The Investigation of Safety Management Systems and Safety Culture

Since every Safety Management System (SMS) is intended to provide a framework by which an organisation manages risk, it is inevitable that accident investigators will take a close interest. The good investigator will always want to understand how the SMS was intended to control risk and how this
control failed when put to the test.
This paper seeks to provide a practitioner’s view on the investigation of SMS. In doing so it hopes to answer the following questions: What are the key elements of a typical safety management system that an investigator is likely to encounter? How should the role of these elements in the
causation of an accident be investigated? How have SMSs been featured in real investigations? How should the investigator address safety culture? Can investigations influence the shape of safety management systems?

Discussion Paper 2017-20