Towards a new tool for measuring Safety Management Systems performance

Available on: http://www.resilience-engineering.org/REPapers/Cambon_Guarnieri_Groeneweg_P.pdfInternational audienceThis paper deals with the assessment of Safety Management Systems performance and presents a new tool developed for that purpose. It recognizes two dimensions in a SMS: a structural facet corresponding to the formal description of the system and an operational one focused on the system's influence on the working environment and practices of people. Building up the operational performance of a SMS actually strengthens the overall resilience of the organization. Authors of the paper believes that the operational performance of SMS can be measured using Tripod Delta. This method is actually designed to detect weak areas in the environment in which people are working and the level of control that the organization has on it. The method and its interesting model of organizational resilience are presented in the paper. In the framework of this paper, Tripod is used as an input to measure the SMS operational performance. Both of the tools designed to measure the structural and operational performances of Safety Management Systems are then described

Developments in the Safety Science Domain and in Safety Management From the 1970s Till the 1979 Near Disaster at Three Mile Island

Objective: What has been the influence of general management schools and safety research into causes of accidents and disasters on managing safety from 1970 till 1979? Method: The study was limited to original articles and documents, written in English or Dutch from the period under concern. For the Netherlands, the professional journal De Veiligheid (Safety) has been consulted. Results and conclusions: Dominant management approaches started with 1) the classical management starting from the 19th century, with scientific management from the start of the 20st century as a main component. During the interwar period 2) behavioural management started, based on behaviourism, followed by 3) quantitative management from the Second World War onwards. After the war 4) modern management became important. A company was seen as an open system, interacting with an external environment with external stakeholders. These schools management were not exclusive, but have existed in the period together. Early 20th century, the U.S. 'Safety First' movement was the starting point of this knowledge development on managing safety, with cost reduction and production efficiency as key drivers. Psychological models and metaphors explained accidents from ‘unsafe acts’. And safety was managed with training and selection of reckless workers, all in line with scientific management. Supported by behavioural management, this approach remained dominant for many years, even long after World War II. Influenced by quantitative management, potential and actual disasters after the war led to two approaches; loss prevention (up-scaling process industry) and reliability engineering (inherently dangerous processes in the aerospace and nuclear industries). The distinction between process safety and occupational safety became clear after the war, and the two developed into relatively independent domains. In occupational safety in the 1970s human errors thought to be symptoms of mismanagement. The term ‘safety management’ was introduced in scientific safety literature as well as concepts as loose, and tightly coupled processes, organizational culture, incubation of a disaster and mechanisms blinding organizations for portents of disaster scenarios. Loss prevention remained technically oriented. Till 1979 there was no clear relation with safety management. Reliability engineering, based on systems theory did have that relation with the MORT technique as a management audit. The Netherlands mainly followed Anglo-Saxon developments. Late 1970s, following international safety symposia in The Hague and Delft, independent research started in The Netherland

Safety management systems from Three Mile Island to Piper Alpha, a review in English and Dutch literature for the period 1979 to 1988

Objective: Which general management and safety models and theories trends influenced safety management in the period between Three Mile Island in 1979 and Piper Alpha in 1988? In which context did these developments took place and how did this influence Dutch safety domain? Method: The literature study was limited to original English and Dutch documents and articles in scientific and professional literature during the period studied. Results and conclusions: Models and theories of human errors, explaining occupational accidents were still popular in the professional literature. A system approach was introduced into mainstream safety science, starting in process safety, and subsequently moving into occupational safety. Accidents were thought to be the result of disturbances in a dynamic system, a socio-technical system, rather than just human error. Human errors were also perceived differently: they were no longer faults of people, but consequences of suboptimal interactions during process disturbances. In this period quality of safety research increased substantially, also in the Netherlands. Major disasters in the 1980s generated knowledge on process safety, and soon process safety outplaced developments in occupational safety, which had been leading before. Theories and models in this period had advanced sufficiently to explain disasters, but were still unable to predict probabilities and scenarios of future disasters. In the 1980s ‘latent errors’ appeared in safety literature, and in The Netherlands the concept of ‘impossible accidents' appeared. Safety management was strongly influenced by developments in quality management

Accidents at sea: Multiple causes and impossible consequences

Accidents are the consequences of highly complex coincidences. Among the multitude of contributing factors human errors play a dominant role. Prevention of human error is therefore a promising target in accident prevention. The present analysis of 100 accidents at sea shows that human errors were not as such recognizable before the accident occurred. Therefore general increase of motivation or of safety awareness will not remedy the problem. The major types of human error that contribute to the occurrence of accidents are wrong habits, wrong diagnoses, lack of attention, lack of training and unsuitable personality. These problems require specific preventive measures, directed at the change of undesired behaviors. Such changes should be achieved without the requirement that people comprehend the relation between their actions and subsequent accidents

