Introductie safety management
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This document provides an introduction to safety management. It discusses the need for a Safety Management System (SMS) and SMS manual to help manage safety. It outlines key topics in safety evolution like organizational, human, and technical factors. Human error is defined and explained using models like the Swiss cheese model. The strategic approach of reducing and managing errors to achieve zero errors is presented. Maintaining a just culture and positive safety culture is important for reporting errors and continuously improving safety.
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Introductie safety management
- 1. INTRODUCTION IN SAFETY MANAGEMENT Training by D. Snoeken CMM/ Safety Manager Flight School Seppe 15-12-2014
- 2. SUBJECTS - Objective SMS - SMS Manual - Safety Evolution in Aviation - Threats to Safety and Quality - Human Error Defined - Human Error - Human Factors - Human Error Model - Error Mechanism Categories - Strategic Approach - Safety/ Risk Management - Safety Policy/ Just Culture
- 3. OBJECTIVE The objective is to explain the need for a Safety Management System
- 4. WHY A SAFETY MANAGEMENT MANUAL? To Manage Safety! Why do we have to Manage Safety?
- 5. SAFETY EVOLUTION IN AVIATION TODAY Organizational Factors Human Factors Technical Factors 1950s 1970s 1990s 2000s
- 6. Threats to Safety en Quality “ We have met the enemy……and he is us!” Errors happen!
- 7. HUMAN ERROR DEFINED An inappropriate or undesirable human decision or behavior that reduces or has the potential to reduce effectiveness, safety, or system performance A human action/decision that exceeds system tolerances • “An action is taken that was ‘not intended by the actor
- 8. HUMAN ERROR
- 9. ACCIDENTS INCIDENTS ERRORS AND UNREPORTED OCCURRENCES Accidents are only the tip of the iceberg! For every accident there are 600 errors and/or unreported occurrences
- 10. HUMAN FACTORS Stress Complacency Distraction Fatigue Communication Resources Knowledge Assertiveness Awareness Norms Pressure Lack of communication Complacency Lack of knowledge Distractions Lack of teamwork Fatigue Lack of resources Pressure Lack of assertiveness Stress Lack of awareness Norms
- 11. CREW DOOR BATT. DOOR Loadmaster exits crew door to check battery door. Engines were running WHAT IF?
- 12. Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet.
- 14. HUMAN ERROR MODEL Basic Errors Unsafe Acts Unintended Action Intended Action Slip Lapse Mistake Violation Skill-Based- Attentional Failures Skill-Based- Memory Failures Rule-based or Knowledge-based Mistakes Routine violations Exceptional violations Sabotage INCIDENT/ACCIDENT
- 15. Attention Failures Memory Failures Failures in Execution Misapplication of a good rule Application of a bad rule DecisionErrors Error Mechanism Categories Skill Based: Rule Based: Knowledge Based: Inaccurate knowledge of the system Incomplete knowledge of the system
- 16. WHAT TO DO ABOUT IT? Instead of trying to change the human condition – change the conditions under which people work Reduce the error-provoking nature of the task, the team, the workplace and the organization Strengthen and improve defenses to limit and contain the bad effects of those errors that will still occur
- 17. STRATEGIC APPROACH Re + Md → ØE error defenses Events Reducing Managing ZEROleads toand
- 18. SWISS CHEESE MODEL ACCIDENT & INJURY Hazard Organizational Influences Unsafe Supervision Pre-Conditions for Unsafe Acts Unsafe Acts Latent Conditions Latent Conditions Latent Conditions Active Conditions Failed or Absent Defenses
- 20. INTRODUCTION IN RISK MANAGEMNT Een continue proces net als het kwaliteits proces Identificeren – Analyseren – Mitigeren – Monitoren - ..........enz We blijven rondgaan totdat het risiko aanvaarbaar laag is
- 21. SAFETY POLICY Belangrijke verklaring van de Accontable Manager waarin hij verklaart verantwordelijk te zijn voor al onze operaties en services! Dit betekent nogal wat!! Dit kan alleen als wij er allemaal aan mee doen!!! Hij moedigt dan ook iedereen aan potentiele gevaren en gevaarlijke situaties te melden!!
- 22. JUST-CULTURE Een Rechtvaardige Cultuur is hiervoor een NOODZAAK De melder van voorvallen mag NOOIT gestraft worden Dat mogen we verwachten van onze Accountable Manager maar ook van de Overheid!!
Editor's Notes
- According to Wiener, "Complacency is caused by the very things that should prevent accidents, factors like experience, training and knowledge contribute to complacency. Complacency makes crews skip hurriedly through checklists, fail to monitor instruments closely or utilize all navigational aids. It can cause a crew to use shortcuts and poor judgment and to resort to other malpractices that mean the difference between hazardous performance and professional performance.
- Wij doen hetzelfde als leerlingen solo gaan! Met draaiende motor uitstappen!?
- Slips and Lapses In a familiar and anticipated situation people perform a skill-based behaviour. At this level, they can commit skill-based errors (slips or lapses). In the case of slips and lapses, the person’s intentions were correct, but the execution of the action was flawed - done incorrectly, or not done at all. This distinction between being done incorrectly or not at all is another important distinction. When the appropriate action is carried out incorrectly, the error is classified as a slip. When the action is simply omitted or not carried out, the error is termed a lapse. “Slips and lapses are errors which result from some failure in the execution and/or storage stage of an action sequence.” Reason refers to these errors as failures in the modality of action control: at this level, errors happen because we do not perform the appropriate attentional control over the action and therefore a wrong routine is activated. Examples of slips and lapses in aviation A classic example is an aircraft’s crew that becomes so fixated on trouble-shooting a burned out warning light that they do not notice their fatal descent into the terrain. In contrast to attention failures (slips), memory failures (lapses) often appear as omitted items in a checklist, place losing, or forgotten intentions. Likewise, it is not difficult to imagine that when under stress during in-flight emergencies, critical steps in emergency procedures can be missed. However, even when not particularly stressed, individuals have forgotten to set the flaps on approach or lower the landing gear. (Lapses -> balie dames schrijven to list of op de dagstaat) Mistakes Once a situation is recognised as unfamiliar, performance shifts from a skill-based to a rule-based level. First of all, the human tries to solve the problem by relying on a set of memorised rules and can commit rule-based mistakes. These kinds of error depend on the application of a good rule (a rule that has been successfully used in the past) to a wrong situation, or on the application of a wrong rule. In the case of planning failures (mistakes), the person did what he/she intended to do, but it did not work. The goal or plan was wrong. This type of error is referred to as a mistake. When we recognise that the current situation does not fit with any rule stored, we shift to knowledge-based behaviour. At the knowledge-based behaviour level we can commit planning errors (Knowledge based mistakes). They basically concern the difficulty we have in gathering information on all the aspects of a situation, in analysing all the data and in deriving the right decision. Planning is based on limited information, it is carried out with limited time resources (and cognitive resources) and it can result in a failure. Carola/ joris roelofs/ Jacco Arensman en de kaart rondvlucht map
- Decision making on basis of SB – RB - KB
- James Reason Foute Management beslissingen: Onvoldoende of onvolledige procedures Kosten besparingen Geen trainingen Onvoldoende Supervisie: Niet corrigeren van bekende problemen Workload/ stess Onvoldoende training Vermoeidheid (mentaal physiologisch) Fouten Verkeerde Perceptie Foute Beslissingen