Premium on Safety - Issue 48, 2023 - 11

BEST PRACTICES
*before the big bang. (*Read the book Left of
Bang for how soldiers use this same process
for safety.)
A couple of early industrial safety paradigms
inspired SMS. These help unpack and
decode some of the tenets of safety culture.
Herbert William Heinrich's Accident
Pyramid from the 1931 book Industrial
Accident Prevention: A Scientific Approach
graphically depicts the percentage of activities
that succeed due to luck alone. When we rate
an activity's safety only by its success, we
disregard the complicity of statistical threats;
The Aviation Safety Reporting
System, managed by NASA,
has been an early adopter of
safety culture and a model for
aviation safety improvement. This
system solicits voluntary reports
and provides error forgiveness
in all areas of aviation, from
maintenance to piloting and ATC.
we are using luck as a planning tool. " In a
workplace, for every accident that causes a
major injury, there are 29 accidents that cause
minor injuries and 300 accidents that cause
no injuries, " Heinrich wrote.
In my flight organization, we coded success
by luck or a near-miss as an accident
waiting to happen. Statistical " dumb
luck " permits success in risky operations
that could just as easily have become an
accident. With honest reflection, every pilot
can confess to a few of these. SMS aims
to identify and expose these near-miss
activities, determine their motivations, and
retire them. Highly risky behaviors are
removed from future operations.
This kind of accountability, honest reflection,
and a statistical understanding that just
because it worked before does not assure
future success. Every new activity is a coin toss
dependent upon statistical risk analysis. Our
shared human bias toward repeatability-the
future will necessarily resemble the past-
must be rooted out with honest safety culture.
Normalizing risks through lucky success is just
drifting into failure.
James Reason's famous Swiss Cheese
Model of safety is another paradigm
that points out the eventual failure of all
safety layers without continuous oversight.
Reason popularized an understanding of
James Reason's famous Swiss Cheese Model of safety is
another paradigm that points out the eventual failure of
all safety layers without continuous oversight.
latent failures that lie dormant in systems
and wait for opportunities to become
accidents. These are the target for safety
culture and SMS. A well-designed safety
system erects many checks that impede an
accident trajectory and with " safety gates "
preventing disaster. Unfortunately, the
holes in the Swiss cheese occasionally line
up, and tragedy results. Latent failures need
to be unearthed before the boom. Safety
requires ongoing analysis and redirection to
maintain safe operation.
11

https://www.goodreads.com/en/book/show/22663095 https://www.goodreads.com/en/book/show/22663095 https://www.memic.com/workplace-safety/safety-net-blog/2019/october/heinrichs-pyramid-does-it-hold-up-90-years-later https://www.memic.com/workplace-safety/safety-net-blog/2019/october/heinrichs-pyramid-does-it-hold-up-90-years-later https://www.researchgate.net/publication/282940101_From_theory_to_practice_Itinerary_of_Reasons'_Swiss_Cheese_Model https://www.researchgate.net/publication/282940101_From_theory_to_practice_Itinerary_of_Reasons'_Swiss_Cheese_Model

Premium on Safety - Issue 48, 2023

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