Accountability at the active failure - Home - PACDEFF · Title: Accountability at the active...

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Michael D EvansSafety Engineering Manager AerospaceBAE Systems Australia

Accountability at the active failure

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• Have we become so focussed on organisational and systemic issues that we no longer hold people accountable for what they did or did not do

• Do people learn if they are not held accountable?

Just culture have we gone too far?

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• Safety culture• Just culture• Reason model• Safety culture and accountability• Incident decision tree• Learning process• Analysis of reporting data• Accountability at the active failure

Presentationoutline

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Some essential ingredients of a safety culture:

• Good reporting culture• Just culture• Good learning culture• Managements commitment to safety• Personal accountability.

Safety culture

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• Punitive approach to safety – Pre 1990’s

• “No blame” approach – 1990’s Positive

• acknowledge that people make “honest mistakes”

– Negative

• Failed to confront wilful, dangerous behaviour

• Did not draw a clear line on culpability

• A “just and fair culture” approach – 2000s Positive

• Focussed on finding systemic and organisational issues

• Treated people fairly when they made mistakes and low level violations

– Negative

• Moved the focus from active failure

Evolution of just culture

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“A culture in which front line

operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.” (Eurocontrol, 2005)

Definition of just culture

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The Reason model: the organisational accident

OPERATIONS

LATENT DEFICIENCIES IN DEFENCES(HOLES IN THE DEFENCES - SWISS CHEESE MODEL)

DEFENCESBARRIERS

ACCIDENTS&

SERIOUSINCIDENTS

WORKPLACElocal conditions

ERROR-PRODUCINGCONDITIONS

VIOLATION-PRODUCINGCONDITIONS

ORGANISATIONorganisationalDeficiencies:

latent conditions

MANAGEMENTDECISIONS

ANDORGANISATIONAL

PROCESSES

TASKING

PERSONgroup/team

VIOLATIONS

ERRORS

Adapted from Reason 1990

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Reason’s ‘swiss cheese’ model

Organizationalfactors

Unsafesupervision

Accident

Unsafe actpreconditions

Latent condition

Active conditionsUnsafe

Failed orabsent defences

/ safety nets

Adapted from Reason 1990

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Safety culture and accountability

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Incident decision tree

Hudson 2008

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Given the same circumstances and criteria would a person with the same training, competency and experience have done exactly the same thing or made the same decision

The substitution test is so important

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• For learning to happen there is usually a consequence to an action• People learn from mistakes and violations• It can be as simple as telling the person they performed a violation• There does not need to be punitive action

Learning process

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• Cause – What a person did or did not do error/slip/lapse/violation (active)

• Contributing factors – human factor or organisational (latent)

• Corrective and preventative action• Closeout details – reporting to the customer• Lesson’s learnt

Analysis of reporting data

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• During investigation we must;

• Determine the cause at the active failure

• Define all of the latent organisational and systemic issues

• It is key to

• Make recommendations for preventative and corrective action

• Hold people accountable for what they did or did not do

• Whether they be managers in organisational issues

• Or operators in the active failure

Accountability at the active failure

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In summary

• Holding people to account is not apportioning blame • But if they are not held to account then they don’t learn and• The incident will most likely recur

Holding people to account is an essential part of the learning culture and the overall safety culture

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Questions?

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Referenced documents

• Patrick Hudson SPE Leiden University, Margot Vuijk Dockwise BV, Robin Bryden Shell International EPS-HSE, Dominika Biela Leiden University, Charles Cowley Shell International 2000 A New Model for a Just and Fair Culture

• Reason, James (2000-03-18). Human Error Models and Management

• Reason, James (1990-04-12). "The Contribution of Latent Human Failures to the Breakdown of Complex Systems

Accountability at the active failure - Home - PACDEFF · Title: Accountability at the active...

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