Speaker : Werner Schierschmidt

Title : Human Factors in a Safety Management System –

Breaking the Chain

High risk products

High cost products

Safety is a must

Quality is not negotiable

Failure is not an option

Tightly controlled requirements

SMS in Aerospace and Defence

SAA Boeing 707 (Namibia) 1968

Tenerife Disaster (KLM 747 – PanAm 747) 1977

JAL Boeing 747 1980

Aloha Airlines Boeing 737 1988

British Airways Flight 5390 1990

Examples of Accidents

Why are there still Accidents?

60

40

20

30

20

10

1960 1970 1980 1990 2000 2010

Traffic Growth

Accidents per year

Traffic Growth

Accidents per year

Accid

en

ts p

er y

ear

Mil

lio

ns o

f d

ep

art

ure

s

Wicken’s Information Processing

Receptors

and

Sensory

Memory

Stores

Attentional

MechanismPerception

Working

MemoryResponse

Long-term

Memory

Motor

Programmes

Ignore it

Respond to it

Consider it

Remember it

Activate other processing

Stages of Skill Acquisition

Cognitive

Stage

Associative

Stage

Autonomous

Stage

Knowledge

Based

Rule

Based

Skill

Based

Practice Time

||

Rasmussen’s Generic Error Modelling Framework

ActivityMode of Control

Focus of Attention

Error Forms

Skill-based slips & lapses

Routine actions Mainly automatic processes

(Rules)

On something other than the

task at hand

Largely predictable

“strong-but-wrong” error forms

(Rules)

Rule-based mistakes

“Trained for” problem solving

Directed at problem related

issuesKnowledge-based mistakes

Novel problem solving

Resource limited consciousprocesses

Variable

Competence

Skills Knowledge

Attitude

Error Mistake

Violation

Competence

Error Modelling Flowchart

Unsafe

Acts

Unintended

Action

Intended

Action

Slips

Lapses

Mistakes

Violations

Attentional Failures

Memory Failures

Rule/Knowledge

based mistakes

Intentional deviation

from procedures/rules

Routine Violations

Situational Violations

Optimising Violations (for “kicks or a laugh”, i.e. personal gain)

Types of Violations

Interventions

Errors Mistakes

Violations

Highly Routine TasksProblem solving /

Misapplying Rules

Intentional Rule Breaking

• Job Awareness• Job Rotation

• Job Knowledge• Improve Data

Remove the need to Violate

Organizational Factors

Situational Factors

People Factors

Performance Shaping Factors

Dirty Dozen

• Lack of Communication • Lack of Resources

• Complacency • Pressure

• Lack of Knowledge • Lack of Assertiveness

• Distractions • Stress

• Lack of Teamwork • Lack of Awareness

• Fatigue • Norms

Hazard Management

Hazard

OwnersOk to Go

Control

Owners

EventHazard

ReportsDatabase

SAG

SRB

James Reason Model

Incidents / Accidents

600 Unsafe

Acts

1 Fatal Accident

10 Non-fatal Accidents

30 Reportable Incidences

In Aviation:

Human Factors

contributes to

80 - 85%

Blame

Loosing face

Do not think the event is significant, i.e.: near miss – no outcome

Always been like this in the past – status quo

Too hard to get things changed – learned helplessness

Why do we not report?

Beliefs:

Professionals will make mistakes

Professionals will develop unhealthy norms

Expectation that system safety will improve

Duties:

To raise your hand and say: “I made a mistake”

To resist the growth of “at-risk” behaviour

To absolutely avoid reckless conduct

Just Culture (not a “Blame-Free Culture”)

Reactive Safety Management

Investigation of accidents and incidents

Based upon the notion of waiting until something breaks to fix it

Most appropriate for:

o Situations involving failures in technology

o Unusual events

Types of Safety Management Systems

Proactive Safety Management

Mandatory and voluntary reporting systems, safety audits and surveys

Based upon the notion that system failures can be minimised by:

o Identifying safety risks within the system before it fails

o Taking the necessary actions to reduce such safety risks

Types of Safety Management Systems (cont.)

Predictive Safety Management

Confidential reporting, data analysis, normal operations monitoring

Based upon the notion that Safety Management is best accomplished by

looking for trouble

Aggressively seek information from a variety of resources

Types of Safety Management Systems (cont.)

Basic Error Management System

CF

CF CF

CF

E

R

R

O

R

EVENT

REPORT

INVESTIGATION

INTERVENTION

FEEDBACK

D

A

T

A

B

A

S

E

REVIEW

BOARD

JUST

CULTURE

Re-active

Pro-active

Predictive

Roadmap

Pathological

(un-controllable)

Reactive

Calculative

Pro-active

Generative

Navigating SMS through a Safety Culture

Just Culture

Reporting Culture

Informed Culture

Learning Culture

1. Understanding / Initiating

2. Planning / Enabling

3. Engaging / Implementing

4. Managing & Measuring

5. Benefits Realisation

6. Continual

Improvement

Wo

rld

-Cla

ss

Safe

ty M

an

ag

em

en

t P

erf

orm

an

ce

Point A

Point B

Humans are the strongest Link

Humans want to stick to their

Habits and Norms, they do not

like to break links in chains

Breaking the Chain

A successful Human Factors and SMS

programme is all about breaking links

in future accident chains

Thank you for your attention !

Safety is a Journey

Enjoy the Ride