1. System Safety: A systematic processes

2. Making Risk Control Decisions
1. Identify
the Hazards
2. Assess
the Risks
3. Analyze
Risk Control
Measures
4. Make
Control
Decisions
5. Implement
Risk Controls
6. Supervise
and Review

3. Risk Control Measurement Analysis
Identify control
options
Determine
control effects
Prioritize risk
control measures

4. Making Risk Control Decisions
Select Risk
Control
options
Make Decision at
appropriate level

5. The Risk Control Macro Option List
Reject
Avoid
Delay
Transfer
Spread
Compensate
Reduce

6. Macro Options REJECT AVOID DELAY TRANSFER
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”

7. Macro Options (cont) SPREAD COMPENSATE REDUCE
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

8. 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

9. 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

10. 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

11. Preliminary Hazard Analysis in system life cycle
System Concept
System Definition
System Development
PHA
System Production
System Operation

12. SSHA in the system life cycle
System Concept
System Definition
System Development
SSHA
System Production
System Operation

13. System Safety Organization

14. Determine 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

15. 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

16. THE “ENHANCED” RISK ASSESSMENT MATRIX
- Numeric Code is used to prioritize hazards and determine their acceptability using a quantitative methodology
Probability
Frequent
Likely
Occasional
Seldom
Unlikely A B C D E S E V R I T Y I 1 2 6 8 12 3 4 7 11 15 5 9 10 14 16 13 17 18 19 20
Catastrophic II
Critical
III
Moderate
Negligible IV
Risk Levels
6-7 7

17. Decision Making Guideline
RISK LEVEL
Extremely High
High
Medium
Low
DECISION LEVEL
Senior Executive
Managing Director
Program Manager
Any person in a leadership position

18. When you have finished your analysis and prepare to make your decision, ask yourself 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

19. When you have finished your analysis and prepare to make your decision, ask yourself the following questions:
“If I accept this risk do the total benefits outweigh the total costs…or…do the costs outweigh the total benefit?”

20. Cost of Mishap vs. Risk Management
Mishap Costs
Risk Reduction Effort

21. Cost of Hazard Mitigation
Mishap Costs
Cost of countermeasures
Risk Reduction Effort

22. “Balanced” Risk Management
Mishap Costs
Cost of countermeasures
Risk Reduction Effort

23. Implementing Risk Controls
1. Identify
the Hazards
2. Assess
the Risks
3. Analyze
Risk Control
Measures
4. Make
Control
Decisions
6. Supervise
and Review
5. Implement
Risk Controls

24. Reason Model Layers of Risk Control Detect and Eliminate Hazard
Occurrence
Hazard
Latent
Conditions
Unsafe
Acts
Defences can be Breached
Detect and Eliminate

25. Risk 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

26. System Safety Precedence A 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
High quality energy sources
Low MTBF hardware
Failures that do occur are not catastrophic
No single point critical items allowed
Physically isolate harmful environments or conditions
Passive barriers tend to be more effective than active ones
Airbag versus seatbelt example
Warning devices are not positive protection
Alert may be incremental, i.e., time to prevent damage versus time to escape disaster
Lowest level of control relies on training and SOPs
Quickest and cheapest to implement
Least effective
Most commonly used control

27. Hazard Reduction Precedence
Design to eliminate hazard
Design to reduce hazard no
Eliminated?
Provide Safety Devices
Reduced?
yes no
Provide Warning Devices
yes
Provided?
Provide hazard risk assessment package for management
Conclude hazard analysis no
Provide special procedures, or training
yes
Provided? no
yes
Provided?
Accept hazard or dispose of the System no
yes

28. Implementing Risk Controls
Clear
Implementation
Plan
Establish
Accountability
Provide
Support

29. Risk Controls MUST be an Integrated 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)

30. Why Integration? Bottom Line: Reduces $$$$ and work effort
Compels a “balance” of mission needs
Force Multiplies the knowledge of designers, experience of manufacturers and operators
Standardizes references (common language)
Reduces unforeseen needs
Eliminates redundancy
Strengthens accountability throughout the organizational chart
Bottom Line: Reduces $$$$ and work effort

31. Clarify 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

32. How 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”

33. “Buy-In Continuum USER OWNERSHIP STRONGEST CO-OWNERSHIP TEAM MEMBER
INPUT
COORDINATION
COMMENT AND FEEDBACK
BLIND ALLIGENCE WEAKEST

34. Top 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)

35. Leadership
Use the power of command and the influence of organizational leaders
Use motivation models
Create positive incentives
Insure vertical accountability throughout the organization

36. THE WELL SUPPORTED RISK CONTROL
A POLICY
PILLAR
A TRAINING
PACKAGE
A MEASUREMENT
PACKAGE
A MOTIVATIONAL
PACKAGE
COMMAND
SUPPORT
PACKAGE
TOOL KIT PACKAGE
JOB AIDS 10
9-10

37. SUPERVISE AND REVIEW 6. Supervise and Review 1. Identify the Hazards
2. Assess
the Risks
3. Analyze
Risk Control
Measures
4. Make
Control
Decisions
5. Implement
Risk Controls
6. Supervise
and Review
10-12 9

38. Supervise and Review
Supervise
Review
Feedback
3-49

39. Supervision Nothing new here…just like any supervisory process
Insure controls are effective and in place
Monitor progress through schedules
Correct ineffective control measures

40. 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

41. Use Quantitative Analysis (Rates 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

42. Support trends and analyses with scientific understandings of accident root causal factors
Critical behaviors & attitudes (Man)
Critical conditions (Medium)
Critical mechanics (Machine)
Critical oversight (Management)
Critical tasking (Mission)

43. Developing Meaningful Performance 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

44. 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

45. Factors 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)

46. Questions? 6. Supervise and Review 1. Identify the Hazards 2. Assess
the Risks
3. Analyze
Risk Control
Measures
4. Make
Control
Decisions
5. Implement
Risk Controls
6. Supervise
and Review
10-12 9