Bringing Tripod Delta to France for the analysis of organizational factors

International audienceThis paper deals with the Tripod Delta method aiming at assessing organizational failures in the working environment. Ecole des Mines justifies why this method was selected among several organizational safety assessment methods currently available. Since its development by Leiden and Manchester Universities, the method has been very successful at the companies that implemented it. In this context, furthermore sustained by the current need in France for organizational safety assessment methods, three partners (Ecole des Mines de Paris, Leiden University and AdviSafe Risk Management) have gathered around the "Tripod-France" project aiming at bringing the concept to France and experimenting the method on a French pilot plant. The context, objectives and results of this ongoing project are presented in the following paper

Developments in the safety science domain, in the fields of general and safety management between 1970 and 1979, the year of the near disaster on Three Mile Island, a literature review

Objective: What influence has research conducted by general management schools and safety research had upon the causes of accidents and disasters in relation to the managing of safety between 1970 and 1979? Method: The study was confined to original articles and documents, written in English or Dutch from the period under consideration. For the Netherlands, the professional journal De Veiligheid (Safety) was consulted. Results and conclusions: Dominant management approaches started with (1) classical management starting from the 19th century incorporating as a main component scientific management from the early 20th century. The interwar period saw the rise of (2) behavioural management which was based on behaviourism, this was followed by (3) quantitative management from the Second World War onwards. After the war it was (4) modern management that became important. A company was seen as an open system, interacting with an external environment with external stakeholders. These management schools of thought were not exclusive, but existed side by side in the period under consideration. Early in the 20th century, it was the U.S. ‘Safety First’ movement that marked the starting point of this knowledge development in the sphere of safety managing, with cost reduction and production efficiency as the key drivers. Psychological models and metaphors were used to explain accidents resulting from ‘unsafe acts’. Safety was managed by training and targeting reckless workers, all in line with scientific management. Supported by behavioural management, this approach remained dominant for many years until long after World War II. Influenced by quantitative management, potential and actual disasters occurring after the war led to two approaches; loss prevention (up-scaling in the process industry) and reliability engineering (inherently dangerous processes in the aerospace and nuclear sectors). The distinction between process safety and occupational safety became clear after the war when the two evolved as relatively independent domains. In occupational safety in the 1970s human error was thought to be symptomatic of mismanagement. The term ‘safety management’ was introduced to scientific safety literature alongside concepts such as loosely and tightly coupled processes, organizational culture, disaster incubation and the notion of mechanisms blinding organizations to portents of disaster scenarios. Loss prevention remained technically oriented. Until 1979 there was no clear link with safety management. Reliability engineering that was based on systems theory did have such a connection with the MORT technique that served as a management audit. The Netherlands mainly followed Anglo-Saxon developments. In the late 1970s, following international safety symposia in The Hague and Delft, independent research finally began in the Netherlands

Criteria for recommendations after perioperative sentinel events

Background The recurrence of sentinel events (SEs) is a persistent problem worldwide, despite repeated analyses and recommendations formulated to prevent recurrence. Research suggests this is partly attributable to the quality of the recommendations, and determining if a recommendation will be effective is not yet covered by an adequate guideline. Our objectives were to (1) develop and validate criteria for high-quality recommendations, and (2) evaluate recommendations using the criteria developed. Methods (1) Criteria were developed by experts using the bowtie method. Medical doctors then determined if the recommendations of Dutch in-hospital SE analysis reports met the criteria, after which interobserver variability was tested. (2) Researchers determined which recommendations of Dutch perioperative SE analysis reports produced from 2017 to 2018 met the criteria. Results The criteria were: (1) a recommendation needs to be well defined and clear, (2) it needs to specifically describe the intended changes, and (3) it needs to describe how it will reduce the risk or limit the consequences of a similar SE. Validation of criteria showed substantial interobserver agreement. The SE analysis reports (n=115) contained 442 recommendations, of which 64% failed to meet all criteria, and 28% of reports did not contain a single recommendation that met the criteria. Conclusion We developed and validated criteria for high-quality recommendations. The majority of recommendations did not meet our criteria. It was disconcerting to find that over a quarter of the investigations did not produce a single recommendation that met the criteria, not even in SEs with a fatal outcome. Healthcare providers have an obligation to prevent SEs, and certainly their recurrence. We anticipate that using these criteria to determine the potential of recommendations will aid in this endeavour. </p