Arbutus Technical Consulting

Arbutus Technical Consulting Blog

This blog contains Bruce Elliott's commentary on issues that seem to him to be important in systems and systems safety engineering. Please feel free to add your comments here or to discuss any of the points raised directly with Bruce.

September 5th, 2010 Is there a fundamental missing from the Yellow Book?

Like a lot of middle-aged men, I could do with losing a bit of weight. But, when I was a young man, I used to be in the unhealthily underweight category on the charts and I can remember being pleased when I put on enough weight to make it to the healthily normal category. The trouble is that over 25 years the gradual increase took me all the through the normal range and out the other side.

Safety management systems suffer from middle-aged spread as well. Over time they accumulate flab in the form of unnecessary process steps, unnecessary documents, unnecessary sections within documents and unnecessarily complex approval processes.

To some extent this happens in all aspects of business but it is worse in safety because of the belief that, if in doubt, it is safer to leave something in than to take it out. Now if we are talking about the safety of the people affected by the system being built, I don’t think that’s true for reasons that I will explain. But there is undoubtedly a personal risk to anyone suggesting taking something out of being accused of recklessness or of being blamed if something were subsequently to go wrong.

So, over time, our rational individual behaviour imposes a ‘ratchet’ on the evolution of safety management system. When we miss something out that should have been there we usually find the mistake later on and put it right. But, when we add something unnecessary, it tends to stay there. Elsewhere, I have argued that ISAs contribute to this ratchet but others contribute as well, for example:

  • A safety engineer is producing a safety plan using the Yellow Book proforma. This has a section on ‘Validation and Verification of External Items’. This seems irrelevant to the project but writing “Not Applicable” might attract adverse comment so they find three paragraphs of anodyne but pointless text to include.
  • As a result of an unfortunate error getting through all stages of project review, the organisation’s head of the relevant discipline decrees that all safety submissions should be sent to them for their review. They regret it almost instantly when their in tray fills up with more material than they can read but leave the instruction in place.
  • A safety authority notices that there is a gap in the safety planning but rather than ask for the safety plan to be reissued, finds it convenient to ask for a separate paper on the topic. The project complies but now there are two overlapping planning documents instead of one.

Over time this gets expensive. We may not see the cost but that doesn’t mean it isn’t there. If our safety plan could have been 20 pages long but ends up being 40 pages long then it takes every new project member another hour to read it. And every update takes another day, including formulating and discussing changes to the unnecessary pages. So these unnecessary pages add a small fraction of a percentage point to the cost of the project. On its own, that cost might not be worth doing anything about but, if it is repeated across many documents then it starts to adds up.

I have kept a rough personal tally during my career of the ratio of the number of hours of technical effort expended on an engineering activity to the number of pages of reviewed technical output. For the majority of the projects that I have calculated this ratio for, it has fallen within a relatively small range. That is what I would expect – the effort of preparing and checking two different pages of technical data must surely be in the same order of magnitude.

Therefore, reducing the number of pages of output from a technical activity should reduce the cost. I won’t claim that reducing the number of pages by 20% will reduce the cost by the same fraction but I would expect a reduction of at least 10%. However there are two important warnings:

  • Firstly, as soon as you use a metric to set targets it becomes distorted and ceases to be a reliable indicator.  So if you ask your staff to produce fewer pages, don’t be surprised if you start to see a smaller font size.
  • Secondly, we can expect to see a cost reduction no matter which pages we cut out. The trick, of course, is to cut out the ones we don’t need. More on that later.

As I have already suggested though, I think that this is about far more than money. I observe that:

  • Unnecessary activities and outputs shift the focus for safety engineers away from working with the project delivery staff in order to control hazards towards creating documents and steering them through approval processes.
  • Having multiple parties reviewing submissions introduces the danger that each party will rely on the other to look at some aspect of the submission. So this aspect gets reviewed less thoroughly than it would if there had been only one party reviewing it.
  • Unnecessary activities and outputs increase the latency of the safety management process, that is, the delay between a design proposal being made and an assessment being available of how safe it is. The longer the latency, the harder it becomes to influence the design.

Therefore, I maintain that, all other things being equal, adding unnecessary activities and output to a safety management programme will make things less safe. I now think there is a fundamental missing from the Yellow Book along the following lines:

Elimination of waste

If your organisation is carrying out some safety management activities which cannot plausibly reduce risk, does not contribute to confidence in safety and it is not required for legal or business reasons, then you should stop doing it. If your organisation’s safety management documents have content which is not associated with reducing risk, does not contribute to confidence in safety and it is not required for legal or business reasons, then you should remove it.

In my opinion, the safety community needs to make sure that all its work is in accordance with this fundamental and it needs to do so urgently. Those of us working in Western economies know that we are in for an extended period of tight budgets. If we don’t cut out waste surgically ourselves, someone else is going to wield the axe indiscriminately.

Moreover, those of us who are working on project and programmes that have been running for some time almost certainly need to take a long, cool look at the structures which have grown around us, identify the parts that are unnecessary and cut them out.

Postscript

By now, some readers must be asking, “Am I talking about ‘Lean safety’ and, if so, why don’t I use the L word?”

I probably am talking about lean safety. I went on a brilliant course with “lean” in its title once, which opened my eyes to how much wasted effort there was around me and how much better things could be of that were eliminated. That surely must have influenced what I have written here.

However, I am wary of giving a name to something which seems to me to be broadly common sense. Once you have a name then, soon after, you have a project team, a steering group, newsletters and mugs. Perhaps that’s the right thing to do for you but it’s certainly not necessary. Some people swear by their patent dieting method but, if I were just to eat less and exercise more, I would lose weight. I could start doing that today if I wanted to without giving the process a name. In just the same way, you and I could just ask ourselves, “Do we need all of this?” the next time we wrote or reviewed a safety paper. I plan to do just that.

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