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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
Accidentsperyear
Millionsofdepartures
Wicken’s Information Processing
Receptors
and
Sensory
Memory
Stores
Attentional
Mechanism
Perception
Working
Memory
Response
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
Activity
Mode 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
issues
Knowledge-based
mistakes
Novel problem
solving
Resource limited
conscious
processes
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 Tasks
Problem 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
Owners
Ok 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
World-Class
SafetyManagementPerformance
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

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Human Factors in a Safety Management System - Breaking the Chain

  • 1. Speaker : Werner Schierschmidt Title : Human Factors in a Safety Management System – Breaking the Chain
  • 2.  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
  • 3.
  • 4.  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
  • 5.
  • 6. 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 Accidentsperyear Millionsofdepartures
  • 8. Stages of Skill Acquisition Cognitive Stage Associative Stage Autonomous Stage Knowledge Based Rule Based Skill Based Practice Time ||
  • 9. Rasmussen’s Generic Error Modelling Framework Activity Mode 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 issues Knowledge-based mistakes Novel problem solving Resource limited conscious processes Variable
  • 11. 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
  • 12.  Routine Violations  Situational Violations  Optimising Violations (for “kicks or a laugh”, i.e. personal gain) Types of Violations
  • 13. Interventions Errors Mistakes Violations Highly Routine Tasks Problem solving / Misapplying Rules Intentional Rule Breaking • Job Awareness • Job Rotation • Job Knowledge • Improve Data Remove the need to Violate
  • 14.  Organizational Factors  Situational Factors  People Factors Performance Shaping Factors
  • 15. 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
  • 16. Hazard Management Hazard Owners Ok to Go  Control Owners EventHazard ReportsDatabase SAG SRB
  • 18. Incidents / Accidents 600 Unsafe Acts 1 Fatal Accident 10 Non-fatal Accidents 30 Reportable Incidences In Aviation:  Human Factors contributes to 80 - 85%
  • 19.  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?
  • 20.  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”)
  • 21.  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
  • 22.  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.)
  • 23.  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.)
  • 24. 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
  • 26. 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 World-Class SafetyManagementPerformance Point A Point B
  • 27. Humans are the strongest Link Humans want to stick to their Habits and Norms, they do not like to break links in chains
  • 28. Breaking the Chain A successful Human Factors and SMS programme is all about breaking links in future accident chains
  • 29. Thank you for your attention ! Safety is a Journey Enjoy the Ride