A systems approach to risk management through leading safety indicators

The goal of leading indicators for safety is to identify the potential for an accident before it occurs. Past efforts have focused on identifying general leading indicators, such as maintenance backlog, that apply widely in an industry or even across industries. Other recommendations produce more sy...

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Published in:	Reliability engineering & system safety Vol. 136; pp. 17 - 34
Main Author:	Leveson, Nancy
Format:	Journal Article
Language:	English
Published:	Elsevier Ltd 01.04.2015
Subjects:	Accidents Causation Deviation Failure Hazards Indicators Leading indicators Mathematical models Process safety Risk management Safety STAMP STPA System safety System safety Process safety STAMP Leading indicators Risk management STPA
ISSN:	0951-8320, 1879-0836
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Abstract	The goal of leading indicators for safety is to identify the potential for an accident before it occurs. Past efforts have focused on identifying general leading indicators, such as maintenance backlog, that apply widely in an industry or even across industries. Other recommendations produce more system-specific leading indicators, but start from system hazard analysis and thus are limited by the causes considered by the traditional hazard analysis techniques. Most rely on quantitative metrics, often based on probabilistic risk assessments. This paper describes a new and different approach to identifying system-specific leading indicators and provides guidance in designing a risk management structure to generate, monitor and use the results. The approach is based on the STAMP (System-Theoretic Accident Model and Processes) model of accident causation and tools that have been designed to build on that model. STAMP extends current accident causality to include more complex causes than simply component failures and chains of failure events or deviations from operational expectations. It incorporates basic principles of systems thinking and is based on systems theory rather than traditional reliability theory. •Much effort has gone into developing leading indicators with only limited success.•A systems-theoretic, assumption-based approach may be more successful.•Leading indicators are warning signals of an assumption’s changing vulnerability.•Heuristic biases can be controlled by using plausibility rather than likelihood.
AbstractList	The goal of leading indicators for safety is to identify the potential for an accident before it occurs. Past efforts have focused on identifying general leading indicators, such as maintenance backlog, that apply widely in an industry or even across industries. Other recommendations produce more system-specific leading indicators, but start from system hazard analysis and thus are limited by the causes considered by the traditional hazard analysis techniques. Most rely on quantitative metrics, often based on probabilistic risk assessments. This paper describes a new and different approach to identifying system-specific leading indicators and provides guidance in designing a risk management structure to generate, monitor and use the results. The approach is based on the STAMP (System-Theoretic Accident Model and Processes) model of accident causation and tools that have been designed to build on that model. STAMP extends current accident causality to include more complex causes than simply component failures and chains of failure events or deviations from operational expectations. It incorporates basic principles of systems thinking and is based on systems theory rather than traditional reliability theory. •Much effort has gone into developing leading indicators with only limited success.•A systems-theoretic, assumption-based approach may be more successful.•Leading indicators are warning signals of an assumption’s changing vulnerability.•Heuristic biases can be controlled by using plausibility rather than likelihood. The goal of leading indicators for safety is to identify the potential for an accident before it occurs. Past efforts have focused on identifying general leading indicators, such as maintenance backlog, that apply widely in an industry or even across industries. Other recommendations produce more system-specific leading indicators, but start from system hazard analysis and thus are limited by the causes considered by the traditional hazard analysis techniques. Most rely on quantitative metrics, often based on probabilistic risk assessments. This paper describes a new and different approach to identifying system-specific leading indicators and provides guidance in designing a risk management structure to generate, monitor and use the results. The approach is based on the STAMP (System-Theoretic Accident Model and Processes) model of accident causation and tools that have been designed to build on that model. STAMP extends current accident causality to include more complex causes than simply component failures and chains of failure events or deviations from operational expectations. It incorporates basic principles of systems thinking and is based on systems theory rather than traditional reliability theory.
Author	Leveson, Nancy
Author_xml	– sequence: 1 givenname: Nancy surname: Leveson fullname: Leveson, Nancy email: leveson@mit.edu organization: Aeronautics and Astronautics, Engineering Systems, MIT, Cambridge, MA, USA
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Snippet	The goal of leading indicators for safety is to identify the potential for an accident before it occurs. Past efforts have focused on identifying general...
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SubjectTerms	Accidents Causation Deviation Failure Hazards Indicators Leading indicators Mathematical models Process safety Risk management Safety STAMP STPA System safety
Title	A systems approach to risk management through leading safety indicators
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