Can safety be managed, can risks be anticipated?

Transcription

1 Can safety be managed, can risks be anticipated? Experiences from aviation, health care, petroleum Human Factors & Safety seminar Espoo, March Karina Aase

2 Can safety be managed, can risks be anticipated? That s the question(s)! The question(s) has raised a continuous debate within safety science! AGENDA: The safety science debate Evidence? Examples from aviation, health care, petroleum

3 The question(s) is ok, but what is the goal(s)? To function reliable and to anticipate risks caused by either technology, organizational structures, and practices (Reiman & Oedewald 2009) + Productivity Financial safety Environmental safety Personnels safety

4 Can safety be managed, but what is safety? Safety is not something an organization possesses, it is a competence that should be continuously learned and developed (Gherardi & Nicolini, 2000) Learning safety accurs in practice, in contextual work settings (Brown & Duguid, 1991; 2001)

5 The safety science debate Information processing Decisionmaking? Resilience Engineering? Normal Accidents Energy & barriers? Contextual setting High Reliability Organisations??: does the theories answer our question in different contextual settings?

6 HRO versus NA High Reliability Organizations (HRO) Accidents can be prevented Safety is the priority Redundancy (duplication and overlap) enhances safety Decentralized decision making A "culture of reliability to create uniform and appropriate responses Continuous operations, training, and simulations Trial and error learning supplemented by anticipation and simulations Normal Accidents (NA) Accidents are inevitable Safety is one of a number of competing objectives Redundancy often causes accidents Centralization is needed for tightly coupled systems A military model is incompatible with democratic values Organizations cannot train for unimagined, highly dangerous operations Denial of responsibility, faulty reporting, and reconstruction of history cripple learning efforts

7 Energy and barriers Hazards Adapted from Reason, 1997

8 Decision making Actors cross boundaries for acceptable risk due to optimalisation of their own behaviour or work practice Activities have a tendency to move towards the boundaries for acceptable risk practice since the actors seek for suitable trade-offs concerning workload and productivity

9 Safety space (Rasmussen, 1997) Boundary of functionally acceptable performance Error margin Financial/management pressure Optimise locally Acceptable behaviour (risk) Resulting perceived boundary of acceptable performance Work tasks/ workload

10 Goal conflicts Production Easy to measure ( revenue, earnings, expenses ) Indicates success in a positive fashion (e.g., increasing earnings) Is reinforcing, and has high salience (the bottom line is the "bottom line" for a firm) Relationship between application of resources (money effort, time) and production goals is relatively certain, making it easy to utilize feedback Safety Difficult to measure (indirect, discontinuous, difficult to interpret) The feedback is provided "negatively" (fewer accidents or incidents) Has little reinforcement value, high salience only after an accident or a serious near-miss Relationship between application of resources and safety goals is relatively uncertain, making it hard to utilize the feedback

11 Information processing Accidents are not fundamental surprises. Precursors or warnings are nearly always identified on hindsight. Accidents develop through a long chain of events with root causes like lack of information flow and misperception among individuals (incubation period). (Barry Turner, 1978)

12 Does the theories answer our question(s)? Theoretical perspective Normal Accidents (NA) High Reliability (HR) Energy and barriers Decision making Information processing Resilience Engineering Can safety be managed and risks be anticipated? Sooner or later, accidents happen due to complexity in the systems NO! Organising for safety as top priority, emphasising redundancy, safety culture, and trial and error to learn YES! Individual, cultural and organisational barriers prevent accidents to develop and escalate YES/no Simultaneous priorities are emphasized, balancing risk and safety against productivity and efficiency NO/yes Information is the key to understand and learn from accidents, information processing mechanisms are vital yes/no Unforeseen technological, environmental or behavioural phenomena will occur, safety is created through proactive resilient processes rather than reactive barriers and defenses Yes

13 Evidence? How do we collect it? Depending on what perspective we believe in: safety management system audits safety culture evaluations organisational culture studies reviews of human performance programs, operational experience etc usability evaluations of critical technology qualitative risk assessment quantitative risk assessment accident statistics and many more

14 Evidence within risk assessment (statistics)? (Source: Amalberti et al 2005) Fatal iatrogenic adverse events Blood transfusion Himalaya mountaineering Cardiac surgery in patient in ASA 3-5 Medical risk (total) Anesthesiology in patient in ASA 1 Chartered flight Commersial large-jet aviation Microlight aircraft or helicopters Road safety Chemical industry (totalt) Railways Nuclear industry Very unsafe Risk Ultrasafe

15 Lets look at some examples.

16 What does the petroleum sector believe in? The Norwegian petroleum sector can draw today on a knowledge bank which allows government, industry and unions to reap safety gains. That makes it possible to monitor and influence risk level trends throughout the business (Petroleum Safety Authority, 2009) YES, safety can be managed YES, risks can be anticipated

