A SAFETY CULTURE WITH JUSTICE: A WAY TO IMPROVE SAFETY PERFORMANCE

A SAFETY CULTURE WITH JUSTICE: A WAY TO IMPROVE SAFETY PERFORMANCE Dr John Bond C-MIST; e-mail: john.bond007@ntlworld.com A Just Safety Culture as it relates to industrial safety has been defined as A way of 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. This concept combined with monitoring of equipment and procedures and sharing accident information, now being successfully developed in the aviation industry, could well be adopted in the petrochemical industry although the introduction of these ideas would have to be accepted by the regulatory and legal bodies. A Culture of Justice approach in the petrochemical industry would assist the reporting of incidents in a disciplined manner and allow the sharing of lessons learnt. KEYWORDS: just safety culture; safety culture; learning lessons; sharing information, monitoring operations INTRODUCTION When a serious accident happens in an organisation the immediate response of the emergency services is rightly to tend the injured parties and establish a safe and environmentally acceptable situation. After this an investigation of the accident will seek witnesses and evidence to establish all the causes of the accident. The police and HSE or Environment Agency will seek information to establish whether a crime or violation of regulations has been committed. The insurance company will wish to establish who has covered the risk. The legal profession will establish whether there is a case for exemplary compensation and the media will seek information on who can be blamed. The victims of the accident, however, will seek the justice of compensation, the justice of avoiding a similar accident in the future and the justice of a disciplinary approach for those responsible. Unfortunately such outcomes are infrequent. In the petrochemical industry for instance:. Compensation to the victims is often delayed while blame is established.. Responsibility is seldom accepted for the error.. The lessons learnt from the investigation are not always learnt within the organisation and are seldom made available to all engineers in the industry as a whole so that a similar accident in the future can be avoided.. Justice is not seen to be done by the regulatory bodies who also are looking for someone to blame.. The lawyers seek customers on a no win no fee basis.. The media always look for someone to blame and seldom report the true situation. In the industrial world it is clear that the ethics of a fair safety culture are not always followed. The blame culture which pervades our industries and which is much loved by the legal and media professions is one of the major hindrances to improved safety. If this blame culture could be replaced by one of justice then a major step forward in sharing accident information could be established with a consequent improvement in safety, health and the environment. It is significant that despite manufacturers competing commercial interests the makers of Formula 1 racing cars share information on their safety design in order to protect drivers in the event of a crash. There have been remarkable cases of the driver walking away from a quite horrific crash. The safety design is based on the assumption that at some time the driver will make a mistake but the driver is not criminalised for the error he has made and his life is saved by the safety design. The civil aviation industry which covers aircraft manufacture, operation, maintenance and air traffic control has successfully established a Just Safety Culture approach to enhance their existing safety culture. It complements their Flight Data Analysis Programme required by the International Civil Aviation Organisation (ICAO, a United Nations body) and their accident/incident reporting systems MORS (Mandatory Occurrence Reporting Scheme). This approach has been spearheaded by ICAO, the European Commission, Eurocontrol and the Flight Safety Foundation and has been successful in the UK, Australia and Canada. Efforts to establish this Just Safety Culture throughout the international aviation community has not been successful, due primarily to problems with the regulatory and judiciary bodies. In supporting a resolution agreed with professional engineers condemning the criminalisation of accident investigations the President of Flight Safety Foundation, William Voss (16), stated: We are increasingly alarmed that the focus of governments in the wake of accidents is to conduct lengthy, expensive, and highly disruptive criminal investigations in an attempt to exact punishment, instead of ensuring the free flow of information to understand what happened and why, and prevent recurrence of the tragedy. 1

The petrochemical industry could learn a lesson from the civil aviation industry and establish a similar Just Safety Culture approach to improve safety and create an effective accident reporting system, although to get the full benefit there would need to be the active support of the Health and Safety Executive and the legal profession. An operations data analysis programme similar to that adopted by British Airways SESMA (Special Event Search and Master Analysis) could be developed for the modern computer controlled plants. THE SAFETY CULTURE IN THE PETROCHEMICAL INDUSTRY The modern well-developed safety culture in this industry covers both the personal and work place accident causation factors and is based on the HSE management model (7) with full commitment by the Chief Executive Officer. The safety policy encompasses leadership, management systems, competence, responsibility and communication. With the improved safety and the lower number of accidents the industry has had to look at near-misses. To understand the causes of these near-misses and to encourage their reporting, a no-blame approach was adopted in the 1980s and is still used today. This was a step in the right direction at the time since it accepted that errors could be made unintentionally with no intention of disciplining anyone. A well-meaning no blame approach is not altogether desirable as it is impractical to condone reckless non-compliance with operational procedures. Furthermore, the passive acceptance of reports of unacceptable operating methods discredits the management system and does not help. THE CONSEQUENCES OF HAVING A BLAME CULTURE The blame culture that has pervaded the community encourages people and companies to avoid their responsibility for a mishap and to pass the cause on to someone else. Invariability the person at the base of the workforce receives the blame even though it may not be solely his/her fault. This leads to poor investigation of an accident with only the personal factor being identified and not the work place or organisational factors. When people fail it is usually because they are working in a flawed system. Blaming a person is a simple, expedient method of removing blame from the organisation and hence hides the latent flaw in the system. James Reason s (11) organisation causation model for accidents recognises this and introduces a Just Safety Culture approach to replace the no-blame approach. Despite all the good intentions of people the main reasons why lessons learnt from accidents have not been made available, particularly to the engineer, are:. The workplace or organisational causation factors have not been recorded.. Often the cause is attributed solely to an individual.. Insufficient information on the safety and environmental effects as well as the use of emergency equipment is given.. Companies have not released the information for legal reasons.. Companies have not wished to admit that the accident ever took place. The Prime Minister, Mr. Tony Blair, has said (2): They (the public) want to know that, where something has gone wrong, lessons have been learnt and that the same mistake won t be made in the future to someone else. So, wherever possible, we want claims settled informally and quickly, without going to court... Sometimes we have to accept: no-one is to blame. Such an approach is easy to state; hard to do. But at least if we start to debate the problem, there is a chance we can begin addressing it. Industry in the main has a wish to share lessons learnt from accidents but to do this they have to overcome the reluctance of the regulatory, insurance and legal bodies to change. A Just Safety Culture approach could be more acceptable to employees once it is understood and should be acceptable to the regulatory bodies. A Just Safety Culture approach encourages the reporting of accidents and the carrying out a full investigation to find all of the causes. These investigations need to be reported to others so that the industry as a whole can learn the lessons. The Just Safety Culture approach has been adopted in a few forward looking companies and Figure 1 shows a typical disciplinary approach by one UK Company. THE SAFETY APPROACH IN THE CIVIL AVIATION INDUSTRY The civil aviation industry has developed a Flight Data Analysis Programme (FDAP) which records operational and equipment data on the whole of each flight. A disc is removed after each flight and analysed by a Special Event Search and Master Analysis (SESMA) software automatically and this can evaluate the whole flight regarding the state of equipment and the flight procedure. Output from the analysis can automatically show the state of the equipment and feed this information into maintenance programmes. Compliance with procedures can also be recorded and fed back into training programmes for crew members. The civil aviation industry also has three major information systems to share information and lessons learnt comprising Mandatory Occurrence Reporting Scheme (MORS), Global Analysis and Information Network (GAIN) and Confidential Human Incident Reporting Programme (CHIRP). It is for the adoption of these approaches to safety that the Just Safety Culture becomes important. 2

