What Is Safety Culture?
"Safety culture can be defined as the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety; act to preserve, enhance, and communicate safety concerns; strive to actively learn, adapt, and modify (both individual and organizational) behavior based on lessons learned from mistakes; and be rewarded in a manner consistent with these values" (Zhang, Wiegmann, von Thaden, Gunjan, & Mitchell, 2002).
Without true management buy-in and commitment, safety will not be effective at lower levels, and programs that depend on a healthy safety culture, such as SMS and Human Factors, will be bound to fail. Accidents are typically not caused by a single errant individual, but rather a chain of events that may have been hiding dormant in the system for months or even years (also known as latent conditions). The individual that causes the accident may simply be the "trigger puller" for a chain of systemic failures. TACG President Dr. Bob Baron discusses this in more detail in his article The Organizational Accident. Or not.
There were a few sentinel events that occurred in high-risk industries that precipitated the need to address safety culture; foremost, the world's worst nuclear power plant accident that occurred at Chernobyl in 1986. That same year, NASA lost the Challenger space shuttle shortly after liftoff. Through an extensive investigation, it was revealed that both of these accidents had human factors and safety culture-related underpinnings that attributed to the trigger events. However, it wasn't until the inflight breakup of Continental Express Flight 2574 in 1991 that the aviation industry, specifically, began to take notice of how a pathogenic safety culture could contribute to an aircraft accident. Among the findings of the National Transportation Safety Board (NTSB) investigation of Flight 2574:
The failure of Continental Express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane's horizontal stabilizer deice boots that led to the sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose-down pitchover and breakup of the airplane. Contributing to the cause of the accident was the failure of Continental Express management to ensure compliance with the approved maintenance procedures, and the failure of the FAA surveillance to detect and verify compliance with approved procedures (NTSB, 1992).
This report revealed, among other things, deficiencies in management oversight. However, what was not stated in the Probable Cause was the role that corporate culture played in the accident chain. This was not elucidated until John Lauber (then NTSB board member) offered a dissenting opinion. Lauber believed that the Probable Cause was shortsighted, due to the fact that a deficient corporate culture was not included as part of the Probable Cause. In his dissenting opinion letter, Lauber suggested that the Probable Cause should be rewritten as follows:
The National Transportation Safety Board determines that the probable causes of this accident were (1) the failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures, and (2) the consequent string of failures by Continental Express maintenance and inspection personnel to follow approved procedures for the replacement of the horizontal stabilizer deice boots. Contributing to the accident was the inadequate surveillance by the FAA of the Continental Express maintenance and quality assurance programs (NTSB, 1992).
It was this dissenting opinion by Member Lauber that set the wheels in motion for the proposition that a pathogenic (or non-existent) safety culture can have a significant contributing affect on accident causation. This subsequently led to the development of a Corporate Culture checklist, which the NTSB uses as part of accident investigations in the current day.
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According to Professor James Reason, "A Just Culture promotes an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior." Reason also states that a Just Culture is, "A way of safety thinking that promotes a questioning attitude, is resistant to complacency, is committed to excellence, and fosters both personal accountability and corporate self-regulation in safety matters."
A Just Culture promotes safety by acknowledging "to err is human." Errors will always occur. However, some errors should not be addressed by retribution, when in fact the system itself might be flawed. However, a clear line must be drawn which differentiates between what is common everyday human error versus flagrant or willful violations that could, and should, be dealt with in a punitive manner.
Presentation on Building a Strong Safety Culture