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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?
Human Error (Reason 2000)
Person approach
humans are fallible
behaviours
happy vs sad
training
decision making
external influences
respect
System approach
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designed to countermeasure human error
technology
Just Culture
Consultation
Just culture
worker buy in
worker input
Safety Matter Expert consult
audit
external
internal
compliance
KPI
SMS development and maintenance
System
Business targets
objectives of management
safety Vs Financial
lead and lag reporting
systematic processes
requires human integration
real time
fail safe systems = guards, protections, locks , checks
reflects the ideal world rather than true reflection of work
systems are only as good as its implementation
Poor implementation = poor output
poor results
poor data
Poor reporting = loss of organisational support
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Hazard identification
preventative /lead indicators
Resilience
Sustainable
evolution of change
safe to fail
allows error to happen
learn from failures
Corrective actions as failures occur
Operate how the system was designed
Communication streams
How was it designed
end user training
how is it delivered?
online
one on one
Verification of competency
outsourced training
assumed knowledge
trade qualifications
Accepted views
Engineer design