17 Anticipating risks in petroleum DFU Defined situations of hazard and accident Data sources 1 Non-ignited hydrocarbon leaks Data acquisition* 2 Ignited hydrocarbon leaks Data acquisition* 3 Well kicks/loss of well control DDRS/CDRS (PSA) 4 Fire/explosion in other areas, flammable fluids Data acquisition* 5 Vessel on collision course Data acquisition* 6 Drifting object Data acquisition* 7 Collision with field-related vessel/installation/shuttle tanker 8 Structural damage to platform/stability/ anchoring/positioning failure CODAM (PSA) CODAM (PSA) + industry 11 Evacuation (precautionary/emergency evacuation) Data acquisition* 12 Helicopter crash/emergency landing on/near installation Data acquisition* * Data collection in cooperation with operator companies

18 Managing safety in petroleum The Norwegian Petroleum Safety Authority has on behalf of the Norwegian government taken the step of requiring petroleum companies to develop a safety culture The party responsible shall encourage and promote a sound health, environment and safety culture (Regulations relating to health, environment and safety in the Norwegian petroleum activities, 2001, section 11)

19 Evidence within health care? Theoretical perspective Normal Accidents (NA) High Reliability (HR) Energy and barriers Decision making Information processing Safety practices within health care Accidents happen, but not due to complexity within the health care system Safety is not top priority, focus on developing safety cultures and learning lacks Limited consciousness regarding risks and possible consequences, hard to develop and implement specific barriers Productivity has a tendency to win in the goal conflict between safety and productivity Lack of mechanisms for information processing to understand and learn from undesired events

20 Evidence within health care? Risk perception and priority? Health care organisations have only to a limited extent performed general risk analyses as background for their priorities. Resources and competence? Health care organisations have only to a limited extent specialised and competent personnel to manage undesired events. The work has often low prestige and impact in the organisations. Health care organisations have no outline of the costs related to undesired patient events. (Norwegian Directorate of Health, 2005)

21 Evidence using safety culture studies? Organisational management support for safety Reporting of (near) misses Teamwork across units Organisational handoffs and transitions Feedback and communication about errors Staffing Org.learning and continuous improvement SUS 2008 Communication and openness Teamwork within units SUS 2006 Non-punitive response to errors Supervisors actions promoting safety Degree of agreement on positive items Prosent and disagreement on negative items. Mean percentage within each dimension.

22 What does the health care sector believe in? Risk is in the nature of medicine because we cut in peoples bodies. People arrive with dramatic stuff, serious illnesses that we are supposed to treat with surgery. That is a risk in itself. There is a grey zone where you must assess if surgery is beneficial or harmful to the patient. You are in focus, and the results of your professional assessments always appear after your actions. I you choose not to do surgery and the patient dies it might be blameworthy, and if you choose to do surgery and the patient dies it might be blameworthy as well. That is probably why we receive complaints, because expectations towards the results are unrealistic NO, safety can not be managed NO, risks can not be anticipated

23 Evidence within aviation - statistics

24 Evidence within aviation safety practices MAKROLEVEL (aviation authority): Professional pride, sense of responsibility, individually oriented work practices. Procedures have respect, status and normative value. MESOLEVEL (ATC and airport operation): Safety practices vary. Goal conflicts regarding safety and efficient traffic handling. Procedures have respect, status and normative value. BUT, are violated related to security, traffic handling and reporting. MIKROLEVEL (maintenance): Professional pride, safety consciousness. Goal conflicts concerning efficient traffic handling are managed by using slack, flexibility and experience-based knowledge. Procedures have respect, status and normative value. BUT, contains grey zones requiring other work practices.

25 Evidence within aviation framework conditions 1. Interfaces between different aviation actors are negatively affected by new organisational and physical interfaces: geographic relocation of aviation authority separation of maintenance and airline company relocation of maintenance base 2. Oil prices 3. Financial crisis So far, collective mechanisms compensate: Professionality, safety consciousness, sense of responsibility Desire to learn and develop personal competence Emphasis on rules, procedures and new technology

26 What does the aviation sector believe in? Supranational regulation International agreements Proseduralisation Reporting and systems YES, safety can be managed, but YES, risks can be anticipated, but

27 Summary what have we? A research community with different beliefs Three sectors with different beliefs Government and authorities with one belief? The public with one belief?

28 At last a warning! How desirable is proceduralisation? 1. The government regulatory context where safety related requirements are designed for companies to comply with 2. The company safety management context where companies are designing their internal safety management systems 3. The safety authority context where inspections and audits seem to produce more and more paperwork instead of a deep understanding of the conditions under which operations are conducted. (Bieder & Bourrier, 2010)

29 Thank you for your attention! Everyone Makes Mistakes Yes Everyone!

30 That opens for discussion?