Safety Management System

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

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

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

“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

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

Unsafe Acts can be “Active Failures”

Unsafe acts are of two (2) distinct types: errors and violations Errors arise from informational problems and fall into three (3) categories: skill-based slips and lapses, rule-based mistakes and knowledge-based mistakes Violations arise from motivational factors and fall into four types: routine (or corner-cutting) violations, thrill-seeking or optimizing violations, necessary violations and exceptional violations Everyone

Safety Attitude Survey

Safety is largely about actions.  But it’s also about attitude. We can observe actions objectively. But it’s harder to see into employees’ heads and hearts and examine their attitude toward workplace safety.  Every employee must be dead serious about safety—or they could end up dead. As well as taking job safety seriously, a positive attitude

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