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

Its the way its done here!

What is it?

Attitudes

Values

Behaviors

Norms

Practices

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.

Symbols & Rituals

❶Posters

❷Coins

❸Safety Boards

❹Safety Stand Down Events

❺Debriefing sessions

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

Got Milk?

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Simply put, SMS

Provides a

house for our

Safety Culture

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.

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How We Measure It

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

Why Does it Matter?

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Carrie Renae Barlow

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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

Build a Just Culture

Implement an SMS

SPEAK UP!

Choose Carefully

Questions?QUESTIONS

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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