
34
35