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Safety Culture: How We Lead
Tom L. Baldwin, BS, NRP, CMTE
SMS Manager
Air Evac Liefeteam
Heli Expo 2015
Orlando, FL
Chernobyl- 1986
-28 employees died
-106 employees suffered from acute radiation sickness.
-200,000 clean up workers were exposed to elevated radiation levels.
-250,000 people permanently displaced.
-The Chernobyl accident was the result of a flawed reactor design that was operated with inadequately trained personnel. ₁
-The term “safety culture” was born.
Space Shuttle Challenger-1986
-7 US Astronauts died
-NASA and Thiokol elected to increase the amount of damage considered "acceptable” in light of damage to the O- rings.₂
-A Command & Control Structure Prevailed.
– Communication inhibited.
– Assumptions were made among a group of like educated people.
Colgan Air Flight 3407-2009
-50 fatalities
-NTSB report reveals training failures that were not adequately addressed and-₅
-A culture that failed to manage fatigue among it’s staff.
-Poor background checks secondary to rapid growth-₁₁
BP Texas City-2005
-15 employee deaths.
-160 employee injuries.
-OSHA issues record breaking fines of more than $87 million to BP. ₆
-“The Texas City disaster was caused by organizational and safety deficiencies at all levels of the BP Corporation. Warning signs of a possible disaster were present for several years, but company officials did not intervene effectively to prevent it”₉
BP Deepwater Horizon-2010
-11 employee deaths.
-The US Chemical Safety Board (CSB) has concluded that “safety lapses by BP and others led to the explosion”₃
-“The product of an inadequate safety culture”₃
-“The Deepwater oil spill is a classic failure' of BP management” ₄
–former BP consultant
Leadership
Employee Selection & Retention
Policy & Procedure
Just Culture
Symbology & Rituals
Training & Socialization
Leaders & Followers: The Birth of a Culture!
Safety culture begins with leadership however-
Leadership cannot effectively mandate a culture of safety.
They can however, enlist followers to champion a cause!
Leadership: How We Lead
-Establishes Core Values
-Set & Enforce Company Policy
-Demonstrate Commitment
-Model Desired Behavior
-Communicate Expectations
-Select and Retain Team Members Who are Aligned With Your Values
Employee Selection & Retention
Ensure that new and existing employees are aligned with the organization’s values.
POP QUIZ
❶Posters
❷Coins
❸Safety Boards
❹Safety Stand Down Events
❺Debriefing sessions
Under which of the Four Pillars of SMS do these Items Fall?
Safety Promotion
Just Culture
“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes”
-Dr. Lucian LeapeProfessor, Harvard School of Public HealthTestimony before Congress on Health Care Quality Improvement
Just Culture-The Duties
Duty to Produce an Outcome
Duty to Follow Procedure
Duty to Avoid Causing Unjustified
Harm
Just Culture-The Behaviors
Human Error
Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
Behavioral choice to consciously disregard a substantial and unjustifiable risk.
At-Risk Behavior
Reckless Behavior
Just Culture-The Learning Environment
Human Error
Inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.
Behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.
Behavioral choice to consciously disregard a substantial and unjustifiable risk.
At-Risk Behavior
Reckless Behavior
Coaching
Consoling
Punitive
Aligns Values and
Expectations
Make Better
Behavioral Choices
Helps to Design
Better Systems
Holds us Accountable for our
Choices
Develops a
Learning Culture
Just Culture-A Primer
Policy & Procedure
What types of policy & Procedure do we need?
-Hazard ID
-Risk Assessment
-Non-punitive Reporting
-Open Door Policy
-PPE Usage
Training & Socialization
Initial training and orientation begin socializing the employee to your culture.
Socialization and recurrent training ensures that it sticks.
Do We Have it?
“It is worth pointing out that if you are convinced that your operation has a good safety culture, you are almost certainly mistaken”₈
-James Reason, Ph.D.
When We Get it?
Reports of At Risk Behavior & Human Error will increase
Reports of accidents & Incidents will decrease
Carrie Renae Barlow
31
Denise C. Adams
Charles D. Smith
Herman "Lee" Dobbs, Jr.
