In detail, the following aims are set for the S-MIS process:
To identify proactive safety indicators considering an organization’s characteristics To periodically assess these proactive safety indicators
To aggregate the assessed proactive safety indicators to an appropriate level To interpret the results of the periodically assessed proactive safety indicators To enable well-founded, safety-related decisions
To achieve these aims, seven process steps are required (cf. Figure 7.1). Three distinguishable groups with clearly different roles participate in these steps.
FIGURE 7.1 Seven consecutive steps of the S-MIS process. The facilitators guide the core group through Steps 1–4 and 6–7. The focus group participates in Step 5.
Core group: Group of experienced safety experts representing the organization in question. The main role of the core group is to develop the indicator model as well as the instruments for indicator measurement, the interpretation of measurement data, and the preparation of safety management decisions.
Focus group: Representatives of the organization or the organizational unit in which the safety indicators are applied. The main role of the focus group is to apply the instruments for indicator measurement developed by the core group. So, the focus group provides quantitative as well as qualitative data regarding the indicators.
Facilitators: The role of the facilitators is to facilitate the S-MIS process by guiding the core group as well as the focus group through their respective process steps. To do so, the facilitators provide methodological know-how required in the different steps, as well as extensive knowledge regarding the state of the art in safety sciences.
Steps 1–4 of the S-MIS process aim to define and operationalize safety indicators on the basis of the core group’s expertise. In Step 5, the safety state of the organization is assessed by the focus group. Finally, in Steps 6 and 7, the core group interprets the results of the assessment and prepares safety-related decisions. The seven steps are described below in more detail. Results from pilot studies are presented for illustrative purpose.
7.6.1 S TEP 1: S AFETY P ERSPECTIVES
7.6.1.1 Aim
In the first step, the core group elaborates in a participatory process a shared understanding of safety.
7.6.1.2 Method
The facilitators present different concepts from safety science (e.g., Amalberti, 2013; Dekker, 2006;
Hollnagel, 2004; Perrow, 1992; Reason, 1990) to the core group. In a guided discussion, the core group’s members connect these concepts with their own organizational experiences. Based on their discussions, the core group members determine requirements for an appropriate model of safety indicators.
7.6.1.3 Example
The facilitators introduce, for example, the different types of unsafe acts according to Reason (1990) to the core group. Reason differentiates unintended from intended unsafe acts. Unintended unsafe acts are caused by either a lack of attention (slip) or a memory flaw (lapse). Intended unsafe acts occur because of either errors in planning or violations. Errors in the planning of a task are more difficult to detect than slips or lapses. Most likely, an error in the planning of a task is not detected before the objective of an action is obviously missed (Hofinger, 2008).
The core group discusses situations in which unsafe acts happened. Doing so, a core group member remembers a situation in which the workload was very high. As a consequence, he had to cut some formal safety rules. According to Reason (1990), the intended skipping of formal procedures is a violation. However, there are reasons for such violations. In order to understand why violations happen and what measures are suitable to prevent violations, the context of the violation needs to be taken into account. This insight is generalized into a requirement for an appropriate model of safety indicators: the context of unsafe acts needs to be considered by the model. Similarly, further requirements were derived from the discussion of the theoretical safety concepts (cf. Table 7.1).
TABLE 7.1
Examples of Requirements for an Appropriate Model of Safety Indicators as Derived by the Core Group
Requirement for an
Appropriate Model of Rationale of Requirement
Safety Indicators
The context of unsafe acts needs to be considered.
If an unsafe act happens, not only the unsafe act and its consequences need to be considered, but also the context of the situation in which the unsafe act happened.
Attitudes need to be represented.
An occurrence investigation can be biased by unconscious attitudes. Hence, attitudes need to be critically reflected.
The concept of resilience needs to be represented.
A safety management system should include resilience as a trait. In case of variation and disturbances, the organization should be able to adapt and sustain normal functioning.
7.6.2 S TEP 2: B ASIC I NDICATOR M ODEL
7.6.2.1 Aim
The aim of the second step is to identify main, high-level indicators on the basis of the core group members’ tacit knowledge regarding enablers of safe acting.
7.6.2.2 Method
Step 2 is completed in three substeps. In substep 2.1, the tacit knowledge of each core group member regarding enablers of safe acting is elicited. To do so, the Model Inspection Trace of Concepts and Relations (MITOCAR) method is applied (Pimay-Dummer, 2006). Each core group member separately completes sentences, for example,
Safe acting is enabled by … if ….
Safe acting is hindered by … if ….
Safe acting is dependent on … because ….
In substep 2.2, the facilitators apply a qualitative content analysis. Diverse types of enablers of safe acting (e.g., influencing factors, preconditions, conditions, and barriers) result from the analysis. Finally, in substep 2.3, the core group clusters the enablers of safe acting. When all enablers are assigned to one cluster, the clusters are labeled. After the labeling, it is verified whether all enablers of a cluster really match the label. If not, the enablers are assigned to a more appropriate cluster. At the end of this process, each cluster represents a high-level indicator regarding enablers for safe acting.
TABLE 7.2
Examples of Results of Steps 2.1 and 2.2: Elicitation of Tacit
Knowledge Regarding Enablers of Safe Acting