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????"
Eliminate flawed systems
Full scope of hazards and risks
Present and forseeable
Correct tools for the task
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
Health and safety reps
Hazard identification stage of design
Occupational safety and health (OSH) management system designer/s
Client or top management
link to coggle.it
Instruction being given
All parties involved
Safety performance indicators
Safety management system
Near miss reporting
Keeping up to date
Different job responsibilities
Guess work needs to be removed
Continuous improvement on an on-going basis
Historical or reactive data
Predict forseeable risks
Proactive safey culture
OHS educational feedback to the workforce
Key performance indicators
Recognition for safe behaviours
Tested and approved
Drugs and alcohol involved?
Reliance on lag reporting
Under reporting of issues
Reactive safety culture
Disappointment and frustration
Ignoring near misses
Remove opportunities for overriding systems
"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
"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
"Walk the walk and talk the talk"
"Prevention is better than cure"
Hierarchy of control
"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.
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