Safety Culture

Publications

Illusions of Safety. Invited position paper for Workshop on Organizational Analysis in High Hazard Production Systems: An Academy/Industry Dialogue, MIT Endicott House, April 15-18, 1997, NSF Grant No. 9510883-SBR (C. Perin and J. S. Carroll).

Workshops

7th Annual CHPRA Workshop: Lessons Learned from Cross Industry Benchmarking. June 7th & 8th 2001, Inner Harbor Hotel, Baltimore, Maryland.

Articles

"The Agenda - Grassroots Leaders," Fast Company, Issue 23, page 114.
Navy commander D. Michael Abrashoff uses a leadership model that's as progressive as any in business.

"No Good Deed Goes Unpunished: Case Studies of Incidents and Potential Incidents Caused by Protective Systems," Process Safety Progress, Vol. 16, No. 3 (Fall), 1997, pp. 132-139. Article by A. M. Dowell III and D. C. Hendershot.

"Organizational Factors Associated with Safety and Mission Success in Aviation Environments," by Ron Westrum and Anthony J. Adamski. In Handbook of Aviation Human Factors by D. J. Garland, J. A. Wise, and V. D. Hopkin, (1999).
Available from chpra@engr.wisc.edu

This article examines the organizational factors in aviation safety and mission success. The organizations involved cover the entire range of aviation organizations, from airline operations departments to airports, manufacturing organizations, air traffic control, and corporate flight departments. Organizational factors include such things as organizational structure, management, corporate culture, training, and recruitment. Although the greater part of this article is focused on civil aviation, it also uses examples from other high-tech systems. We concentrate on key organizational processes involved in recent studies and major accidents.

Toward Effective Corrective Actions for Programs and Processes
Constance Perin
Second Draft

This paper expands on Constance Perin's talk at the CHPRA workshop, entitled "Re-modeling Operational Logics," on formal versus substantive logics. "Formal logics" come from technical specifications, the design basis, and the rules and procedures that they generate. "Substantive logics" consist of just about everything else that it takes to reduce risk -- processes, programs, professional judgment, skill of the trade, experience, best estimates, and management expectations and philosophies. Each is equally logical. Emphasizing this fact, not thinking that they are so different in importance, may help to reduce the conflict between them.

"Deregulation and Nuclear Power Safety: What Can We Learn from Other Industries?" Electricity Journal, May 2001, pp. 49-60. By Vicki Bier, James Joosten, David Glyer, Jennifer Tracey, and Michael Welsh.
Available from chpra@engr.wisc.edu

This paper expands on Vicki Bier's talk at the CHPRA workshop, on the effects of deregulation on safety. The paper presents an examination of the effects of deregulation on safety in the U.S. aviation and rail industries, and the UK nuclear power industry. The results provide evidence that changes associated with deregulation can be expected to create major challenges to the management of safety by the U.S. nuclear power industry and its safety regulators.

Books and Reports

Beyond Aviation Human Factors: Safety in High Technology Systems
Daniel E. Maurino (Editor), Rob E. Lee, Neil Johnston, James Reason.
Ashgate Publishing Company, 1999.

The authors believe that a systemic organizational approach to aviation safety must replace the piecemeal approaches largely favored in the past. Accident records show a flattening of the safety curve since the early 1970s. However, instead of new kinds of accidents, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inactions of front-line operational personnel. The organizational model proposed by the authors argues for a broadened approach, which considers the influence of all organizations involved in operations (the "blunt end"), in addition to individual human performance (the "sharp end"). This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners. It comprises six chapters. In the first, the fundamentals, background, and justification for an organizational approach to aviation safety and prevention endeavors are explained. Four case studies follow, which illustrate the application of the organizational accident causation model to the flight deck, maintenance, and air traffic control environments. The last chapter suggests different ways to apply the model as a prevention tool that enhances organizational effectiveness. Training, operational, non-technical, and quality control personnel in aviation will find Beyond Aviation Human Factors of interest, as will personnel in other high-technology production industries.

Managing the Risks of Organizational Accidents
James Reason
Ashgate Publishing Company, 1997.
Available from Barnes and Noble

Victims of Groupthink: A Psychological Study of Foreign-Policy Decisions and Fiascoes
Irving L. Janis
Earlier edition
Houghton Mifflin, 1972.
Available from Barnes and Noble

Groupthink: Psychological Studies of Policy Decisions and Fiascoes
Irving L. Janis
In print and widely available
Houghton Mifflin Company, 1986.
Available from Barnes and Noble

Crucial Decisions: Leadership in Policymaking and Crisis Management
Irving L. Janis
Free Press, 1988.
Available from Barnes and Noble

Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences
Robert L. Helmreich and Ashleigh C. Merritt
Ashgate Publishing Company, 1998.
Available from Barnes and Noble

The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA
Diane Vaughan
In print and widely available
University of Chicago Press, 1996.
Available from Barnes and Noble

Safeware: System Safety and Computers
Nancy G. Leveson
Addison-Wesley, 1995.
Abstract at http://sunnyday.mit.edu/book.html

Friendly Fire
Scott A. Snook
Princeton University Press, 2000.
Available from Amazon Books

An Audit by the HSE on British Energy Generation Limited and British Energy Generation (UK)
Limited 1999.
United Kingdom Health and Safety Executive Summary

Videos

Collision Course: What are the odds?
Federal Aviation Administration
Length 19 minutes, 43 seconds
July 25, 2000.
Available from chpra@engr.wisc.edu

Spiral To Disaster
Length 24:00
Coastal Training Technologies

Groupthink
LENGTH: 22 Min
CRM-learning

Safety Programs

Du Pont Safety Training Observation Program (STOP)

Accountability Model and Policy Guidelines
In use at Diablo Canyon Power Plant, Pacific Gas and Electric.
Contact person: Lance Sawyer, (805) 545-3436, lrs1@pge.com

This Accountability Model is currently used at Diablo Canyon, and includes a Culpability Evaluation Flow Chart. It is based in large part on the work of James Reason as described in Chapter 9 of Managing the Risks of Organizational Accidents. Of course, such a model must be carefully developed with representation from all groups, and should be implemented with using effective communication methods and normal change management techniques. The Accountability Policy Guidelines are draft comments that PLG plans to use to ensure all parties understand how to use the basic model. Finally, the Accountability Policy Talk is a presentation that was developed for supervisors at Diablo Canyon to use in explaining the policy and how it will be used with subordinates.

Resources

NASA Aviation Safety Reporting System (ASRS).

"Research Support for the Power Industry," Issues in Science & Technology, Fall 1998.
By M. G. Morgan and S. F. Tierney.

Unintended Consequences: Energy R&D in a Deregulated Energy Market.
J.J. Dooley, Senior Research Engineer
Pacific Northwest National Laboratory
Washington, D.C. PNNL-SA-28561
February 6, 1997.

Federal Research: Changes in Electricity-Related R&D Funding.
General Accounting Office. RCED-96-203
August 16, 1996.