System Safety: A systematic processes. Making Risk Control Decisions 1. Identify the Hazards 2. Assess the Risks 3. Analyze Risk Control Measures 4. Make

System Safety: System Safety: A systematic processesA systematic processes

1. HazardIdentification

2. RiskAssessment

3. Analyze Risk Control

Measures

4. Risk Controls

5. ImplementRisk Controls

6. Follow Through &

Review

1. HazardIdentification

2. RiskAssessment


Measures

4. Risk Controls


6. Follow Through &

Review

Making Risk Control DecisionsMaking Risk Control Decisions

1. Identifythe Hazards

2. Assessthe Risks


Measures

4. MakeControl

Decisions


6. Superviseand Review

Risk Control Measurement Analysis

Identify controloptions

Determine control effects

Prioritize riskcontrol measures

Making Risk Control DecisionsMaking Risk Control Decisions

Select RiskControloptions

Make Decision at appropriate level

The Risk Control Macro Option ListThe Risk Control Macro Option List

• Reject

• Avoid

• Delay

• Transfer

• Spread

• Compensate

• Reduce

Macro OptionsMacro Options

• REJECT– Risk outweighs benefit

• AVOID– Go around the risk, do it in a different way

• DELAY– Maybe the problem will be resolved by time

• If delay is an acceptable option consider if operation is needed at all

• TRANSFER– Better qualified system, i.e.,“Pro’s From Dover”

Macro Options (cont)Macro Options (cont)

• SPREAD– Modular or separate Hazardous Operations

• COMPENSATE– Design parallel and redundant systems

• REDUCE– Design for minimum risk– Incorporate Safety Devices– Provide Warning Devices– Develop SOPs & Train

Providing Management Risk Control Options

• Program Manager looking for optimum combinations– Mission supportive

• Some Risk Controls are incompatible– Evaluate full cost versus full benefit

• Be prepared for numbers game

• Some Controls reinforce one another– Win-Win option

• Redundancy = Robustness– Is it needed?

• Can you afford it? i.e., $$$, #’s, real estate

Decision Making Considerations

• Make decisions at the right time– Don’t rush – Make them as late as possible without

negative impact on timeline

• Make decisions at the right level– It should be established who makes the tough calls– Use RAC or TREC to quantify who, what, when

• Provide Mission supportive options– Use the Macro Option list as a starting point– Be prepared to offer sound advice

What Level is “The Right Level”

• Don’t just pass the buck up to the next level• You should help address the operational realities• Decision should be made at the level that has the

best understanding of the risks, opportunity and authority to commit resources

• Be prepared to address dynamic environments such as flight

• What is your span of control

Preliminary Hazard Analysis in Preliminary Hazard Analysis in system life cyclesystem life cycle

Preliminary Hazard Analysis in Preliminary Hazard Analysis in system life cyclesystem life cycle

System Concept

System Definition

System Development

System Production

System OperationPHA

SSHA in the system life cycleSSHA in the system life cycleSSHA in the system life cycleSSHA in the system life cycle

System Concept

System Definition

System Development

System Production

System Operation

SSHA

System Safety OrganizationSystem Safety Organization

PresidentPresident

Division safety administratorDivision safety administrator

Program director vice-presidentProgram director vice-presidentEngineering Vice-PresidentEngineering Vice-President

Program safety

requirements

Program safety

requirements

Program safety

assurance

Program safety

assurance

Special projects safetySpecial projects safetyFlight safetyFlight safety

System safety engineeringSystem safety engineering Nuclear safetyNuclear safety

Safety staff groupSafety staff group

Determine Risk Control EffectsDetermine Risk Control Effects

• How will this effect probability?• How will this effect severity?• How will this impact other sub-systems?

