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“And now for something completely different”

“And now for something completely different”. Terry Kelly SSECC January 27, 2006. In the beginning – “the list”. acceptable level of risk ‘accountable executive’ confused use of definitions fuzzy thinking (as opposed to fuzzy logic) human factors non-punitive reporting

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“And now for something completely different”

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  1. “And now for something completely different” Terry Kelly SSECC January 27, 2006

  2. In the beginning – “the list” • acceptable level of risk • ‘accountable executive’ • confused use of definitions • fuzzy thinking (as opposed to fuzzy logic) • human factors • non-punitive reporting • performance-based approach • quality management “versus” safety management • regulating an SMS • safety culture • safety measurement • target levels of safety • tools to measure safety

  3. The Short List • Performance-based approach • Regulating an SMS • Safety measurement

  4. SMS Defined • “A systematic, explicit and comprehensive process for the management of safety-risks that integrates operations and technical systems with financial and human resource management …”. - TP13881 (2002)

  5. Defences REASON’S MODEL Accident UnsafeActs Preconditions Window of Opportunity Line Management Decision Makers Unsafe Acts and Latent Unsafe Conditions Latent Unsafe Conditions

  6. Accident Defences System Hazard SafeActs Preconditions Line Management Decision Makers Accident Defences UnsafeActs Preconditions Line Management Decision Makers Risk Management Hazards Breaches in the Defences

  7. Accident

  8. Performance-based • Variation in meaning & understanding • Prerequisites • Evolution from performance-based to process-based

  9. Regulating an SMS • Focus is on compliance • Need measures of compliance • Management systems that are process-driven become process-based

  10. Safety Measurement • Mired in our past best practices • Events —> lagging, descriptive • Misapplication of quality and risk assessment processes • Require explicit and appropriate measures of safety performance

  11. Summary: Current Programs • They do not account for current understanding of accident causation • They are not adequate for current prevention initiatives (e.g. SMS) • A known problem (by some): but not being addressed (seriously) by most • Measurement attention is on technical fixes (new and more software, new and more databases), not on essential determination of what needs to be measured

  12. “We have met the enemy … … and they are us”! - Pogo

  13. Conclusion

  14. Last Concluding Thought “If we are to retain any command … over our own future, the ablest people we have in every field … have to come out of the trenches of their own specialty and look at the whole battlefield”. - John Gardner

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