Paper Number 2004 - 01 - 01 AN OPEN SYSTEMS APPROACH TO SAFETY MANAGEMENT

All major system accidents have, as one contributing factor, a failure of operational personnel to adhere to certain critical procedures. The typical response is to develop more detailed constraints in an attempt to prevent reoccurrence of that sort of accident. This approach exemplifies the worst of rule-based safety management. It is retroactive and fails to recognize the strength of lessons learned by operational personnel in practice. Safety management must embrace a proactive strategy that takes account of the strength of on-the-job adaptation. Nevertheless, rule-based safety management based on principles of rational design cannot be dismissed entirely. It does produce a globally coherent rule set that can be degraded by local adaptations. In this paper I discuss an opensystems approach to safety management, one that reveals effects of local operational adaptations on global constraints to all participants within the system and also promotes global validation of local adaptations before they are permitted to become entrenched. By this means, it will be possible to build a robust and efficient system through an evolutionary process while at the same time, avoiding reliance on brittle and mutually incompatible rule sets that actually compromise safety.