Kathy Fox, Board Member System Safety Society – Canada Chapter’s Springtime Symposium June 2010

1. Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making Kathy Fox, Board Member System Safety Society – Canada Chapter’s Springtime SymposiumJune 2010

2. Outline • Early thoughts about safety • TSB Investigation Reports • Lessons to be learned • Safety Management Systems • What works • What does not work

3. Early Thoughts on Safety Follow standard operating procedures Pay attention to what you’re doing Don’t make mistakes or break rules No equipment failure Things are safe

4. Safety ≠Zero Risk

5. Balancing Competing Priorities Service Safety

6. Sidney DekkerUnderstanding Human Error

7. 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

8. 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)

9. Drifting into Failure(aka: Why do “safe systems” fail? ) Image by Worth100

10. Organizational Drift • MK Air – Flight duty times

11. Organizational Drift (cont’d)

12. Organizational Drift (cont’d) • Source: Dekker (2002: 18, 26)

13. Safety Management System (SMS) “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)

14. Evolution of SMS Derives from research of: • High reliability organizations • Strong safety culture • Organizational resilience

15. Why Change? • Traditional approach to safety management based on: • Compliance with regulations • Reactive response following accidents • Philosophy of “blame and re-train” • This has proven insufficient to reduce accident rate

16. TSB Mandate To advance transportation safety in the air, marine, rail and pipeline modes of transportation that are under federal jurisdiction by: conducting independent investigations identifying safety deficiencies making recommendations to address safety deficiencies reporting publicly on investigations It is not the function of the TSB to assign fault or determine civil or criminal liability. 16

17. TSB Reports • Observations: • Employee adaptations • Inadequate risk analysis • Goal conflicts • Failure to heed “weak signals”

18. Employee Adaptations • Front line operators create “locally efficient practices” • Why? To get the job done. • Past successes taken as guarantee of future safety.

19. Employee Adaptations

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. TSB Reports Observations: • personnel, workload, supervision • training, qualifications • physical or mental fatigue • ineffective sharing of information • gaps created by organizational transitions affecting roles, responsibilities, workload and procedures

26. 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

27. 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

28. Lessons Learned • Goal conflicts, local adaptations, and drift occur naturally. SMS can help identify these. • Organizations can learn from patterns of accident precursors.

29. Benefits and Pitfalls • There is no panacea • But SMS can provide: + Mindful infrastructure to identify hazards, mitigate risks + More reports of “near misses” + Help identify safe practices

30. Conclusion • Effective SMS depends on “culture” and “process” • Successful implementation takes unrelenting commitment, time, resources, and perseverance • There are business benefits and safety benefits • Ongoing requirement for strong regulatory oversight

31. 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

32. Questions?

33. References • Slide # 5: Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd. • Slide # 6: Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd. • Slide # 8: Dekker, S. (2005) Ten Questions About Human Failure • Slide #12: Dekker, S. (2002) The Field Guide to Human Error Investigations. Ashgate Publishing Ltd.,18, 26 • Slide #13: Reason, J. (2001) In Search of Resilience, Flight Safety Australia, September-October, 25-28 • Slide # 15: Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd., p.21 • Slide #23: Bosk, C. (2003)Forgive and Remember: Managing Medical Failure, University of Chicago Press • Slide # 24: Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting : Patient Safety and Quality Healthcare September/October 2007