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Reason System of Safety Management Model - Coggle Diagram
Reason System of Safety Management Model
Management decisions &
Organisational Processes
Tasking
Operations
Resources
people
Allocating resourcing
Poor allocation for number of people required
Too many people
Monetary restrictions
Inadequately trained people
Not suitable skilled worker/s
Scheduling
Poor/lack of scheduling
Untrained
Money restrictions
Time pressure
Communicating
No communication
Inadequate Communication
Communication not being shared
Incorrect communication
Perception
Time Pressure
Macho culture
Managing
Inadequate managing of money
Inadequate managing of materials
Inadequate managing of people
Lack or limited supervision
Untrained workers
Money
Budgeting
Insufficient training
Inadequate tools &equipment
Under manning
Poor supervisor-worker ratios
Low pay
Forecasting
Monetary restrictions
Managerial decisions
Time Pressure
Gaps &/or shortage
Unrealistic
External Pressures
Contractual
Regulatory
Community
Shareholders
Banks / Financial Institutions
Materials
Latent Conditions
Maintenance failures
Clumsy automation
Manufacturers
Unworkable procedures
Poor design
Designer
Gaps in supervision
Shortfalls in training
Organisational Managers
Culture - acceptance of sub-standards
Less than adequate
tools & equipment
Defences Barriers
Protection
Operational hazards
Exposure to people danger
Types of protection /
Layers of protection
Understanding & awareness
Guidance to operate safely
Alarms & warnings
Restore system when
a return to a safe state
Interpose safety barriers
Contain & eliminate
Escape & rescue
Exposure to asset danger
Defences are bypassed
Safeguards
Defences are breached
Active failures
Types of defences
Hard
Automated engineered
safety features
Physical barriers
Alarms & Annunciators
Interlocks
Keys
PPE
Non-destructive testing
designed-in structural weakness
Improved system design
Soft
People & paper
Legislation
Regulatory surveillance
Rules & procedures
Training
Drills & briefing
Administrative controls
Permit-To-Work systems
Shift handovers
Licensing
Certification
Front-Line operators
Person (Group/Team)
Adequate plan but failed actions
(Unintended actions)
Slips
Inattention
distraction or poor vigilance
Actions are largely automatic
Lapses
Failure to remember
Not a common task
Lack of supervision
Didn't complete all the intended actions
Trips
plan is inadequate
(Intended actions)
Failed to assess the information
Failed planning
Formulating intentions
Failed judging the likely consequences
of the planned actions
Violations
Deliberate deviations
from plan (active failures)
Routine violations
Optimizing violations
Indulge aggressive instincts
Personal traits
Intentional actions
Necessary violations
Unsafe acts
Workplace
(Local Conditions)
Error Producing Conditions
Workers accepting
sub-standard conditions
Poor vigilance
Workers not knowing
Lack of experience
Minimal or no supervision
Training gaps
Unusual emergency situation
Faulty equipment &/or tools
Old equipment &/or tools
Poor man/system interface
Lack of communication
Over time / fatigue
Poor housekeeping standards
Hazards not reported &/or fixed
Violation Producing Conditions
Attitudes
Not caring or thinking about consequences
Unwritten rules
Deliberately not following procedure/policy
Poorly developed procedures
No available procedure
Beliefs
Commercial or production goals override safety goals
Time &/or resource pressure
Cost cutting
Expectation on efficiency
Corner cutting
Behavioural
Rarely sanctioned violations