– Some controls support other sub-systems– Some controls may hinder other sub-systems

• What are the costs vs. benefits? – Direct Costs– Indirect Costs

Elements of a Sound Decision Making System

• Accurate information delivered to the various levels of decision maker(s)

• Concise and understandable Paper Trail• Progressive line of accountability to the top• Standardized process -- Like decisions made

consistently at Like levels• Process allows timely decision, capable of

responding to fast-pace and dynamic operations

11 22 66 88 1212

33 44 77 1111 1515

55 99 1010 1414 1616

1313 1717 1818 1919 2020

THE THE “ENHANCED” “ENHANCED” RISK ASSESSMENT RISK ASSESSMENT MATRIXMATRIX

- Numeric Code is used to prioritize hazards and determine their acceptability using a quantitative methodology

ProbabilityFrequent Likely Occasional Seldom Unlikely

I

II

III

IV

Catastrophic

Critical

Moderate

Negligible

A B C D E

S

E

V

E

R

I

T

Y

Risk Levels

Decision Making GuidelineDecision Making Guideline

• RISK LEVEL– Extremely High– High– Medium– LowLow

• DECISION LEVEL– Senior Executive– Managing Director– Program Manager– Any person in a Any person in a

leadership positionleadership position

When you have finished your analysis and When you have finished your analysis and prepare to make your decision, ask yourself prepare to make your decision, ask yourself

the following questions;the following questions;

• If I accept this risk do the total benefits outweigh the total costs…or…

• Do the total costs outweigh the total benefits

When you have finished your When you have finished your analysis and prepare to make your analysis and prepare to make your

decision, ask yourself the following decision, ask yourself the following questions:questions:

“If I accept this risk do the total benefits outweigh the total costs…or…do the costs outweigh the total

benefit?”

Cost of Mishap vs. Risk ManagementCost of Mishap vs. Risk ManagementM

ish

ap C

os

ts

Risk Reduction Effort

Cost of Hazard MitigationCost of Hazard Mitigation

Mis

hap

Co

sts

Co

st

of

co

un

term

eas

ure

s


““Balanced” Risk ManagementBalanced” Risk Management

Mis

hap

Co

sts

Co

st

of

co

un

term

eas

ure

s


Implementing Risk ControlsImplementing Risk Controls


2. Assessthe Risks


Measures

4. MakeControl

Decisions



LatentConditions

LatentConditions

UnsafeActs

UnsafeActs

HazardHazard

Occurrence

Layers of Risk Control

Defences can be Breached

Detect and EliminateDetect and Eliminate

Reason ModelReason Model

Risk Control ROT’sRisk Control ROT’s

• Use the System Safety Precedence order

• Choose the most mission supportive combinations

• Use Integrated Product Teams

• Look for synergistic enhancements– Man – Machine – Medium – Mission - Management

System Safety PrecedenceSystem Safety PrecedenceA systematic approach to Hazard ID – Risk Assess and ControlA systematic approach to Hazard ID – Risk Assess and Control

• Design to minimize hazards• Robust & Redundant systems, assemblies,

components, etc

• Install physical barriers• Isolate known threatening conditions or environments

• Use Warning devices • Alerts to prevent or reduce unwanted event

• Develop Procedures and Training• Most commonly used & abused hazard control

Accept hazard or dispose of the System

Design to

eliminate

hazardDesign to

reduce

hazard

Provide Safety Devices

Provide special

procedures, or training

Eliminated?

Hazard Reduction PrecedenceHazard Reduction Precedence

Reduced?

Provided?

Provided?

Provided?

Provide

Warning DevicesProvide hazard

risk

assessment

package for

management

Conclude hazard

analysis

yes

yes

yes

yes

yes

no

no

no

no

no

Implementing Risk ControlsImplementing Risk Controls

Clear ImplementationPlan

Establish Accountability

ProvideSupport

Risk Controls Risk Controls MUSTMUST be an be an Integrated EffortIntegrated Effort

• Risk controls should be integrated within plans, processes, and operations which they support

• Risk controls should compete for resources e.g. (time/money/people) relative to their significance to the mission

• Risk controls should be compatible with the “system” (System safety management & engineering)

