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Systems failures cause accidents: How can systems be made more fail safe?
Systems failures cause accidents: How can systems be made more fail safe?
Management education. Awareness of due diligence.
Consultation with, and participation from all systems participants. Encourage all workers to be part of the continual improvement of the system.
Leadership and Commitment. Visible leadership and demonstration of commitment to the safety of all working within the system.
Exploratory investigation with open minds and views. Leave predetermined opinions at the door. Encourage a culture of learning.
Competing business priorities. Where does safety sit in the list of business priorities compared to profitability and production.
Build in multiple levels of defenses against system failures.
Proactive risk management and continual improvement activities are critical. Involve all systems participants in these processes.
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How does this happen?
Poor Leadership and Poor Commitment from senior management about safety
Lack of consultation with workers
Complex systems
Safety management system is not implemented, nor continually improved to meet the changing needs of the business.
Safety systems are too complex and convoluted and this encourages short cuts. Is the system designed to meet the needs, capabilities and vulnerabilities of all users.
Ways to improve>
Incentives for all participants of the system to be involved and contribute to the continual improvement of the system. Worker engagement and empowerment. Several studies have linked increased empowerment and ownership of safety decisions to improved safety outcomes
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Aim to improve the overall safety culture to one that is just, encouraging and trusting of all participants without blame
Other considerations
Humans are part of the systems and its workings, but also defenders of the systems.
Decision making by participants of the system - removing opportunities for system overriding and intentional violations of systems.