THE HUMAN ERROR
RISK ANALYSIS
As quoted in my last article (April 2016), risk and incident data analysis is the engine that drives safety management systems (SMS). This is where the work gets done to lower the risk to Safety to as low as reasonably practical (ALARP). My father was fond of sayings
that would often provoke thought and carry a deeper meaning. One he would tell me as a know-it-all teenager was, “You don’t know what you don’t know.” When it comes to SMS, this is exactly right and is the purpose of this article. Many companies proudly proclaim that they don’t need this SMS because they haven’t killed anyone yet. Whenever I used the word yet as a justifi cation for doing something, my father would tell me that yet means “you’re eligible to.” I’ve never forgotten that and I hope that whenever you use that word you’ll remember its deeper meaning as well.
MANAGING RISK REQUIRES
FIVE “A” STEPS A1. Awareness -We must fi rst be aware that there is a risk. For this, a system has to be in place to raise the initial awareness. Training is required here.
A2. Acknowledge - We must acknowledge that there is, in fact, a risk and determine how serious it is. I believe that all risks, audit fi ndings or anything that can cause us grief are initially reported on one form and separated at this point. Thus, a reported pothole will be on the same form as the audit fi nding that pilots are exceeding their fl ight hours. Who might decide
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and deal with the corrective action (CA) will be diff erent. A pothole can be looked at as a frivolous thing to report but one almost destroyed a company. This company had an SMS in place and determined that a pothole on the side of the road up to their hangar was something that could be fi xed when it “got around to it.” The company trailered its helicopters to the jobs behind a truck that carried extra fuel and chemicals to be sprayed. They were late for an important job and as they sped down the hill, a client in his Mercedes was coming up the hill. Murphy’s Law determined that they would meet right where the pothole was. The truck bounced through the pothole but the smaller trailer tires didn’t. As the axle was torn back it swung the truck into the other lane, right behind the Mercedes. A split second diff erence in time or speed and there would have been a huge fi re, with loss of life and possibly
BY GORDON DUPONT
the company. Remember that SMS is simply “putting a system in place that sweats the small stuff so you never have to sweat the big stuff .”
A3. Analyze - We analyze the risk and develop ways to eliminate or mitigate (lessen) the risk or, as a last resort, educate ourselves on how to avoid it.
A4. Act On - There must be someone responsible for the risk with a timeline in which to accomplish the CA. Something has to be done. Feedback must also be provided.
A5. Analyze Again - We must monitor and improve if necessary or possible.
Let’s run through the matrix. You see something that could cause
your company grief or you almost made an error that, had it happened, would have caused grief. Being a Safety-minded person, you complete a hazard report form detailing the hazard and including a suggested CA
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