Thursday, July 31, 2008

Safety Management

I wasn't really very surprised to find out that someone else had been thinking about a narrative database in terms of Aviation Safety. My experience with the Defence Aviation Safety Database is that it gets very wound up over the details and processes. For example, a defective part requires a defect investigation; an insufficient publication needs an amendment. Apart from the occasional question of whether the support systems are sufficient to respond to a booming safety culture that reports every near miss and even the nearly near miss etc, there is the murky circumstances where there was not necessarily a root cause. So this sets us a scene that you have to report a safety event, it is expected to have a root cause or several and something has to be done about it. So apart from a spiralling process driven bureaucracy it becomes unattractive for a person to engage in the safety reporting and thus the system ceases to be useful.

A reasonable person could potentially see that the bureaucratic overheads of telling your story might actually prevent the lesson being learnt. I say this with knowledge of Sensemaker but are there ways of adjusting the micro-culture to talk about its failure and thus change the system we have into something more useful, from the ground up?

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