safety management systems industrial railway safety conference faye ackermans member, transportation...

26
Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta 29 April 2015

Upload: louisa-willa-blake

Post on 29-Dec-2015

216 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

Safety management systemsIndustrial Railway Safety ConferenceFaye AckermansMember, Transportation Safety Board of CanadaFort Saskatchewan, Alberta 29 April 2015

Page 2: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

2

• A history of Safety Management Systems (SMS)

• Three approaches to safety management• SMS requirements for Canadian railways • How it applies to you?• Where does safety culture fit?

Outline

Page 3: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

3

• 1974 Flixborough, Explosion at petrochemical facilityU.K. First

requirement for a “Safety Case”

• 1976 Seveso, Release of 6 tons of chemicalsItaly European safety

regulations

• 1988 Piper Alpha, Explosion and fire aboard oil and gas rigNorth Sea, U.K. Cullen Enquiry

recommends “formalassessments of

major hazards to beidentified and

mitigated” (i.e., a “safety case”)

A history of SMS

Page 4: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

4

Fatality

Major Injury

Minor Injury

Medical

Close Call

Three approaches to safety management

Page 5: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

5

Process safetyReliability engineeringErgonomic and cognitive engineeringAssessing and managing riskHuman reliability

Hazard analysisRisk assessmentsTechnical safety auditsHuman reliability assessmentsCognitive task analysis

Ergonomic guidelines

What it is

Outcomes

Three approaches to safety management (cont’d)The Technical/Engineering Model

Page 6: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

6

What it is

Success defined by

Three approaches to safety management (cont’d)The Organization Model

• Having pro-active (or leading) indicators of the health of the system

• Safety decision-making embedded throughout the organization

• Organization performance - find opportunity for actions to prevent accidents (“find trouble before trouble finds you”)

• Human error viewed as consequence not cause

• Errors are symptoms of latent conditions in the system

• Latent conditions the result of:o Management

decisionso Designo Changes

introduced after earlier accidents

Page 7: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

7

HumanUnsafe Acts

Mistakes

Human Performance

Error Management

Technical/Engineering

MechanicalTechnicalDesign

Man-MachineInterface

Organizational

SMSOrganization

alCulture

Summary: Three approaches to safety management

Page 8: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

8

Safety, leadership, and culture

Source: Leading with Safety. Tom Krause, Behavioral Sciences Technologies

Leadership

Organizational Culture

Safety Enabling Systems

Hazard Recognitionand Mitigation

Skills. Knowledge and Training

Policies and StandardsExposure reduction

Organizational Sustaining Systems

Selection and Development

StructurePerformance Management

Rewards and Recognition

ProcessWorker

Facilities & Equipment

Working Interface

Page 9: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

9

Simple definition

:

The way we do things around here

Culture change

Takes Time

Can be difficult to measure

Key notions:

Behavioural

statement

Leaders must find ways to change

behaviours

Behaviour changes lead to

changes in beliefs which changes the

culture

What is culture?

Page 10: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

10

• Manage occurrences• Report contraventions and hazards• Manage knowledge• Scientifically based schedules for

operating employees

Majors

• Accountability• Establish targets and develop

initiatives• Continuous improvement

Majors andLocal Class I

• Safety policy• Compliance with regulations• Identify safety concerns• Implement / evaluate remedial action• Risk assessments

All railroads(Majors, Local Class I

and II)

SMS requirements for Canadian railways

Page 11: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

11

SMS elements of regulations are all “enabling”

Therefore, they are essential but not sufficient

Paradox: Perception of an overly bureaucratic process versus the

need to make these “living” documents

Risk: A system on paper that does not exist on the shop floor

SMS requirements for Canadian railways – conclusions

Page 12: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

12

• Safety policy• Compliance with regulations• Identify safety concerns• Implement / evaluate remedial

action• Risk assessments

All railroad

s(Majors,

Local Class I and II)

SMS requirements for Canadian railways

Page 13: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

13

• A leadership statement provides an overarching VISION to all employees

• What should it look like?• Use behavioural terms• Keep it short

• What should you do with it?• Communicate, communicate, communicate• “Live” it

• When should you change it?• Not often, but not never

Safety policy

Page 14: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

14

Having a statement and communicating it are not enough:• You must believe in it;• Your actions must match your words;• Your decisions must be consistent with your

statement; and• You must be seen to be credible.

But you must also be aware that …

Page 15: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

15

• Do you have a process for reporting what happened?

• What about a process for reporting what almost happened?

• How do you tap into the knowledge of the “guy” with the boots on the ground?

• How often do you “walk about”?• When you do, are you looking for conditions or

behaviours?• How do you correct the behaviours you see?

Identifying safety concerns

Page 16: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

16

• Do you know how to assess risk?• What triggers a risk assessment?• What should trigger it?• What tools do you use?• Do you document the assessments?• Who do you get involved in the risk assessments?• How do you judge the quality of your process?

o The quality of the product?

Risk assessments

Page 17: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

17

Implementation• How do you decide what the possible actions

are?• How do you decide which actions to take?• What can you do short term?• What needs to be done long term and what

barriers need to be overcome?• Do you have physical defences? Administrative

defences?Evaluation• How do you know if your actions are working?

Implementing and evaluating remedial actions

Page 18: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

18

• Is what I say consistent with what I do?• How quickly do I react to concerns raised?• Has something changed today compared to

yesterday?• What can I do to reduce risk in my operation?• By making a change here, have I created more

risk somewhere else?• How do I know the changes have been truly

implemented?

Ask these questions:

Page 19: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

19

“[An SMS] is a formal framework that helps railway

companies integrate safety into their day-to-day operations.

It encourages the development of a safety culture

throughout all levels of an organization and ensures that

safety is considered a factor in all decision-making.”

Louis Lévesque, Deputy Minister of Transport24 November 2014: Report of the Standing Committee on Public Accounts

SMS: Transport Canada’s vision

Page 20: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

20

• Comply with existing regulations• Examine:

• Operations• Decisions around those operations

• Continuous improvement• Predict hazards using data collection and employee reports• Analyze, assess, control risk

• Monitor controls• Monitor system itself for effectiveness

• Move from reactive to predictive thinking• Change safety culture of leadership, management, and

employees

Wrap-up: SMS for any organization

Page 21: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

21

Reactive

• Respond to accidents

• Write another procedure

Proactive

• Seek hazardous conditions

• Change something to mitigate the risk

Predictive

• Analyze processes to identify potential problems

• Change process and monitor effect of changes

From past to present to future

Page 22: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

22

• Possession of an SMS is NECESSARY but NOT SUFFICIENT ON ITS OWN to ensure sustained safety improvement.

• You still need an organizational culture that supports the system.

• Culture change is led from the top. • Every level of organization must promote and

practice risk reduction.

Reminder: Going beyond regulations

Page 23: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

23

“No amount of regulations for safety management can make up for deficiencies in the way in which safety is actually managed. The quality of safety management … depends critically, in my view, on effective safety leadership at all levels and the commitment of the

whole work place to give priority to safety.”

Lord Cullen

2013 Conference 25th Anniversary Piper Alpha

Notable Quotes – 1

Page 24: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

24

“While the precise circumstances and context of major incidents differ in some respects, at heart I am left with the feeling that there are no new accidents. Rather, there are old accidents repeated by new people.”

Judith Hackitt CBE, Chair of UK HSE

2013 Conference 25th Anniversary Piper Alpha

Notable Quotes – 2

Page 25: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

25

Questions?

Page 26: Safety management systems Industrial Railway Safety Conference Faye Ackermans Member, Transportation Safety Board of Canada Fort Saskatchewan, Alberta

26