Safety Management System

The model of an Organizational Accident (Reason, 1997)

The accident sequence begins with the negative consequences of organizational processes (i.e., decisions concerned with planning, forecasting, designing, managing, communicating, budgeting, monitoring, auditing, and the like). Another very influential factor is the system’s safety culture…. Membership Required You must be a member to access this content.View Membership LevelsAlready a member? Log in here...

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The difference between “hazard” and “risk”

As safety professionals we need to use terms from our profession CORRECTLY.  For example, “risk” is NOT the same as “hazard”.  I think we can all agree that flying in an airplane at 30,000 feet at 500 mph, with 50,000 pounds of jet fuel is hazardous!  But these days on a commercial airliner it is…...

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Accident Investigation Principles (DOE)

The basis for conducting any event investigation is to understand the organizational, cultural, or technical factors that, left unattended, could result in future accidents. Guiding concepts may be summarized as follows:… Membership Required You must be a member to access this content.View Membership LevelsAlready a member? Log in here...

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Accident Causation Models

The Sequence of Events Model This is a simple, linear cause and effect model where accidents are seen as the natural culmination of a series of events or circumstances that occur in a specific and recognizable order. A chain often represents the model with a weak link or a series of falling dominos. This model…...

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Hazardous Attitudes (Conklin)

Pride:  “Don’t insult my intelligence.” Heroic: “I’ll get it done, by hook or by crook.” Invulnerable: “That can’t happen to me.” Fatalistic:  “What’s the use?” Bald Tire:  “Gone 60K miles without a flat yet.” Summit Fever:  “We’re almost done.” Pollyanna:  “Nothing bad will happen.”… Membership Required You must be a member to access this content.View...

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Mental biases that drive unsafe decision making

Workers look for familiar patterns and apply well-tried solutions to a problem. There is the temptation to settle for satisfactory solutions rather than continue seeking a better solutions. The mental biases, or shortcuts, often used to reduce mental effort and expedite decision-making include:… Membership Required You must be a member to access this content.View Membership...

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Delusional Safety Syndrome (DSS)

It has taken me 25 years to diagnose it, but I have finally establish the “Delusional Safety Syndrome” (DSS).  It is the only mental illness known at this time that is actually contagious.  It is spread by close contact with an infected person.  It can lie dormant for years and the infected person can spread…...

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Looking for a FREE Safety Culture Survey?

As part of their Industrial Safety Ordinance Contra Costa County, CA developed a VERY NICE safety culture survey.  It is a requirement for CalARP facilities, but just a GREAT RESOURCE for the rest of us.  Check it out Attachment E: Safety Culture Assessment (PDF).  You may have some work to do to get it in…...

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The “Swiss-Cheese” Model (Professor James Reason)

The “Swiss-Cheese” Model, developed by Professor James Reason, illustrates that accidents involve successive breaches of multiple system defenses. These breaches can be triggered by a number of enabling factors such as equipment failures or operational errors. Since the Swiss-Cheese Model contends that complex systems are extremely well defended by layers of defenses, single-point failures are…...

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Engineering a Just Culture (Reason, 1997)

A wholly just culture is almost certainly an unattainable ideal. However, an organization in which most of its members believe that justice will usually be dispensed is within the bounds of possibility. Two (2) things are clear at the outset. First, it would be quite unacceptable to punish all errors and unsafe acts regardless of…...

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“FROM ROUTINE TO NON ROUTINE”

As Asiana Airlines Flight 214 flew into San Francisco International Airport on Sunday July 7, the Boeing 777’s 291 passengers didn’t know that the man at the controls had never landed this kind of plane at this airport before.  Does it matter that the pilot at the time – aviation veteran Lee Kang-kuk – has only…...

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The Value of Self Assessments

A little boy went into a drug store, grabbed a stool at the counter and pulled it over to the telephone. He climbed onto the stool so he could reach the buttons on the phone and proceeded to dial someone. The store-owner observed and listened to the conversation. Boy: ‘Lady, Can you give me the…...

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