adding value by focussing on defences · 2017-04-26 · q: are you familiar with the swiss cheese...
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AddingvaluebyfocussingondefencesRobMiles C.Eng.CIEHF
IndependentMemberCIRASTechnicalDirectorHu-TechRiskManagementServicesltd
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Q:AreyoufamiliarwiththeSwissCheesemodel?A:YesQ:ExplainittomeinyourworkA:?
Bankruptcy
CatastropheIncreased
investment in
protection
Better defences converted to
increased production
Protection
Production
Trade - offs & the “Un-rocked boat”
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Accidents Near-misses Defencecondition
SentimentOpinion
SafetyclimatesurveysCustomersurveysStafffocusgroupsStaffblogs?
AuditsInspectionsKPIs fordefencesHumanFactorsmetricsSystemnear-misses?
ReportablenearmissesWitnessedeventsFrontlinefailuresDangeroussituationsMinor injury?
DerailmentsCollisionsFatalitiesSerious Injury
Timeavailable
Verifiability
Utility
SPADs
Lagging Leading
Lagging Leading
Lagging Leading
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4
Accidents Near-misses Defencecondition
SentimentOpinion
SafetyclimatesurveysCustomersurveysStafffocusgroupsStaffblogs?
AuditsInspectionsKPIs fordefencesHumanFactorsmetricsSystemnear-misses?
ReportablenearmissesWitnessedeventsFrontlinefailuresDangeroussituationsMinor injury?
DerailmentsCollisionsFatalitiesSerious Injury
Timeavailable
Verifiability
Utility
SPADs
Lagging Leading
Lagging Leading
Lagging Leading
PeakUtility
AllCIRAS reportsareverified
Qualitynot Quantity
CIRAS Reports
PeakUtility
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Concurrenttrainops
Deathorinjury
Collison
Chance?Trainontrack
Possession
Planning Sentinel Super-vision Lookout Escape Emergency
procedure
Days Hours Seconds Minutes
Lookout EscapeEmergencyprocedure
InformationaboutthisLeftSideisoften intheHQ InformationaboutthisRightSideisoftenatthesite
UNSAFEEVENTSUNSAFECONDITIONS
Timepressure
Staffallocation
SMISCIRAS CLOSECALL
Threat:
Workforce isalwaysa+ve (sometimesimperfect)partofadefence,never athreat
Synergy
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Weneedtomakeastepchangeinhowreportsaretaken,analysedandresolved.
Ourproposalistomovetoa‘defences-based’model
DialoguebetweenthereporterandtheCIRASresearcherisabout:
• protections(processes,procedures,systems,equipment)
Whatfailedandwhatworked?
Reliability
Safety Management System
Adaptability
Threats
Engineered defences
Procedural defences
Human defences
CIRAS reports
Incidents
Effective defence
Movingtoa‘Defences-based’model
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Movingtoa‘Defences-based’model
Effective defence
Ineffective control
Trajectory of CIRAS event
Ineffective defence
• CIRASwoulddiscussthereporter’sconcernsacrossagenericbow-tiefortheactivity.
• Thebow-tiewouldbeconfirmedordevelopedwiththereporterandconfirmedwiththeoperator.
• Thepathwayoftheeventwouldbemappedontothediagram,alongwithweakandstrongdefencesidentifiedbytheevent
Thegoal:everyoneinvolved inanoperationwillhavethesameunderstanding ofthehazardsanddefencesandbeequallyempowered toraiseconcerns.
Movingtoa‘Defences-based’model