Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta 29 April 2015

Outline A history of Safety Management Systems (SMS) Three approaches to safety management SMS requirements for Canadian railways How it applies to you? Where does safety culture fit?

A history of SMS 1974 Flixborough, Explosion at petrochemical facility U.K. First requirement for a “Safety Case” 1976 Seveso, Release of 6 tons of chemicals Italy European safety regulations 1988 Piper Alpha, Explosion and fire aboard oil and gas rig North Sea, U.K. Cullen Enquiry recommends “formal assessments of major hazards to be identified and mitigated” (i.e., a “safety case”)

Three approaches to safety management Fatality Major Injury Minor Injury Medical Close Call

Three approaches to safety management (cont’d) The Technical/Engineering Model What it is Process safety Reliability engineering Ergonomic and cognitive engineering Assessing and managing risk Human reliability Outcomes Hazard analysis Risk assessments Technical safety audits Human reliability assessments Cognitive task analysis Ergonomic guidelines

Three approaches to safety management (cont’d) The Organization Model What it is Success defined by Human error viewed as consequence not cause Errors are symptoms of latent conditions in the system Latent conditions the result of: Management decisions Design Changes introduced after earlier accidents Having pro-active (or leading) indicators of the health of the system Safety decision-making embedded throughout the organization Organization performance - find opportunity for actions to prevent accidents (“find trouble before trouble finds you”)

Summary: Three approaches to safety management Human Unsafe Acts Mistakes Human Performance Error Management Technical/ Engineering Mechanical Technical Design Man-Machine Interface Organizational SMS Culture

Safety, leadership, and culture Safety Enabling Systems Hazard Recognition and Mitigation Skills. Knowledge and Training Policies and Standards Exposure reduction Organizational Sustaining Systems Selection and Development Structure Performance Management Rewards and Recognition Organizational Culture Facilities & Equipment Working Interface Worker Process Source: Leading with Safety. Tom Krause, Behavioral Sciences Technologies

What is culture? The way we do things around here Takes Time Simple definition: The way we do things around here Culture change Takes Time Can be difficult to measure Key notions: Behavioural statement Leaders must find ways to change behaviours Behaviour changes lead to changes in beliefs which changes the culture

SMS requirements for Canadian railways Manage occurrences Report contraventions and hazards Manage knowledge Scientifically based schedules for operating employees Majors Accountability Establish targets and develop initiatives Continuous improvement Majors and Local Class I Safety policy Compliance with regulations Identify safety concerns Implement / evaluate remedial action Risk assessments All railroads (Majors, Local Class I and II)

SMS requirements for Canadian railways – conclusions SMS elements of regulations are all “enabling” Therefore, they are essential but not sufficient Paradox: Perception of an overly bureaucratic process versus the need to make these “living” documents Risk: A system on paper that does not exist on the shop floor

SMS requirements for Canadian railways Safety policy Compliance with regulations Identify safety concerns Implement / evaluate remedial action Risk assessments All railroads (Majors, Local Class I and II)

Safety policy A leadership statement provides an overarching VISION to all employees What should it look like? Use behavioural terms Keep it short What should you do with it? Communicate, communicate, communicate “Live” it When should you change it? Not often, but not never

But you must also be aware that … Having a statement and communicating it are not enough: You must believe in it; Your actions must match your words; Your decisions must be consistent with your statement; and You must be seen to be credible.

Identifying safety concerns Do you have a process for reporting what happened? What about a process for reporting what almost happened? How do you tap into the knowledge of the “guy” with the boots on the ground? How often do you “walk about”? When you do, are you looking for conditions or behaviours? How do you correct the behaviours you see?

Risk assessments Do you know how to assess risk? What triggers a risk assessment? What should trigger it? What tools do you use? Do you document the assessments? Who do you get involved in the risk assessments? How do you judge the quality of your process? The quality of the product?

Implementing and evaluating remedial actions Implementation How do you decide what the possible actions are? How do you decide which actions to take? What can you do short term? What needs to be done long term and what barriers need to be overcome? Do you have physical defences? Administrative defences? Evaluation How do you know if your actions are working?

Ask these questions: Is what I say consistent with what I do? How quickly do I react to concerns raised? Has something changed today compared to yesterday? What can I do to reduce risk in my operation? By making a change here, have I created more risk somewhere else? How do I know the changes have been truly implemented?

SMS: Transport Canada’s vision “[An SMS] is a formal framework that helps railway companies integrate safety into their day-to-day operations. It encourages the development of a safety culture throughout all levels of an organization and ensures that safety is considered a factor in all decision-making.” Louis Lévesque, Deputy Minister of Transport 24 November 2014: Report of the Standing Committee on Public Accounts

Wrap-up: SMS for any organization Comply with existing regulations Examine: Operations Decisions around those operations Continuous improvement Predict hazards using data collection and employee reports Analyze, assess, control risk Monitor controls Monitor system itself for effectiveness Move from reactive to predictive thinking Change safety culture of leadership, management, and employees

From past to present to future Reactive Respond to accidents Write another procedure Proactive Seek hazardous conditions Change something to mitigate the risk Predictive Analyze processes to identify potential problems Change process and monitor effect of changes

Reminder: Going beyond regulations Possession of an SMS is NECESSARY but NOT SUFFICIENT ON ITS OWN to ensure sustained safety improvement. You still need an organizational culture that supports the system. Culture change is led from the top. Every level of organization must promote and practice risk reduction.

Notable Quotes – 1 “No amount of regulations for safety management can make up for deficiencies in the way in which safety is actually managed. The quality of safety management … depends critically, in my view, on effective safety leadership at all levels and the commitment of the whole work place to give priority to safety.” Lord Cullen 2013 Conference 25th Anniversary Piper Alpha

Notable Quotes – 2 “While the precise circumstances and context of major incidents differ in some respects, at heart I am left with the feeling that there are no new accidents. Rather, there are old accidents repeated by new people.” Judith Hackitt CBE, Chair of UK HSE 2013 Conference 25th Anniversary Piper Alpha

Questions?