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).
There were a few sentinel events that occurred in the high-risk domain that precipitated the need to address safety culture; foremost, the world's worst nuclear power plant accident that occurred at Chernobyl, (former USSR), in 1986. There were 56 fatalities as of 2004, with more casualties occurring on an ongoing basis, mostly due to cancer. Coincidentally, that same year, NASA lost the Challenger Space Shuttle shortly after liftoff and all seven crewmembers perished. Through an extensive investigation, it was revealed that both of these tragedies 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 began to take a serious look at how a pathogenic safety culture can 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 reveals, among other things, deficiencies in management oversight. However, what was not stated in the Probable Cause was the role that a poor safety 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 poor safety 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 safety culture can have a significant contributing affect on accident causation. Indeed, Continental Express Flight 2574 was the watershed event that made aviation take notice of this insidious, latent, and sometimes deadly part of the overall organizational culture.
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 the fact that humans are vulnerable to errors; errors will always occur; and some errors should not carry with them a personally harsh, punitive, resolution 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 stricter manner.
Another important aspect of a Just Culture is how errors are identified, addressed, and mitigated. This is accomplished through a reporting system. Certain incidents and accidents are subject to mandatory reporting, although these reports are typically filed after some kind of visible event. However, it is the errors that occur that are unreported, dismissed as insignificant, or are "too minor to report" (i.e, occur "below the waterline") that are the ones of most interest. It is these unreported errors that, if not addressed in their early or latent stages, may continue to feed an accident chain and lead to higher-level events.
A Just Culture promotes a voluntary error reporting system where the "little and insignificant" mistakes are actively sought. Some of the individual benefits of this system include confidentiality and immunity from punitive action (with certain restrictions, such as criminal intent). Although a voluntary error reporting system can be a highly effective process for identifying errors before they become problematic, the system is not without a dichotomous element; on one hand, voluntary reporting will allow an organization to look deeper into error commissions that it would not otherwise be aware of. On the other hand, employees might be unwilling to voluntarily report errors for reasons such as loss of confidentiality, embarrassment, lack of trust regarding the use of the information, and not enough time or motivation to fill out the required forms. Therefore, trust, transparency, and training are requisite elements for any voluntary reporting system.
Once the error reports are entered into a database, the information can then be analyzed to look for trends or constant errors, "hot spot" identification, and other categories as required by the organization. The final stage of the error reporting system (a system with a goal of reducing errors) might include all, or some, of the following processes; feedback (through newsletters, emails, safety pamphlets), training or retraining, safety seminars, or even job reassignment.
In order to have a profitable organization, you need to have a safe organization. Aviation is a high-risk industry. Safety Risk Management (SRM) is key in proactively addressing hazards and risks before they become incidents or accidents. All organizations should strive to become a high-reliability organization (HRO).
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 in the organizational system for months or even years (also known as latent conditions). The individual that causes the accident may simply be the "trigger puller" of a chain of systemic failures. TACG President Dr. Bob Baron discusses this in more detail in his article, The Organizational Accident. Or not.
According to the primary authors of HRO (Karl Weick and Kathleen Sutcliffe), "HRO describes a subset of hazardous organizations that enjoy a high level of safety over long periods of time. What distinguishes types of high-risk systems is the source of risk, whether it is the technical or social factors that the system must control, or whether the environment, itself, constantly changes. This latter can be controversial to observers as environments change within a range of expected extremes. It is the surprise of the change, its unexpected presentation that influences the level of reliability. The coupling between technology and people creates the socio-technical system."
Four organizational characteristics of the HRO limit accidents or failures:
- Prioritization of both safety and performance, and shared goals across the organization;
- A “culture” of reliability (or, better, attitude toward reliability) that simultaneously decentralizes and centralizes operations allowing authority decisions to migrate toward lower ranking members;
- A learning organization that uses “trial-and-error” learning to change for the better following accidents, incidents, and, most importantly, near misses;
- A strategy of redundancy beyond technology, but in behaviors such as one person stepping in when a task needs completion.
An HRO is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.
There are Five Characteristics of an HRO:
- Preoccupation with failure
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise