Department of Consumer and Employment Protection Resources Safety 1 Please read this before using presentation This presentation is based on content presented at the 2007 Mines Safety Roadshow held in October 2007 It is made available for non-commercial use (eg toolbox meetings) subject to the condition that the PowerPoint file is not altered without permission from Resources Safety Supporting resources, such as brochures and posters, are available from Resources Safety For resources, information or clarification, please contact: or visit

Toolbox presentation: Safety culture – part 1 Integrating human factors and safety management systems October 2007

Department of Consumer and Employment Protection Resources Safety 3 Safety culture toolbox series 1.Integrating human factors and safety management systems (Author: Bert Boquet, Embry-Riddle Aeronautical Museum) 2.What does safety culture mean for mining? 3.Safety culture in practice in Australian mining

Department of Consumer and Employment Protection Resources Safety 4 International Atomic Energy Agency noted a “Poor Safety Culture” as a factor in the accident. Safety culture: a brief history Chernobyl, 1986

Department of Consumer and Employment Protection Resources Safety 5 Thirty-one people died in the Kings Cross fire, which broke out as commuters headed home. Poor safety culture was cited as a factor. Safety culture: a brief history King’s Cross underground fire, 1987

Department of Consumer and Employment Protection Resources Safety 6 Worst ever offshore petroleum accident, during which 167 people died and a billion dollar platform was destroyed. Poor safety culture was cited as contributing to this accident. Safety culture: a brief history Piper Alpha, 1988

Department of Consumer and Employment Protection Resources Safety 7 44,000 to 98,000 people in the US die each year as a result of medical error. This includes: Wrong medications Too much of a given drug Surgical error Infection control Misdiagnosis In summary, human error

Department of Consumer and Employment Protection Resources Safety 8 “There are activities in which the degree of professional skill which must be required is so high, and the potential consequences of the smallest departure from that high standard are so serious, that one failure to perform in accordance with those standards is enough to justify dismissal.” — Lord Denning

Department of Consumer and Employment Protection Resources Safety 9 “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” — Dr Lucian Leape, Harvard School of Public Health

Department of Consumer and Employment Protection Resources Safety 10 “People make errors, which leads to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems continue.” — Don Norman

Department of Consumer and Employment Protection Resources Safety 11 Nature of blame Operator is seen as having control Operator makes conscious decisions about how to carry out job Operator has rules and procedures to follow Organization has vested interest in blaming operator

Department of Consumer and Employment Protection Resources Safety 12 Nature of blame cont. Because people fear being “punished” for errors made on the job, minor events and mistakes go unreported Furthermore, by focusing on the active failures, this in practice absolves organization from blame (and liability) when accidents occur

Department of Consumer and Employment Protection Resources Safety 13 What does all of this have to do with safety? To improve safety, we must make better use of minor human error events Threat of corporate disciplinary action and regulatory enforcement is a major obstacle to event reporting and investigation Engineering a sound safety culture is how we go about managing human error However, nature of human error remains a problem in most systems

Department of Consumer and Employment Protection Resources Safety 14 Mechanical failure - Catastrophic failures are infrequent events - When failures do occur, they are often less severe or hazardous due to effective intervention programs. Data-driven Research Accident investigation - Highly sophisticated techniques and procedures - Information is objective and quantifiable - Effective at determining why the failure occurred Database analysis - Traditional analyses are clearly outlined and readily performed. - Frequent analyses help identify common mechanical and engineering safety issues. Mitigation Prevention Effective Intervention and Prevention Programs - Designed around traditional categories - Variables are well-defined and causally related - Organization and structure facilitate access and use Accident database Feedback Research sponsors - FAA, DoD, NASA, & airplane manufacturers provide research funding. - Research programs are needs-based and data- driven. Interventions are therefore very effective. Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72,

