Title Slide

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Tri-Service Safety Conference Sonthofen,
Germany 20 March 2007 Don Wright USAREUR
Safety Office DSN 314-370-6535
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Purpose Introduce the concept of Safety
Management Systems (SMS) as an industry Best
Practice and consider its application for use at
the organizational or higher level.
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• Agenda
• Intro to SMS
• Background
• Whats Different?
• A Short Course in Accident Causation
• Reasons Influence Human Factors
• SMS Principles, Components, Structure
• So What?
• Where Can I Find More Info?

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• SMS What is it?
• Businesslike Approach to Safety Management
• Best Practices
• Systems Approach to Safety
• Organized, Proactive, Allows Safety Mgmt
• Focus is on Organizational Aspect of Human
  Factors

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• SMS Defined
• Safety safety is a term used to mean the
  condition to which risks are managed to
  acceptable levels
• Management to distill it to its purest form,
  management can be defined as the allocation of
  resources to achieve specific goals
• System which means an organized set of
  programs, processes, and procedures used to
  deliver goods or services

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SMS Defined Turning this upside down, we could
say that a safety management system is an
organized set of programs, principles, processes,
and procedures for the allocation of resources to
achieve the condition where risks are managed to
acceptable levels.
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• SMS Where From?
• Professor James Reason Organizational
  Accident
• Transport Canada 2005 Decision
• International Civil Aviation Organization
  2006
• Federal Aviation Administration - 2007

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• So Whats Different?
• Common Safety Programs
• Systematic Approach vs Crisis of the Day
• Program Structure Organized
• Change in Management Concept
• Shift in Focus from the Individual to
  Organization

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What Causes Accidents?
This can only happen with the human element
involved. The question is Why?
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A Short History of Accident Causation
Accident Causation

• Early Safety Philosophy
• Carelessness and Stupidity (Negligence)
• Changes in Industry Over Past 120 Years
• Complex Machinery
• Electricity
• Shift Work Time Management
• Assembly Lines

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Heinrichs Accident Causation Model
Domino Theory
(1931)
Social Environment And Ancestry
Fault of the Person (Carelessness)
Unsafe Act Or Condition
Accident
Injury
Mistakes of People
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Armys Accident Causation Model
System Defects
Command or Management Error
System Defect
Operating Error
Mishap
Results
Safety Program Defect
Safety Manager Error
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Typical Investigation Findings
Where do we usually look to prevent accidents?
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Actionable Investigation Findings
Where should we look to prevent accidents?
gt 80 Identified as Human Error
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• Human Factors Principles
• Principle 1 Human errors are inevitable within
  an organization
• Principle 2 Blaming an error on an individual
  is like blaming a mechanical failure on the
  equipment
• Principle 3 An accident, no matter how minor,
  is a failure of the system
• Principle 4 Accident investigation and error
  prevention go hand-in-hand

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Human Factors
Reasons Model

• Productive Activities
• Integration of man and machine
• Preconditions
• Motivated workers reliable equipment
• Line Management
• Operations, Maintenance, Training
• Decision Makers
• Resources, Climate, Operations

(Reasons Model, 1990)
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Components Of A Productive System
Operating Environment
Inputs (Social, Economical, Political)
Decision Makers Plant and Corporate
Management
Feedback Loops
Line Management Operations Maintenance Tr
aining
Preconditions Reliable equipment motivated
workers
Productive Activities Integration of Man and
machine
Product Safe Operations
(Reasons Model, 1990)
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Breakdown of a Productive System
Operating Environment
Latent Conditions
Inputs