Figure 1. Disciplinary action The European Community at an ICAO meeting (9) in describing The need for a Just Culture reported: Lack of full and open reporting continues to pose a considerable barrier to further safety progress in many areas. Major impediments are a fear of prosecution and a lack of appropriate confidentiality. The effectiveness of reporting is totally dependent on a conducive reporting environment a Just Culture defined as a culture in which front line operators are not punished for actions or decisions that are commensurate with their experience and training, but also a culture in which violations and wilful destructive acts by front line operators or others are not tolerated. The ICAO has issued a Safety Management Manual (8) which describes a positive corporate safety approach with five cultures described in detail. The Informed, Learning and Flexible cultures are familiar to the chemical engineer. The Reporting Culture encourages management and operational personnel to share freely all critical safety information without fear of disciplinary action. This reporting is not restricted solely to internal corporate management but includes international management. The Just Safety Culture is fundamental for the good reporting of hazards, near-misses and accidents. It does, however, require the organisation to inform all employees of what is acceptable and what is unacceptable behaviour. In rejecting the blame culture, the ICAO Safety Management Manual (8) states in Section 4.5.40: If an accident was the result of an error in judgement or technique, it is almost impossible to effectively punish for that error.... If punishment is selected in such cases, two outcomes are almost certain. Firstly, no further reports will be received of such errors. Secondly, since nothing has been done to change the situation, the same accident could be expected again. A Just Culture has also been defined (6) as: A way of 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. The approach has been described by James Reason (11 and 12) and has been applied in the Air Traffic Management area of the aviation industry to improve safety. He states that: A prerequisite for a just culture is that all members of an organisation should understand where the line must be drawn between unacceptable behaviour, deserving of disciplinary action, and the remainder, where punishment is neither appropriate nor helpful in furthering the cause of safety. He further describes three causation models in his approach to accident causation:. The Personal Factor. The main emphasis here is on the inadequate capability, lack of knowledge, lack of skill, stress and improper motivation leading to the unsafe act or condition and resulting in personal injury.. The Workplace Factor. This includes inadequate supervision, engineering, purchasing, maintenance and work standards. This has its origins in reliability engineering and includes the HAZOP operation and risk analysis. 3

. The Organization Factor. This model views the human error more as a consequence rather than a cause and is indicative of latent inadequacies in the leadership or management system. Just Safety Culture combines the whole approach of reporting safety matters, monitoring equipment and procedures into a safety management system which becomes a coherent structure that becomes acceptable and comprehensible to the employees and hence to the public. This in turn results in greater motivation of personnel and is seen to improve overall safety in the whole aviation industry when it is supported at the very top of the industry and the regulatory bodies. The adoption of the Just Safety Culture approach in the aviation industry has resulted in an increase in the reporting of incidents while keeping low the fatal accident rate. The fatal accident rate (fatalities per million hours flight) over a period of ten years for UK Registered/operated Large Public Transport Aeroplanes (3 year moving average) was only 5 fatalities over the ten year period. The three countries where the Just Safety Culture has been fully adopted, Australia, Canada and the UK, currently have a 3 year moving average fatal accident rate of zero compared with a figure of 13 for the whole world. These figures are based on Western designed aircraft with similar training courses but different management and regulatory systems. It is not surprising that Lord Broers, Past President of the Royal Academy of Engineering stated (3): One crucial recommendation emerges (from the debate in the Royal Academy of Engineering). That the investigation of accidents should concentrate on finding the cause of the accidents not the person or persons to blame. The latter only leads to defensiveness and cover up. The investigation should seek the cause of the accident so that it may be eliminated in the future. The airline industry s remarkable safety record is thought by some to be because the investigators seek the cause of accidents rather than hunt down the person to blame. Lord Cullen (4) has also made the same point: The sole objective of the investigation of accidents or incidents should be the prevention of accidents and incidents. It should not be the purpose of such investigations to apportion blame or liability CAN THE PETROCHEMICAL INDUSTRY LEARN FROM THE AVIATION INDUSTRY? I believe that with the modern computer controlled plant an Operations Monitoring system could be adopted which logged the operations each day. Analysis of the operation could also be carried out by software which could highlight any variation in equipment operation such as compressor vibration, operations out of sequence, abnormal pump pressures, reaction temperatures profiles out of normal pattern, corrosion of tank bases etc. It could also monitor procedures such as reliance on high level alarms to stop transfer operations to tanks, alarms failed to be back on line after testing, start-up of complex equipment and similar procedures. The Operations Monitoring system could also check on a number of parameters concerning