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

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

3. 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

4. Safety ≠ Zero Risk But why not?

5. Reason’s Model (“Swiss cheese”)

6. 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.

7. Dekker: Understanding Human Error
Tools
Tasks
Operating Environment

8. 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

9. Balancing Competing Priorities
Service
Safety

10. 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)

11. MK Airlines (October 2004)

12. 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)

13. 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

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

15. 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

16. “Requisite Imagination”

17. 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

18. 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

19. Fox Harbour

20. Aircraft Attitude at Threshold

21. Goal Conflicts

22. Weak Signals

23. 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

24. 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

25. 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

26. 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.

27. 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.

28. 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.

29. 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

30. 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

31. 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

32. 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

33. Questions?

34. 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