Iceberg Thinking and Safety Defences Chris Langer CIRAS April 2016 - - PowerPoint PPT Presentation

Iceberg Thinking and Safety Defences

Chris Langer CIRAS April 2016

The Iceberg

• new reps’ meetings
• asking questions:
• drivers
• culture
• UK interest:
• across transport

sectors

• International interest:
• Spain, Germany, South

Korea, and US

Drivers of reporting behaviour? Events

• performance before safety
• blame
• complacency: individual and management
• apathy

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-I Safety-II

• Reactive approach
• Focuses on things that go wrong
• Emphasis on human error
• Inclination to blame frontline staff
• Proactive approach
• Focuses on things that go right
• Emphasis on variability in

human performance

• Shared responsibility for system
• utcomes

Safety-I

Confidential reporting can help drive Safety-II