the ageing of the plant equipment. Many other operations such as relief valves lifting below their set pressures or operating because the temperature of the LPG being pumped into the tank is too high could also be monitored and action taken before an accident happens. Such a system, as in the aviation field, would show up abnormal operations before they lead to an accident as well as deviation of equipment which needs maintenance before it breaks down. Adoption of such an Operations Monitoring system combined with a Just Safety Culture approach would give a new emphasis to improving safety by sharing accident information. THE REGULATORY BODIES AND A JUST SAFETY CULTURE In the UK the Air Accident Investigation Board (AAIB) has the right of entry to investigate accidents involving aircraft. In the Regulations (14) they have an objective: The sole objective of the investigation of an accident or incident under these Regulations shall be the prevention of accidents and incidents. It shall not be the purpose of such an investigation to apportion blame or liability. The provider of any evidence given to the AAIB cannot be used in other court actions. This ensures that the full evidence can be given to the investigators. The results of the investigation and all recommendations are made available to the public. Thus once the blame culture has been removed from the scene, the safety approach takes a different path and the investigation can then concentrate on the primary objective of establishing all the causes of the accident, the personal factor, the work place factor and the organisation factor. The regulator for the civil aviation industry in the UK is the Civil Aviation Authority (CAA) and they receive the accident reports and take appropriate action. The CAA recognises the Just Safety Culture approach and encourages companies to take the disciplinary action. The CAA has stated (1): We promote a just culture. Since 1976 the CAA has run a mandatory Occurrence Reporting Scheme where we have asked industry to 4

submit to us the quite low level incidents that are happening in the industry. We have given a guarantee that we shall not take punitive action against those people who report to us, except in cases of gross negligence. We expect industry to behave in the same way and to use that data with us for continuous improvement... We can then work towards the let us not let this happen again type of scenario. It is clear that since people do not go to work with the intention of violating a rule or procedure it is more appropriate that the industry itself takes the appropriate disciplinary action. This does not prevent the regulatory body taking appropriate action in the case of gross negligence or criminal behaviour but the Just Safety Culture approach ensures that the company takes appropriate action which can be monitored by the regulatory body. In the civil aviation industry the European Organisation for the Safety of Air Navigation (5) has also recognised the requirement for a Culture of Justice and its Permanent Council has endorsed a recommendation:... alleviating existing legal, managerial and organisation constraints with respect to safety data reporting and safety data flows for European air traffic management. The Just Safety Culture ideas are prominent in its European Safety Programme launched in February 2006. The HSE has a duty of investigating accidents as well as being the regulatory body although prosecutions are often handed over to the Criminal Prosecution Service (CPS). It might be thought advisable that these two duties be separated, as in the aviation, rail and marine industries, so that the investigation is carried out to establish all the causes of the accident rather than to find a person to blame. This would leave the disciplinary side to consider whether a violation of a regulation had been established. Because the company with a Just Safety Culture approach would take disciplinary action against its employee as necessary the HSE could then be relieved of a lot of its work. The HSE should consider a requirement for a mandatory reporting system in a future Accident Investigation Regulation. THE LEGAL PROFESSION AND A JUST SAFETY CULTURE Probably the greatest impediment to reporting errors and sharing accident information is the fear of the legal consequences. The civil aviation industry (15) has concluded that: The legal world holds the view that the system is inherently safe and that the humans are the main threat to that safety.... the safety environments in the aviation system are largely achieved as a result of an open exchange of information between the layers of the system. Contrary to what some may believe, human error cannot be avoided by designing it out of the system or disciplining operators. Error is a normal component of human performance. This fact must be incorporated into design, implementation and operation of complex systems where it is the expected outcome. The adversarial approach of the legal profession ensures that reporting of accidents is avoided and hinders the process of improving safety. This legal system creates in industry a don t get caught approach. Consequently engineers have been advised not to keep records of accidents in case they are demanded in court. Companies are advised by their lawyers not to admit