Safety and Risk Management Systems: the Fifth Echoes

  1. Dr. Romney B. Duffey BSc, PhD, FASME scientist manager speaker Principal Scientist ASME Fellow past Chair active member1 and
  2. John W. Saull CEng, FRAeS, DAE aviation regulator executive director head member chairman2

Published Online: 31 OCT 2008

DOI: 10.1002/9780470714461.ch7

Managing Risk: The Human Element

Managing Risk: The Human Element

How to Cite

Duffey, R. B. and Saull, J. W. (2008) Safety and Risk Management Systems: the Fifth Echoes, in Managing Risk: The Human Element, John Wiley & Sons, Ltd, Chichester, UK. doi: 10.1002/9780470714461.ch7

Author Information

  1. 1

    Atomic Energy of Canada (AECL), Canada

  2. 2

    International Federation of Airworthiness (IFA), UK

  1. The concept of measuring safety management given in this Chapter was first established in R.B. Duffey and J.W. Saull, Measuring and Predicting Organizational Learning and Safety Culture, Proc. The Eighth International Conference on Probabilistic Safety Assessment and Management (PSAM 8), New Orleans, USA, 14–19 May 2006.

Publication History

  1. Published Online: 31 OCT 2008
  2. Published Print: 24 OCT 2008

ISBN Information

Print ISBN: 9780470699768

Online ISBN: 9780470714461



  • Safety Management Systems (SMS);
  • Safety and Risk Management Systems - Fifth Echoes;
  • safety culture and safety surveys - learning paradox;
  • Kean Canyon Plant and Occupational Safety and Health Administration (OSHA);
  • learning environments and safety cultures;
  • human error rates passing red lights;
  • Instantaneous Rates (IR);
  • scrams and unplanned shutdowns;
  • FDA National Electronic Injury Surveillance System (NEIS)


This chapter contains sections titled:

  • Safety Management Systems: Creating Order Out of Disorder

  • Workplace Safety: The Four Rights, Four Wrongs and Four Musts

  • Acceptable Risk: Designing for Failure and Managing for Success

  • Managing and Risk Matrices

  • Organisational Factors and Learning

  • A Practical Safety Culture Example: The Fifth Echo

  • Safety Culture and Safety Surveys: The Learning Paradox

  • Never Happening Again: Perfect Learning

  • Half a World Apart: Copying the Same Factors

  • Using a Bucket: Errors in Mixing at the JCO Plant

  • Using a Bucket: Errors in Mixing at the Kean Canyon Explosives Plant

  • The Prediction and Management of Major Hazards: Learning from SMS Failures

  • Learning Environments and Safety Cultures: The Desiderata of Desires

  • Safety Performance Measures: Indicators and Balanced Scorecards

  • Safety and Performance Indicators: Measuring the Good

  • Human Error Rates Passing Red Lights, Runway Incursions and Near Misses

  • Risk Informed Regulation and Degrees of Goodness: How Green is Green?

  • Modelling and Predicting Event Rates and Learning Curves Using Accumulated Experience

  • Using the Past to Predict the Future: How Good is Good?

  • Reportable Events

  • Scrams and Unplanned Shutdowns

  • Common-Cause Events and Latent Errors

  • Performance Improvement: Case-by-Case

  • Lack of Risk Reduction: Medical Adverse Events and Deaths

  • New Data: Sentinel Events, Deaths and Blood Work

  • Medication Errors in Health Care

  • Organisational Learning and Safety Culture: the ‘H-Factor’

  • Risk Indicator Data Analysis: A Case Study

  • Meeting the Need to Measure Safety Culture: the Hard and the Soft Elements

  • Creating Order from Disorder

  • References