We all aim for safe processes. However, providing safety is a complex endeavour. What is it that makes a process safe? And what is the contribution of humans? It is very common to consider humans a risk factor prone to errors. Therefore, we implement sophisticated safety management systems (SMS) in order to prevent potential "human failure". These SMS provide an impressive increase of safety.
In safety science this approach is labelled "Safety-I", and it starts to be questioned because humans do not show failures only. On the contrary, they often actively contribute to safety, sometimes even by deviating from a procedure. This "Safety-II" perspective considers humans to be a "safety factor" as well because of their ability to adjust behaviour to the given situation. However, adaptability requires scope of action and this is where Safety-I and Safety-II contradict each other. While the former restricts freedom of action, the latter requires room for manoeuvring.
Thus, the task of integrating the Safety-II perspective into SMS, which are traditionally Safety-I based, is difficult. This challenge was the main objective of our project. We discovered two methods that contribute to the quality of SMS by integrating Safety-II into SMS without jeopardizing the Safety-I approach.
Inhaltsverzeichnis
Preface
1 Introduction
2 Safety Management Systems (SMS)
2.1 Pillars of SMS
2.2 A Safety-II based Tool Developing Existing Safety-I based SMS
3 Safety-I and Safety-II
3.1 Safety-I
3.2 Safety-II
3.3 Safety-II as Complementarity and Extension of Safety-I
4 Theoretical Background of the Measure Evaluation Tool (MET)
4.1 Efficiency-Thoroughness Trade-Off
4.2 One-Best-Way, Bimodality and Work-As-Imagined
4.3 Performance Adjustments, Prioritizations, Variability and Work-As-Done
4.4 Safety Boundaries
4.5 Compliance, Non-Compliance and Over-Compliance
4.6 Factors influencing Activity Performance
4.6.1 Activity and Output
4.6.2 Operating Conditions: Input, Time, Control, Precondition and Resources
4.6.3 Primary and Secondary Operating Conditions
4.6.4 Focus of Operating Conditions: Adverse Event vs. Normal Operation
5 The Measure Evaluation Tool (MET)
5.1 Objectives of the MET
5.2 Steps of the MET
5.3 Guiding Questions of the MET
5.4 Application Concept of the MET
6 Guidelines for Implementing the MET in existing SMS
6.1 Process Integration
6.2 Change Process
6.3 Training Need
7 Theoretical Background of the Effectiveness Assessment Tool (EAT)
7.1 Levels of Implementation Check and Effectiveness Assessment
7.1.1 Level 1 HF-Measures
7.1.2 Level 2 Implementation
7.1.3 Level 3 Knowledge, Skills and Attitude
7.1.4 Level 4 Behavior
7.1.5 Level 5 Transfer Promoters and Barriers
7.1.6 Level 6 Outcome
7.2 Implementation Check
7.3 Effectiveness Assessment
8 The Effectiveness Assessment Tool (EAT)
8.1 Objectives of the EAT
8.2 Steps of the EAT
8.2.1 Step 1 Development of Indicators
8.2.1.1 Definition of Construct
8.2.1.2 Definition of Indicators
8.2.1.3 Definition of References
8.2.2 Step 2 Descriptive Measurement of Indicators
8.2.2.1 Quality Criteria
8.2.2.2 Methods of Data Collection
8.2.2.3 Methods of Data Evaluation
8.2.3 Step 3 Normative Assessment of Indicators
8.3 Guiding Questions of the EAT
8.4 Application Concept of the EAT
9 Guidelines for Implementing the EAT in existing SMS
9.1 Process Integration
9.2 Change Process
9.3 Training Need
10 Bibliography
11 List of Figures
12 List of Tables