anything in connection with accidents which results in companies not sharing accident information. The consequence is that accidents are frequently repeated. The adversarial process is counter-productive and should be modified to remove the blame culture from such an approach. The Robens Report on Health and Safety at Work of 1972 (13) identified this point: Relatively few offences are clear cut, few arise from reckless indifference to the possibility of causing injury, few can be laid without qualification at the door of a single individual. The typical infringement or combination of infringements arises rather through carelessness, lack of knowledge or means, inadequate supervision or oversight, or sheer inefficiency. In such circumstances the process of prosecution and punishment by the criminal courts is largely an irrelevancy. CONCLUSIONS It is clear that in the vast majority of accidents or nearmisses employees were acting with the best intentions and did not expect a serious event to occur from their actions. It has to be accepted that to err is human but we can learn from these events and share with others the lessons learnt, as has occurred in the civil aviation and racing car industries. The advantages of an Operations Monitoring system, an Incident Reporting and Sharing system and a Just Safety Culture system are:. There is an improved reporting of incidents or nearmisses.. There is improved motivation of all staff as they are fully aware of the justice of the system.. There is an improvement in operational management with recognition of responsibility.. There is a move towards a self-regulation system, an original objective of the Robens Report (13). Those affected by accidents do not trust industry or the regulatory bodies because justice is not seen to be 5

done throughout the whole process. In order to be accepted by the public as a responsible industry there is need for:. The Petrochemical Industry to adopt an Operations Monitoring system, a full Reporting of Lessons Learnt system and a Just Safety Culture in all aspects and to be audited regularly. Management must accept responsibility for accidents immediately and recognise that honest errors do occur. When there is reckless violation the necessary disciplinary action must be taken without regard to status within the company.. The regulatory bodies to separate their investigative and regulatory sides and to adopt the whole Just Safety Culture approach. The regulatory bodies must become forces for error reduction rather than forces for disciplinary action and error concealment. They must accept the self-regulation approach of Just Safety Culture.. The insurance industry to recognise the Just Safety Culture approach and to ensure that reasonable compensation is paid promptly.. The legal profession to accept the full consequences of the Just Safety Culture approach and to recognise that admitting errors is a positive approach to reducing accidents and saving lives and injuries. If a Just Safety Culture is adopted fully by all the bodies concerned and audited as part of corporate governance then the public will begin to recognise that Justice can be done. There will be increased safety reporting of errors, greater trust and responsibility amongst employees and more effective safety and operational management. REFERENCES Alcott, B. The Civil Aviation Industry. Royal Academy of Engineering The Economics and Morality of Safety. ISBN 1-903496-26-8. April 2006. Blair, A. Compensation Culture Speech given at the Institute of Public Policy Research. 26 May 2006. Broers, Lord Risk and Responsibility BBC Reith Lecture 2005. Cullen, Lord, Ladbroke Grove Rail Inquiry Part 2 Paragraph 11.11, HSC, December 1962. European Organisation for the Safety of Air Navigation. Press Release 10 April 2006. Global Aviation A Road Map to a Just Culture: Enhancing the Safety Environment Information Network First Edition September 2004. Health and Safety Executive Successful Health and Safety Management Health and Safety Booklet HS(G) 65 ISBN 0 7176 0425 X, 1991. International Civil Aviation Organisation. ICAO Safety Management Manual Doc. 9859 AN/460 First Edition 2006. Available on the internet. International Civil Aviation Organisation. Proposals for Further Improvement of Aviation Safety Worldwide. Working Paper DGCA/06-WP/11. Presented by Austria on behalf of the European Community, Montreal 22 March 2006. Proposals for Further Improvement of Aviation Safety Worldwide. Working Paper DGCA/06-WP/11. Presented by Austria on behalf of the European Community. Montreal 22 March 2006. Reason, James Managing the Risks of Organisational Accidents Ashgate Publishing Ltd. 2005. ISBN 1 84014 105 0. Reason, James. Achieving a safe culture: theory and practice. Work and Stress 1998, Vol. 3 page 293 306. Robens, Lord (Chrmn) (1972) Safety and Health at Work. Cmnd 5034 (London: HM Stationery Office). Statutory Instruments 1996 No. 2798. The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996. The International Federation of Air Traffic Controllers Association. The Need for a Just Culture in Aviation Safety Management Eleventh Air Navigation Conference Montreal 22 September 2003. Voss, William. Flight Safety Foundation, Aviation Safety Groups Issue Resolution Condemning Criminalization of Accident Investigations Canada 18 October 2006. 6