• Excessive Cost Cutting
• Inadequate Support Policies and Supervision

• Too Few People
• Budget Constraints

• Ft. Anywhere
• Night

Latent Conditions

• Deficient Training Program and Execution
• Improper Personnel Assignments

Active and Latent Conditions

• Poor Crew Coordination/ Duty Cycle
• Loss of Situational Awareness

Active Conditions

• Failed to Stay Alert
• Exceeded Limitations

Failed or Absent Defenses
Accident

• Destroyed equipment

Adapted from Reason (1990)
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The essential is invisible to the eyes
Unsafe Acts
Preconditions
Unsafe Supervision
Organizational Factors
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ORGANIZATIONAL INFLUENCES
Wiegmann-Shappell
Organizational Climate
Resource Management
Organizational Process
UNSAFE SUPERVISION
Inadequate Supervision
Planned Inappropriate Operations
Failure to Correct Problem
Supervisory Violations
PRECONDITIONS FOR UNSAFE ACTS
PRECONDITIONS FOR UNSAFE ACTS
Personnel Factors
Environmental Factors
Substandard Conditions of Operators
Substandard Conditions of Operators
Personal Readiness
Crew Resource Mismanagement
Technological Environment
Physical Environment
Adverse Physiological States
Physical/ Mental Limitations
Adverse Mental States
Adverse Mental States
Human Factors Analysis and Classification System
- HFACS
UNSAFE ACTS
Errors
Errors
Violations
Perceptual Errors
Skill-Based Errors
Decision Errors
Routine
Exceptional
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Practical Application
Vicinity Ad Dawr, Iraq
Mission Execute a four-vehicle combat patrol to
escort a fuel convoy from FOB Tinderbox to LSA
Anaconda.
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Practical Application
DIRECTION OF TRAVEL
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Practical Application
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Practical Application
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Practical Application
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Practical Application
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M1114 Rollover Accident
Operating Environment
Latent Conditions
Inputs

• Lack of Enforcement Seatbelts, Load Plan, etc.
• Lack of Risk Management / Rollover Drills

• Experience base in tracked vehicles
• Decentralized operations

• NVG w/ limited illumination
• Unfamiliar route

Latent Conditions

• Deficient Drivers Training Program
• Improper Crew Pairing / Duty Assignments

Active and Latent Conditions

• Fatigue / Maintenance
• Loss of Situational Awareness

Active Conditions

• Unlicensed Driver
• Unserviceable NVGs
• Unapproved Procedures

Failed or Absent Defenses
Accident

• 1 Fatal / 2 Injured
• Damaged Equipment

Adapted from Reason (1990)
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M1114 Rollover Accident
Operating Environment
Latent Conditions
Inputs

• Enforcement of Procedures
• Risk Management / Rollover Drills

• Experience base in tracked vehicles
• Decentralized operations

• NVG w/ limited illumination
• Unfamiliar route

Latent Conditions

• Effective Drivers Training Program
• Proper Crew Pairing / Duty Assignments

Active and Latent Conditions

• Well Rested / Proper Maintenance
• Maintain Situational Awareness

Active Conditions

• Licensed Driver
• Serviceable Equipment
• Execute to Standard

Defenses in Place
Successful Operations
Adapted from Reason (1990)
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A Soldiers Failure is a Culmination of Failures
Throughout an Organization
Organizational Influences

• Drivers Training Program Failure

Unsafe Supervisory Practices

• Failed to Correct a Known Problem
• Inadequate Officer/NCO Supervision
• Inadequate Maintenance Supervision

Human factors at every level of the Department of
the Army can influence mission outcomes for the
individual Soldier. When failures occur at the
different levels they open windows of opportunity
for the Soldier to fail.
Preconditions for Unsafe Acts

• Fatigue
• Inexperience
• Support Failure

Unsafe Soldier Actions

• Failure to Follow Procedures
• Speeding Violation
• Driving Blind
• Driving Skill Error

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• SMS Principles, Concepts, Structure
• Reason Person vs System
• Person Approach
• Focus on individual error / violation
• Blame inattention, poor motivation,
  carelessness, negligence, and recklessness
• Countermeasure directed against individual
  campaigns, threats, discipline (naming,
  blaming, shaming)

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• Human Error
• Old View
• Human error is the cause of trouble
• To explain failure, you must seek failure
• You must find peoples inaccurate assessments,
  wrong decisions, and bad judgments

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The Blame Game
Human Error
Blame Person
Errors Repeated More blameworthy
Sanctions
Not effective
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• SMS Principles, Concepts, Structure
• Reason Person vs System
• System Approach
• Human error is inevitable
• Errors are consequences rather than causes
  
• Countermeasure directed against
  organizational defenses that allowed the error
  to happen

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• Human Error
• New View
• Human error is a symptom of trouble deeper inside
  the system
• To explain failure, do not try to find where
  people went wrong
• Instead, find out how peoples assessments and
  actions made sense at the time given the
  circumstances that surrounded them

