Complicated systems cause errors

The annual MSSM conference on safety, health and environment onboard was held on 26-27 August in Nyborg, Denmark. Much of the conference was about safety culture, and I will let Professor Sidney W. Dekker summarise: ”Parts fail, but systems drift into failure”.
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Accidents are a result of organizational behavior and system errors, which due to strict financial thinking lead to the collapse of safety systems, writes Matserik Eriksson.

The annual MSSM conference on safety, health and environment onboard was held on 26-27 August in Nyborg, Denmark.
Much of the conference was about safety culture, and I will let Professor Sidney W. Dekker summarise:
”Parts fail, but systems drift into failure”. By this he means that the standardisation of equipment, design and other factors increase safety but the increasing complexity of all the systems reduces the freedom of action of the individual.
Our technical systems have developed so quickly that we do not understand how they work, and so we focus on the behaviour of the individual when something goes wrong instead of
looking at the system which the individual is working in.
Safety rules hopelessly behind
There is no simple solution to the problem and systems only become more complicated as time goes by. Our safety rules and safety cultures have lagged way behind this development.
Accidents are a result of organizational behaviour and system errors, which lead to the collapse of safety systems due to strict financial thinking.
So how can we avoid this drifting towards mistakes? We must have an open safety culture where everybody dares to express their opinion and where managers dare to listen to ”bad news”. We must listen to others’ viewpoints and consult people in the organization in order to gain more perspectives on things. The more diversity there is at a workplace, the safer it becomes. This can only be achieved in a decentralized organization where you work with social diversity as early as the recruiting stage.
The longer you wait and the older the crew becomes, the more difficult it is to achieve an open attitude in a working group or an organization. You have to keep the discussion moving forwards and not assume that successes in the past are a guarantee for future security. Professor Dekker says that, ”Human error is not the reason behind accidents or near-accidents. Human error is a symptom of deeper problems.” This opinion is also expressed by Martin Hernqvist from the Swedish Club Academy, who points out that there are still many accidents and near-accidents at Swedish workplaces. Why? We must find another approach to human error. The biggest problem is that we do not question things when we see that something has gone wrong, and this is often due to fear. And how should we solve this problem? Well, we must create workplaces that are more people-friendly, open and encourage people to question issues. We need to change attitudes, not knowledge.
matserik_erikssonMatserik Eriksson
/ Stena Line Scandinavia AB
and member of the SAN board

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