Why Integration?Why Integration?• Compels a “balance” of mission needs• Force Multiplies the knowledge of designers,

experience of manufacturers and operators • Standardizes references (common language)• Reduces unforeseen needs• Eliminates redundancy • Strengthens accountability throughout the

organizational chart

• Bottom Line: Reduces $$$$ and work effortBottom Line: Reduces $$$$ and work effort

Clarify ImplementationClarify Implementation

• Fully involve operational personnel

• Provide specific task-oriented guidance

• Test your intervening strategies (Verify & Validate)

• Coordinate – Coordinate – Coordinate– Use SSWG’s to proliferate throughout the

orgainzation

How Implementation Breaks DownHow Implementation Breaks Down

• Operators dislike it• Management dislikes it• Wrong control selected for right reason• Too costly (cost vs. benefit)• Out weighed by other priorities (mission need)• It is misunderstood (poorly defined problem

statement) • Can’t establish a need (Poor performance metrics)

“Can’t prove the accident about to happen”

“Buy-In Continuum

• USER OWNERSHIP STRONGESTSTRONGEST• CO-OWNERSHIP• TEAM MEMBER• INPUT• COORDINATION• COMMENT AND FEEDBACK• BLIND ALLIGENCE WEAKESTWEAKEST

Top Down CommitmentTop Down Commitment

• The Bosses commitment is second to no safety program

• Signed policies and directives by CEO• Genuine management support

– Sustained and consistent behavior throughout org chart

– Resources match verbal commitment

– Accountability reflected in performance reports

• Follow up and review (self assessments)

LeadershipLeadership

• Use the power of command and the influence of organizational leaders

• Use motivation models

• Create positive incentives

• Insure vertical accountability throughout the organization

THE WELL SUPPORTED RISK THE WELL SUPPORTED RISK CONTROLCONTROL

THE WELL SUPPORTED

CONTROL

A TRAINING PACKAGE

JOB AIDSCOMMAND SUPPORTPACKAGE

A MOTIVATIONALPACKAGE

A MEASUREMENTPACKAGE

A POLICYPILLAR

TOOL KIT PACKAGE


2. Assessthe Risks


Measures

4. MakeControl

Decisions



SUPERVISE AND REVIEWSUPERVISE AND REVIEW

Supervise and ReviewSupervise and Review

Supervise Review Feedback

SupervisionSupervision

Nothing new here…just like any supervisory process

Insure controls are effective and in place

Monitor progress through schedules

Correct ineffective control measures

Quality Management Tools

• Performance metrics are a challenge• Can’t prove the accident that didn’t happen• Find Q & Q methods to measure control

effectiveness e.g. (Resources expended)• Data Information Knowledge • Trend and Analyze

– Pareto Charts– Bell Curve

Use Quantitative Analysis (Rates Use Quantitative Analysis (Rates and Numbers) when:and Numbers) when:

• You have statistically significant data base

• You need to “Drill Down” to find root causes

• You seek to proactively prove future risk based on historical data

Support trends and analyses with scientific Support trends and analyses with scientific

understandings of accident root causal factorsunderstandings of accident root causal factors

• Critical behaviors & attitudes (Man)• Critical conditions (Medium)• Critical mechanics (Machine)• Critical oversight (Management) • Critical tasking (Mission)

Developing Meaningful Developing Meaningful Performance MetricsPerformance Metrics

• Locate or collect supportive data– Be careful what you ask for

• Select critical indicators

• Establish practical performance measures– Keep them simple

• Trend and Analyze– Use what you collect

Performance Feedback

• Are costs within budget

• Are cost vs. benefit trends favorable

• Are benefits exceeding costs

• Are indirect and direct costs included in the assessments

Factors for ConsiderationFactors for Consideration

• Lessons learned input to databases– Avoid repeating history and expensive lessons

“re-learned”

• Cross-tell between units, departments and divisions (potentially all interested parties)

• Feedback throughout the organization (CEO to new hire)


2. Assessthe Risks


Measures

4. MakeControl

Decisions



Questions?Questions?

Documents

System Safety: A systematic processes. Making Risk Control Decisions 1. Identify the Hazards 2. Assess the Risks 3. Analyze Risk Control Measures 4. Make