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This presentation by Terry Kelly at SSECC on January 27, 2006, explores the intricacies of safety management systems (SMS). It discusses the acceptable level of risk, the role of an accountable executive, and the importance of non-punitive reporting and performance-based approaches. Key insights are provided into safety culture, measurement tools, and the evolution from performance-based to process-based approaches. The presentation highlights the need for comprehensive safety performance measures that reflect current understandings of accident causation and emphasizes the importance of collaboration across specialties for effective safety management.
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“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 • performance-based approach • quality management “versus” safety management • regulating an SMS • safety culture • safety measurement • target levels of safety • tools to measure safety
The Short List • Performance-based approach • Regulating an SMS • Safety measurement
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)
Defences REASON’S MODEL Accident UnsafeActs Preconditions Window of Opportunity Line Management Decision Makers Unsafe Acts and Latent Unsafe Conditions Latent Unsafe Conditions
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
Performance-based • Variation in meaning & understanding • Prerequisites • Evolution from performance-based to process-based
Regulating an SMS • Focus is on compliance • Need measures of compliance • Management systems that are process-driven become process-based
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
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
“We have met the enemy … … and they are us”! - Pogo
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