The concept of a safety management system (SMS) to control the risks of operational activities has already been introduced in high-risk industries some decades ago. Nevertheless, such an SMS is often criticized as burdensome and complex. Through its requirement to formalise all main activities, the SMS is perceived as bureaucratic and as a vehicle for pure compliance, exemplary for the old view on safety management. Furthermore, the SMS is often perceived as detached from an organisation’s core and operational activities, and as incompatible with local practice. It is questioned whether it can deliver the expected safe performance....

Despite the systems approach to accident analysis being the dominant research paradigm and the concept of SMS being introduced in high-risk industries already for several years, accident investigation practice is still poor in analysing the basic elements that compose a safety management system (SMS) and in embracing system theory. In search of a systemic method for accident analysis that is easily applicable and less resource demanding than the actual methods, Accou and Reniers (2019) developed the SAfety FRactal ANalysis (SAFRAN) method. The method, which is based on the principles of an SMS with resilience as the explicit safety strategy, aims at finding a good balance between examining the complexity of a socio-technical system and making optimal use of limited resources and people; factors that often restrict the possibility for in-depth analysis of accidents. A series of practical tests, often involving active accident investigators, made it possible to examine and validate the SAFRAN method against the criteria Underwood (2013) developed to evaluate systemic accident analysis methods. Based on the performed evaluation, which includes elements related to the development of the method as well as system approach and usability characteristics, the study concludes that, when it comes to applying a systems approach to accident analysis and with the aim of creating more sustainable and resilient performance, the current investigation practice could gain from having the SAFRAN method as part of the investigation toolkit.

In order to manage the performance of socio-technical systems in a safe and sustainable way, the importance of looking at human and organisational factors (HOF) and their contribution to adverse events is widely recognised. In reality, however, the scope of accident and incident investigations stays usually limited to investigating the immediate causes and decision-making processes related to the accident sequence (e.g. Antonsen, 2009). Important factors, including design and planning decisions, contributing to accidents are hereby often overlooked and the weaknesses in the Safety Management System are hardly ever analysed. The SAfety FRactal ANalysis (SAFRAN) method (Accou and Reniers, 2019) can guide investigators in an intuitive and logic way, to ask questions that help to gain deeper understanding of the capability of organisations to monitor and manage safety critical variability. The essence of using the SAFRAN method for evaluating the performance of the different processes in a socio-technical system, is to approach them in a similar way, building on the generic elements that compose a SMS and systematically looking at the HOF that influenced actions and decision making, regardless of the hierarchical level they are situated at. This paper presents the SAFRAN method, specifying its HOF taxonomy and sharing examples of supporting HOF questions. The approach enables non-experts in HOF to systematically identify the different elements that introduce critical variability in performance and to recognise what additional expertise can be called upon when needed.

Although mandatory in most high-risk industries, the safety management system (SMS) is often criticized as burdensome and complex. Through its requirement to formalize all main activities, the SMS is perceived as bureaucratic and a vehicle for pure compliance and Safety I (one). Furthermore, the SMS is often detached from an organization’s core activities, goes against local practice and does not deliver the safe performance that was hoped for. By comparing the model behind SMS with specific requirements for process capability, this paper identifies a safety fractal that reflects the basic requirements that are needed to control safety related activities at all levels within an organization. It is further argued that the constituent elements of this safety fractal are particularly suitable to organize resilient performance, provided that resilience is explicitly identified as the safety strategy to follow and, as such, consequently implemented. This approach is then positioned against common safety management concepts as management system maturity, leadership and safety culture, leading to a systematic and a more comprehensive view on how to measure safety performance and resilience.

The concept of a safety management system (SMS) to control the risks of operational activities has been introduced in high-risk industries already some decades ago. SMS requires accidents/incidents to be reported and analysed and measures to be taken to prevent future events. Additionally, national investigating bodies have been given the role of independently investigating serious events, with the same goal. The current practice in accident and incident investigation however, does not provide a systematic approach to analyse elements of SMS. As a direct consequence, the opportunity to use these investigations for introducing sustainable system changes is often missed. The paper describes the SAfety FRactal ANalysis (SAFRAN) method that is developed to guide investigators to explore the composing elements of an SMS in a natural and logic way, starting from the findings close to operations that explain the occurrence – being the elements accident investigators are first confronted with. The paper further informs on the application of the SAFRAN method to review a selected set of published railway accident investigations, all reporting on occurrences related to over-speeding, possibly resulting in a (lethal) derailment. The depth and focus of the performed investigations is assessed and compared with a reference mode of expected findings that would result from an analysis that is applying the SAFRAN logic. This demonstrates the need, in order to introduce sustainable changes, to focus accident analysis on an organisation's capability of managing the variability that might put successful process performance at risk.