And now for something completely different

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And now for something completely different

• Terry Kelly
• SSECC
• January 27, 2006

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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

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The Short List

• Performance-based approach
• Regulating an SMS
• Safety measurement

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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)

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Accident
Defences
Unsafe Acts
Preconditions
Line Management
Decision Makers
Risk Management Hazards
Breaches in the Defences
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Accident
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Performance-based

• Variation in meaning understanding
• Prerequisites
• Evolution from performance-based to process-based

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Regulating an SMS

• Focus is on compliance
• Need measures of compliance
• Management systems that are process-driven become
  process-based

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Safety Measurement

• Mired in our past best practices
• Events gt lagging, descriptive
• Misapplication of quality and risk assessment
  processes
• Require explicit and appropriate measures of
  safety performance

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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

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We have met the enemy

• and they are us!
• - Pogo

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Conclusion
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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