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• SMS Principles, Concepts, Structure
• Essential Transformations
• Safety as a Core Business Practice
• Accountable Executive
• Organizational Approach to Accident
  Prevention

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The management dilemma
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• SMS Principles, Concepts, Structure
• Safety as a Core Business Practice
• Safety efficiency positively linked
• Manage safety as any other core program
• Compare maintenance vs safety

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• SMS Principles, Concepts, Structure
• Maintenance
• Trained / qualified maintenance manager
• Function is planned, budgeted, resourced
• Standards established, trained, enforced
• Procedures documented, records kept
• Routine inspections for QA
• Emergency procedures in place
• Everyone supports the program command
  emphasis

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• SMS Principles, Concepts, Structure
• Safety
• Trained / qualified safety manager?
• Function is planned, budgeted, resourced?
• Standards established, trained, enforced?
• Procedures documented, records kept?
• Routine inspections for QA?
• Emergency procedures in place?
• Everyone supports the program command
  emphasis?

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• SMS Principles, Concepts, Structure
• Safety as Core Business Practice
• Make organization decisions based on
  technical input
• No budget, no investment not serious
• Hold managers accountable for standards,
  training, enforcement
• Set goals, plan, and measure performance
• Get buy-in by supporting the program
  command emphasis

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• SMS Principles, Concepts, Structure
• Accountable Executive
• Safety manager relies on persuasion
• SMS holds managers accountable
• Authority and accountability co-exist
• Military already identifies Accountable
  Executive

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• SMS Principles, Concepts, Structure
• Organizational Approach to Prevention
• (4 Ps of Safety Management)
• Philosophy Set standards at highest level
• Policy Responsibility, authority,
  accountability
• Procedures Clear directions
• Practices What really happens on the job

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• SMS Principles, Concepts, Structure
• Organizational Approach to Prevention
• Accidents are organizational issues
• Safety culture is promoted informed,
  just, reporting, learning
• Anticipates problems before accidents occur

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• SMS Putting it All Together
• Features of an SMS
• Senior Management Commitment
• Safety Policy
• Safety Information
• Establishing Safety as a Core Value
• Setting Safety Goals
• Hazard Identification and Risk Management

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• SMS Putting it All Together
• Features of an SMS
• Establishing a Safety Reporting System
• Safety Audit / Assessment
• Accident/Incident Reporting/Investigation
• Safety Orientation Recurrent Training
• Emergency Response Plan
• Documentation

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• SMS Putting it All Together

Organizational Measures - Indications of a
Positive Safety Culture

• Senior management places strong emphasis on
  safety
• Decision-makers / operational personnel hold
  realistic view of short / long term hazards
• Those in senior positions
• Foster a climate for criticism, comments, and
  feedback from lower levels
• Do not force views on subordinates
• Take action on identified hazards

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• SMS Putting it All Together

Organizational Measures - Indications of a
Positive Safety Culture

• Senior management promotes a non-punitive
  working environment (not blanket immunity)
• Recognition of importance to communicate safety
  info at all levels (internal / external)
• Realistic rules relating to hazards / safety
• Personnel are trained / understand importance
  of safety
• Safety ethic that discourages unsafe behavior

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Organizational Measures - Indications of a
Positive Safety Culture
Source System Safety Manual (ICAO) 2006
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• 1. Safety Management Plan
• Safety Policy
• Non-punitive Safety Reporting Policy
• Roles, Responsibilities Employee Involvement
• Communication
• Safety Planning, Objectives Goals
• Performance Measurement
• Management Review

Transport CanadasSMS Components Elements

• 2. Document Management
• Identification Maintenance of Applicable
  Regulations
• SMS Documentation
• Records Management

• 3. Safety Oversight
• Reactive Processes
• Proactive Processes
• Investigation and Analysis
• Risk Management

4. Training
5. Quality Assurance
6. Emergency Preparedness
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So What?

• Does any of this make sense?
• Does it have an application in DoD?
• Would these principles improve safety in your
  organization?

Let me know your thoughts! don.wright_at_us.army.mil
DSN 314-370-6535 Com 49-6221-57-6535
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Where can I find more information?

• www.tc.gc.ca/CivilAviation/SMS/Menu.htm
• http//www.paris.icao.int/
• CD Material

QUESTIONS?