What is all this talk about system safety?

In applying system safety, we gain many other secondary benefits that enhance the system and the designs within the system, and there are further improvements in decision-making, and operations management. Consider some of the additional enhancements that system safety enables:

Proactive thinking?-?System safety requires thinking out of the box and looking forward to considering what can go wrong in a particular situation and then planning on taking steps to correct the situation. A fly-fix-fly mentality does not prevent accidents --- but forward thinking does.

Avoiding common pitfalls, or lack of hindsight –?Typically accident investigators point out were, how, or who made the decision errors that had caused the problem that contributed to the accident. Applying good system safety practice helps avoid these pitfalls associated with safety-related decisions. There are common themes[i]?that are linked with safety-related decisions and as to why accidents happen:

???Problems, which have previously shown up as apparently minor incidents or near misses but have never been properly assessed.?

???No one ever imagined that the circumstances of the accident could happen, so there were no mitigations to deal with them.

???People thinking that it is someone else’s job to deal with the problem, hazard, or risk.

???Sloppy process, task, or work practices building up over time because they are easier and cheaper.

???Systems being modified or used in ways for which were not designed or intended.

???People fail to report or state a safety concern because of many reasons: political, social, or psychological motives.

???The local or over all safety culture does not support an open system safety process.

???People generally do not understand risks and probabilities and they tend to become over complacent when exposed to a particular risk when harm has not occurred.

???If not directly exposed to the risk, decision makers may not appreciate the magnitude of the risk. The further away the person is from the hazard the less it is perceived as dangerous.?

Enhanced life cycle planning?–?The total support system is evaluated, and planning is considered for safety logistics. The system is supported throughout its life cycle. Consideration is given to risks associated with deployment, installation, assembly, maintenance, shipping, testing, training, literature development, and disposal. Note that accidents can happen at any time during the life cycle of the system.

Risk-based decision-making?–?Safety issues are evaluated by their risks and risk ranking is conducted. The important safety issues are the high or medium risks. Resources can then be allocated by risk and the importance of the mitigation. Expenditures are made based upon risk and risk drivers --- hazards and mitigation.??

Expedited decision-making?-?Risk-based decision-making saves time and decreases excessive discussion or wheel spinning. What is and what is not important is defined by risk rather than subjective biases or what is perceived to be an important consideration that does not consider safety.

System perception –?System safety facilitates discussion and thought through a holistic or inclusive view. We can consider the big picture and look at all elements of the system: the human, hardware, software, and environment. No aspect of the system is excluded; consideration is given to operations, functions, tasks, procedures, and architecture.??

Integrated perception -?Accidents can happen anywhere, at any time, for many diverse reasons. System accidents can occur because of many different contributors, and accidents cut across many abstract boundaries, i.e., business, divisions, or organizations.??System safety looks at potential accidents holistically. When potential accidents are evaluated an integrated picture of what can happen in the real world is estimated. A common means of integration is the contemplation of system accidents or system risks. Consider these examples: an error is software code causes a processor to inadvertently shut down and result in loss of communication at a critical time. A technician is accidentally shocked, drops a tool into a rack, which causes a fire and loss of communication.?

Consensus decision-making –?One person should not have to make a safety-related decision, which affects a high or medium risk, without support, input, and documentation. Responsibility for the safety of the system should be shared between participants. Good consensus decision-making enhances safety. Experience from many points of view can improve decision-making. Formal and informal consensus safety reviews are conducted, and system safety efforts are enhanced by agreement. System Safety Working Groups review or conduct analyses, studies, assessments, and conduct closed-loop hazard tracking and risk resolution.?

Validation and verification of mitigations -?A safety validation and verification process is conducted. Mitigation is validated when it is determined that it will fix the safety problem. Verification addresses the formal implementation of the mitigation within the system. The mitigation is formally accepted into the design, procedure, or process and there is evidence and documentation that the mitigation will work or is working.

Evidence of Best Practice –?An important part of the system safety process assures proper documentation of risk-based decisions, which have been made by open consensus. Documents such as safety engineering reports, safety assessment reports, meeting minutes, action records, all document the system safety process. Analyses, studies, and assessments are openly conducted, discussed, and reviewed. The results of discussions and reviews are recorded. Peer review of system safety efforts is also conducted, which further enhances the process. Following and documenting system safety practices also supports liability claims defense.

Closed-loop decision-making?–?As a result of system safety analysis, safety problems are characterized by hazards and risks. Every identified risk is evaluated and ranked. Risks are considered open or monitored until they are mitigated. Mitigation is applied formally by safety requirements, hazard controls, or risk controls.

User participation –?An open activity has many benefits and systems are improved by the participation of the people that are involved and are part of the system under evaluation. People with various experience help enhance system safety efforts. Input and feedback are used and needed from participants such as: operators, managers, technicians, engineers, trainers, and other subject matter experts. System safety can integrate inputs and feedback into analyses, studies, tests, simulations, and observations.

Understanding the impacts of change on risk –?According to system safety logic any change within the system that can affect safety must be analyzed. To understand the safety effect, analysis is needed to identify medium or high risks. System safety methods, which involve change analysis and comparative risk assessment, are applied to identify, and evaluate hazards and risks.

Improvements in design and processes via concurrent engineering?– Designs and processes are improved and enhanced when concurrent engineering is applied. System safety stems from concurrent system engineering principles, which are comprised of specialties in reliability, maintainability, quality, logistics, human factors, software performance, and system effectiveness, all are important aspects in addressing systems. Different system specialists work together in concert to develop good system requirements that collaborate, that are integrated.?

Limited thinking…

Why do we always limit ones thinking when it comes to understanding system risks??

Why don't people get integration of system elements: hardware, software, firmware, logic, the human and environment?

Why don't we understand how to think in order to analyze system risks?

Why can't we understand all the aspects of the integrated human and system?

Why don't we understand all contrivances and abstractions of entities in that it is all connected?

Maybe because very few understand how to comprehend this notion of a system risk?

Limited thinking results in uncontrolled risks so stop blaming the exposed and operators when system accidents and other adverse system outcomes happen. Do you actually understand the different forms of thinking required to analyze system risks??

Methods of Thinking: Holistic thinking, Systems’ thinking, Critical thinking, Inductive and deductive thinking, Reactive, proactive, and predictive thinking, Abstract thinking, Groupthink, Consensus thinking, Micro, Macro, Inclusive, Exclusive, Naked Man, Temporal, Continuum, Subjective, Objective, and various combinations…

Perspectives and Abstractions: Big picture perspective, Decompositions or breakdown, Integrated perspective, Interface perspective, Operational perspective, User perspective, Functional perspective, Structure/Physical perspective, Similarity comparison or generic perspective, State variation, fuzzy logic, and continuum perspective, Temporal perspective, Quantitative/Qualitative perspective, Scientific perspective….?

[i]?Some of the common themes were cited in the following reference: Rhys David, An Introduction to System Safety Management and Assurance, Advantage Consulting Ltd., under contract to MOD, 2005, page5