How do Safety Management Systems Work?

Here’s Designing an Effective Safety Management System (SMS) by Prof. Nancy Leveson

Mostly theory, discusses SMS in general, with the exception of a graphic about the Herald of Free Enterprise nothing about maritime. This part about culture is relevant.

With regards to culture - this graphic:

image

The middle and top levels are not the culture; they merely reflect the organizational culture. While attempting to make changes only at the top two levels may temporarily change behavior and even lower risk over the short term, superficial fixes at these levels that do not address the set of shared values and social norms on the bottom level are likely to be undone and become ineffective over time.