Jesse Lee Jones
Eddy Wayne Sizemore
John N. Campbell
Christopher Michael Denning
Mark Alan Montgomery
Gene L. Grell
Shelly Lair-LangenbauRussell D. Piehl
Jim Dillow
Karen HollisAndy Olesen
Randy Bever
Chris Frakes
Gayla Gregory Kenneth Meyer, Jr.
Kenneth Robertson
Brenda E. French
Alexander B. Kelley
Parker W. Summons
Ryan Duke
Al Harrison
Guy del Giudice
Stephen Thomas DurlerTerry Alan GriffithChristopher Ritz
Mickey C. Lippy Stephen H. Bunker
Sandra Pearson
Wade Weston
Roger Warren
Jana Eileen Bishop
Stephanie Suzzane Waters
Thomas C. Caldwell
Tom Clausing
James W. Taylor
Darren B. Bean
Mark CoyneSteven H. Lipperer
Jack Chase
Tom Palcic
Paul H. LujanMicky Lynn Price
Kelly Bates
Diane Codding
Arthur GotisarCraig Alan Bingham
Mario W. Guerrero
Phil Herring
Lori Schremp Pat Scollard
William Spencei
Kelly Ann Conti
Alicia Betita-Collins
Eric Hangartner
Mark Wallace
Edward C. SannemanLauren Eileen Stone
References
1. NRC. (2013, June 20). Backgrounder on Chernobyl Nuclear Power Plant Accident. NRC:. Retrieved February 26, 2014, from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/chernobyl-bg.html
2. Presidential Commission on the Space Shuttle Challenger Accident. (1986, January 14). Report of the presidential commission on the space shuttle challenger accident. Genindex.htm. Retrieved February 26, 2014, from http://history.nasa.gov/rogersrep/genindex.htm
3. Trager, R. (2012, January 27). BP’s misdirected safety focus blamed for Deepwater debacle. Royal Society of Chemistry. Retrieved February 26, 2014, from http://www.rsc.org/chemistryworld/2012/07/bps-misdirected-safety-focus-blamed-deepwater-debacle
4. Rushe, D. (2013, February 26). Deepwater oil spill a 'classic failure' of BP management, court hears. Theguardian.com. Retrieved February 27, 2014, from http://www.theguardian.com/environment/2013/feb/26/deepwater-oil-spill-trial-bp-failure
5. Sumwalt, R. L. (2010, February 12). The anatomy of an accident: Colgan air flight 3407 (Rep.). Retrieved February 26, 2014, from NTSB website: https://www.ntsb.gov/doclib/speeches/sumwalt/SCAA-100212.pdf
6. OSHA. (2012, July 12). BP texas city violations and settlement agreements. BP Texas City Violations and Settlement Agreements. Retrieved February 26, 2014, from https://www.osha.gov/dep/bp/bp.html
7. Rafaeli, A., & Worline, M. (1999, February 25). Symbols in organizational culture. The William Davidson Faculty of Industrial Engineering and Management. Retrieved February 27, 2014, from http://iew3.technion.ac.il/Home/Users/anatr/symbol.html
8. Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, Hants, England: Ashgate.9. CSB. (2007, March 20). U.S. Chemical Safety Board Concludes "Organizational and Safety Deficiencies at All Levels of the BP
Corporation" Caused March 2005 Texas City Disaster That Killed 15, Injured 180. U.S. Chemical Safety Board. Retrieved February 27, 2014, from http://www.csb.gov/u-s-chemical-safety-board-concludes-organizational-and-safety-deficiencies-at-all-levels-of-the-bp-corporation-caused-march-2005-texas-city-disaster-that-killed-15-injured-180/
10. Sumwalt, R. L. (2008, February 19). Establishing and maintaining a safety culture. NTSB. Retrieved February 27, 2014, from http://www.ntsb.gov/doclib/speeches/sumwalt/rls080219.pdf
11. Von Thaden, T. L., PhD. (October 26). Developing and measuring a robust safety culture. Lecture presented at Swiss Aviation Safety Conference in Switzerland, Bern. Retrieved March 6, 2014, from http://www.bazl.admin.ch/experten/regulation/03086/03087/03088/index.html?lang=en
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