Department of Consumer and Employment Protection Resources Safety 15 Feedback Human error - Errors occur frequently and are the major cause of accidents. - Few safety programs are effective at preventing the occurrence or consequences of these errors. Research sponsors - FAA, DoD, NASA, & Airlines provide funding for safety research programs. - Lack of good data leads to research programs based primarily on interests and intuitions. Interventions are therefore less effective. Fad-driven Research Mitigation Prevention Ineffective Intervention and Prevention Programs Accident investigation - Less sophisticated techniques and procedures - Information is qualitative and illusive - Focus on “what” happened but not “why” it happened Accident database - Not designed around any particular human error framework - Variables often ill-defined - Organization and structure difficult to understand Database analysis - Traditional human factors analyses are onerous due to ill-defined variables and database structures. -Few analyses have been performed to identify underlying human factors safety issues. Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72,

Department of Consumer and Employment Protection Resources Safety 16 Systems approach to human error management Perhaps one of the best models for human error within an organization or a system is one proposed by James Reason:

Department of Consumer and Employment Protection Resources Safety 17 Unsafe acts Adapted from Reason (1990) Failed or absent defences Reason’s “Swiss-cheese” model of human error

Department of Consumer and Employment Protection Resources Safety 18 Reason’s “Swiss-cheese” model of human error Failed or absent defences Preconditions for unsafe acts Unsafe acts Adapted from Reason (1990)

Department of Consumer and Employment Protection Resources Safety 19 Reason’s “Swiss-cheese” model of human error Failed or absent defences Unsafe supervision Preconditions for unsafe Acts Unsafe acts Adapted from Reason (1990)

Department of Consumer and Employment Protection Resources Safety 20 Reason’s “Swiss-cheese” model of human error Reason’s “Swiss-cheese” model of human error Failed or absent defences Organizational factors Inputs Unsafe supervision Preconditions for unsafe Acts Unsafe acts Adapted from Reason (1990) Accident and injury

Department of Consumer and Employment Protection Resources Safety 21 Applying the cheese In order to make full use of the systems approach, one must be willing to look beyond the active failures: Medicine Aviation Air traffic controllers All have become very skilled at identifying active failures Not so for latent failures

Department of Consumer and Employment Protection Resources Safety 22 Practical implications Study of all commercial aircraft accidents in the US 1990–2002 The investigation used the Human Factors Analysis and Classification System to classify both active and latent failures from 1,020 National Transportation and Safety Board Accident Reports Only 58 organizational failures were identified Of these, most were operational processes Most surprisingly, only 46 supervisory failures were identified from the reports The majority being inadequate supervision

Department of Consumer and Employment Protection Resources Safety 23 Where are the latent failures? On the surface, the foregoing data may point to the fact that there may be relatively few latent failures in US commercial aviation Another, more plausible, alternative is that the incidence is under-reported If the case is one of under-reporting, then what?

Department of Consumer and Employment Protection Resources Safety 24 Error reporting and safety systems Any safety management system (SMS) is only as good as the quality and the quantity of the data (errors) that are reported Accidents in and of themselves provide little information regarding the status of an organizations health with respect to safety Poor error data leads to inconsistent results with respect to interventions

Department of Consumer and Employment Protection Resources Safety 25 Violations

Department of Consumer and Employment Protection Resources Safety 26 Intervention approaches (philosophies) Interventions Task/Mission Environment Human/Crew Technology/ Engineering Organizational/ Administrative Scheduling, risk, processesFacilities, weather, stressorsSelection, training, incentivesNew Rules, policies, proceduresDisplays, automation, “bend metal”

Department of Consumer and Employment Protection Resources Safety 27 Intervention approaches (philosophies) Unsafe Acts Unsafe Acts Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors Task/Mission Environment Human/Crew Technology/ Engineering Organizational/ Administrative Interventions

Department of Consumer and Employment Protection Resources Safety 28 Hazard Identification Hazard Identification Hazard Assessment Hazard Assessment Identify Interventions Identify Interventions Intervention Assessment Intervention Assessment Intervention Implementation Intervention Implementation Data Monitor Safety Management Process ScienceServices Identify/Develop HF Programs HF Consulting Focus Groups Feasibility Prioritize HFIX Human Factors Intervention matriX ® Field Tool Investigator Trng HFACS Analysis IdentifyVulnerabilities Human Factors Analysis and Classification System ®

Department of Consumer and Employment Protection Resources Safety 29 Queries Albert (Bert) Boquet Department Chair, Human Factors and Systems College of Arts and Sciences Embry-Ruddle Aeronautical University Daytona Beach FL USA   