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

2. 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?

3. A history of SMS
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”)

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

5. 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

6. 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”)

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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)

13. 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

14. 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.

15. 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?

16. 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?

17. 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?

18. 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?

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. Questions?