SMS: Evolving Approaches to Safety Management Kathy Fox, Board Member Canadian Nuclear Safety Commission Ottawa, Ontario 25 March 2011

Outline Early thoughts on safety Learning Lessons Organizational Drift Employee Adaptations Hazard Identification and Reporting Safety Management Systems What works What doesn’t Why

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

Safety ≠ Zero Risk But why not?

Reason’s Model (“Swiss cheese”)

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.

Dekker: Understanding Human Error Tools Tasks Operating Environment

Why Focus on Management? Management decisions have a wider sphere of influence on operations Management decisions have a longer term effect Managers create the operating environment

Balancing Competing Priorities Service Safety

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)

MK Airlines (October 2004)

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)

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

Elements of SMS 14 14 Hazard Identification Incident Reporting and Analysis Strong Safety Culture 14 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

“Requisite Imagination”

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

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

Fox Harbour

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

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

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.

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.

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.

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 Speak to slide

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

WATCHLIST 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

Questions?

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