Safety: mischief, mishap or mayhem

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Courtesy of WSP | Parsons Brinckerhoff

Over the past decade there have been numerous organisational disasters that have caught the attention of the public, no more so than the recent disaster involving the Russian Submarine Nerpa in which 20 people died as result of a Freon gas release. This raises the question: are such incidents the result of freak mishaps and individual mischief or does safety culture offer an explanation as to why these incidents occur. If so, can we prevent them in the future?

At this time the events surrounding the cause of Nerpa disaster are still unknown, but news reports state that a possible cause was due to an individual crew member activating a fire alarm that led to the release of Freon gas. The apportioning of blame to a specific individual echoes the way in which many such disasters were in the past labelled as the result of operator error or behaviour. Research from the Health and Safety Executive in the UK suggests that over 95 per cent of incidents involve human behaviour, so such claims may not be entirely incorrect. However, what has to be realised is that human risk taking behaviour does not occur in isolation of the working environment, but can often be the result of its influence. The environmental influence to which this alludes is better known as ‘Organisational Safety Culture’.

The ‘Organisational Safety Culture’ is the underlying beliefs and values that underpin decision making and safe working practices within an organisation. Failings in Safety Culture have been identified in many major organisational disasters such as, Chernobyl. A safety culture can be likened to the ‘safety personality type’ of an organisation in that it has a major characteristic or ‘mind set’ that provides an overall impression about the organisation. There are numerous ways in which these typical ‘mind sets’ have been described, but one of the best known descriptions by Parker and Hudson in their safety culture maturity model. Safety culture to them is likened to the development stages of a child, in that an organisation matures its safety culture over time reaching a development stage or ‘mind set’ that makes the organisation more impervious to incidents. According to Parker and Hudson there are five such development stages, these being:

  • Pathological – which is where the organisation perceives safety as something which hinders performance and therefore is only given consideration when a regulator becomes involved
  • Reactive – safety is only important once something has happened
  • Calculative – safety is managed on the basis of risk with procedures and documented procedures to control risks and the use of incident statistics to measure the reduction of loss e.g. Lost Time Incident Frequency Rate.
  • Proactive – safety is managed through the involvement of the workforce and makes use of proactive measures of safety, not just lagging indicators of safety performance i.e. incident data.
  • Generative – safety is a value that has been internalised by everyone, the defining element of this type of culture is that despite there being next to zero incidents the organisation possesses a chronic unease about safety that drives continuous improvement.

Typically, most organisations in the modern world will achieve a calculative level of Safety Culture that drives safety through the use of systems developed and backed by the use of risk assessment. Unfortunately, it is the reliance on these systems in the absence of proactive measures of safety and workforce involvement that leads to complacency - what is termed the ‘Safety Culture Paradox’. This phenomenon exists when organisations feel that they have achieved control over safety and relax. This results in an unrealised erosion in safety until the organisation experiences a serious incident, a phenomenon called the ‘Safety Wave’. This is when an organisation has a period of low incident levels, which results in the ‘lessons learned’ from previous incidents being forgotten and culminates in a serious incident(s) that shocks the organisation into action. This cycle occurs until the next serious incident happens again.

We might question whether the ‘Safety Wave’ was the reason for the Nerpa disaster. In 2000 the Russian submarine Kursk was lost when a torpedo exploded on board the vessel. Four years later another vessel had two ballistic missiles become stuck in their silos and a year after that a submarine became entangled in nets and cables leaving it stranded on the floor of the Pacific Ocean. These incidents were a possible indicator of another disaster yet to come. However, we must not be too critical of the Russian Navy as there are similar examples from industry across the board which indicate that, by no means whatsoever, the ‘Safety Wave’ phenomenon is unique to one type of organisation. This therefore poses the question: what do we need to learn from such events? To understand this we need to look at how organisational accidents occur.

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