Iceberg Thinking and Safety Defences Chris Langer CIRAS April 2016
The Iceberg • new reps’ meetings Events • asking questions: • drivers • culture • UK interest: performance before safety • • across transport blame • sectors complacency: individual and management • • International interest: apathy • • Spain, Germany, South Korea, and US Drivers of reporting behaviour?
Performance before safety Events ‘Best performing rig in the Gulf’
Blame and complacency Events Driver blamed in • immediate aftermath, but: Driver alert system • switched off two years before accident One risk analyst estimated • the probability as ‘once every six months’
Apathy staff begin to say: • ‘I can’t be bothered to report it.’ • ‘I can’t be bothered about safety.’ • far more difficult to uncover and investigate • may become embedded within the culture • getting people to engage… • New Zealand police recruitment strategy example • fewer than 2 per cent engaged with a ‘homeless’ child actor • >> video clip
From Safety-I to Safety-II Safety-II Proactive approach • Focuses on things that go right • Safety-I Safety-I Emphasis on variability in • human performance Reactive approach • Shared responsibility for system • Focuses on things that go wrong • outcomes Emphasis on human error • Inclination to blame frontline staff • Confidential reporting can help drive Safety-II
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