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Systems failures can cause accidents: How can systems be made more fail…
Systems failures can cause accidents: How can systems be made more fail safe?
"if only they had operated the thing the way they were supposed to, the accident wouldn't have happened"
"Accident prevention is witchcraft, not systematic at all????"
Systems
Eliminate flawed systems
Proper training
Full scope of hazards and risks
Present and forseeable
Maintenance programs
Behavioral observations
Correct tools for the task
Administrative controls
Policies
Procedures
Guidelines
Forms
Checklists
Continuous monitoring
Reliance on workplace inspections
Reliance on safety observations
OHS professionals to operate like a business
Safety population is our target audience
Commitment to the safety management system
Plan, do, check, act
Different options for workers to express concerns
HSE Advisors
Health and safety reps
Supervision
Management
Union delegates
Hazard identification stage of design
Occupational safety and health (OSH) management system designer/s
Client or top management
End user
link to coggle.it
Accident prevention
Management education
Demonstrate leadership
Commitment
Belief
Instruction being given
All parties involved
Consult
Co-ordinate
Co-operate
Safety performance indicators
Ongoing consultation
Continuous monitoring
Auditing
Workplace inspections
Proactively analyse
Inspections
Quality review
Safety management system
Near miss reporting
Keeping up to date
Latest trends
New technologies
Different job responsibilities
Requirements
Investment
Money
Time
Resources
Guess work needs to be removed
Continuous improvement on an on-going basis
Historical or reactive data
Predict forseeable risks
Proactive safey culture
Risk management
Due diligence
Engagement
OHS educational feedback to the workforce
Key performance indicators
Recognition for safe behaviours
Auditing
Education
Education
Tested and approved
Failures
Production pressures
Competing priorities
Wrong decisions
Drugs and alcohol involved?
Reliance on lag reporting
Under reporting of issues
Reactive safety culture
Disappointment and frustration
Ignoring near misses
Complacency
Remove opportunities for overriding systems
Good leadership
Good leadership
"Sometimes it is what we have missed that can change and improve the system"
"Senior managements attitude influences all their employees"
Reason (1998) stated: 5 areas of improvement
Reason, J., 1998. Achieving a safe culture: theory and practice. Work & Stress, 12(3), pp.293-306.
Creating an informed culture
A reporting culture
A just culture
A flexible culture
A learning culture
WHAT IF?????
"Hindsight is a beautiful thing"
The "what if" terminology can be used to our advanatge. This term can be linked to how we could have prevented the accident
Develop trends
Inspiring leaders
"Walk the walk and talk the talk"
"Prevention is better than cure"
Hierarchy of control
Eliminaton
Substitution
Isolation
Engineering controls
Administrative controls
PPE
"Reason (2000) discusses establishment of a reporting culture as vital for implementation of an effective risk management process; establishing user friendly modes of hazard and incident reporting is crucial"
Reason, J., 2000. Human error: models and management. Western Journal of Medicine, 172(6), p.393.
Reporting
Reporting
Reporting
Reporting
Scissor lift example
Protruding object underneath
If it is only one worker in the basket, He cannot be rescued because there is a protruding object underneath and the extension can only be operated manually. Therefore the ground controls are not adequate in the rescue plan
Additonal rescue plan needs to be implemented
Complacency in traditional controls
