Transcript Please read this before using presentation  This presentation is based on content presented at the 2007 Mines Safety Roadshow held in October.

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:
[email protected]
or visit
www.docep.wa.gov.au/ResourcesSafety
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Toolbox presentation:
Safety culture – part 2
What does safety culture
mean for mining?
October 2007
Safety culture toolbox series
1. Integrating human factors and safety management systems
2. What does safety culture mean for mining?
(Author: Martin Knee, State Mining Engineer)
3. Safety culture in practice in Australian mining
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Safety culture
A big round of applause please! Here is
the man who set up our Safety Culture!!
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Safety culture
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Safety culture – What is it?
“The safety culture of an organisation is the product
of individual and group values, attitudes,
competencies and patterns of behaviour that
determine the commitment to, and the style and
proficiency of, an organisation’s health and safety
programmes. Organisations with a positive safety
culture are characterised by communications
founded on mutual trust, by shared perceptions of
the importance of safety and by confidence in the
efficacy of preventive measures.”
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Safety culture – What is it really?
“What people at all levels in an organisation
do and say when their commitment to safety
is not being scrutinised — what they do
when no-one is watching.”
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What are we up against?
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Active failures

Active failures are the unsafe acts committed by people
who are in direct contact with the system

They take a variety of forms:
 slips
 lapses
 fumbles
 mistakes
 procedural violations
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Latent conditions

Latent conditions are the inevitable “resident pathogens”
within the system

They arise from decisions made by designers, builders,
procedure writers, and top level management

Such decisions may be mistaken, but they need not be

All such strategic decisions have the potential for
introducing pathogens into the system
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Latent conditions cont.
Latent conditions have two kinds of adverse effect.
1. They can translate into error provoking conditions within
the local workplace such as:
 time pressure
 understaffing
 inadequate equipment
 fatigue
 inexperience
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Latent conditions cont.
2. They can create long lasting holes or weaknesses in the
defences such as:
 untrustworthy alarms and indicators
 unworkable procedures
 design and construction deficiencies
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Latent conditions cont.

Latent conditions — as the term suggests — may lie
dormant within the system for many years before they
combine with active failures and local triggers to create an
accident opportunity

Unlike active failures, whose specific forms are often hard
to foresee, latent conditions can be identified and
remedied before an adverse event occurs

Understanding this leads to proactive rather than reactive
risk management
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Our safety cultures …
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… are poles apart
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Gas? What gas?
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For electrical safety — always pool your resources
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What makes you think it came from our mine?
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Do you really have to leave us?
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At least the ashtray is close to the sign!
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Well, at least while I’m smoking I can’t use
my mobile phone
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Error management
Two possibilities:
1. limiting the incidence of dangerous errors
and — since this will never be wholly effective
2. creating systems that are better able to tolerate the
occurrence of errors and contain their damaging effects
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Human fallibility

Two approaches to the problem of human fallibility:


the person
the system

The person approach focuses on the errors of individuals, blaming
them for forgetfulness, inattention, or moral weakness

The system approach concentrates on the conditions under which
individuals work and tries to build defences to avert errors or mitigate
their effects

High reliability organisations — which have less than their fair share of
accidents — recognise that human variability is a force to harness in
averting errors, but they work hard to focus that variability and are
constantly preoccupied with the possibility of failure
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Fallibility management

Person approach directs most management resources at trying to
make individuals less fallible or wayward

System approach strives for a comprehensive management
programme aimed at several targets:
 the person
 the team
 the task
 the workplace
 the institution as a whole
with a view to setting up a “resilient” or “high-reliability” organisation
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Types of human error

We distinguish intentional and unintentional behaviour

Slips are unintended actions

Lapses are unintended failures to act

Mistakes are intended, but the result is not what was
really meant

Violations are intentional failures

Violations can be seen as a form of mistake (I’ll get away
with it)
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To err is human
Types of human error
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Taking chances — making judgments

Expected benefits of comparatively risky behaviour
alternatives

Expected costs of comparatively risky behaviour alternatives

Expected benefits of comparatively safe behaviour
alternatives

Expected costs of comparatively safe behaviour alternatives
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Challenges for high-reliability organisations

Managing complex, demanding technologies so as to
avoid major failures that could cripple or even destroy the
organisation concerned

Maintaining the capacity for meeting periods of very high
peak demand, whenever these occur
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How do organisations cope?
Type
Characteristics
Vulnerable
In denial
Messengers ‘shot’
Rule followers
Deal ‘by the
book’
Whistleblowers
dismissed or
discredited
Conform to rules
Protection of the
powerful
Repair not reform
Information
hoarded
Target = ‘zero’
Reactive
Information
neglected
Responsibility
shirked
Responsibility
compartmentalis
ed
Failure punished
or covered up
New ideas =
‘problems’
New ideas
crushed
Robust
Develop risk
management
capacity
Enlightened
Active leadership
Enhance
systems
Safety
management
plan widely
known
Improve suite of
performance
measures
Competent
people with
experience
Develop action
plans
Accountabilities
understood
Monitor/review
progress
Advanced
performance
measures
Clarify/refine
objectives
Regular reviews
Range of
emergency
responses
catered for
Resilient
Strive for
resilience of
systems
Reform rather
than repair
Responsibility
shared
Actively seek
new ideas
Messengers
rewarded
Proactive as well
as reactive
Failures prompt
far-reaching
inquiries
Flexibility of
operation
Consistent
mindset =
‘wariness’
Descriptor
‘in disarray’
pathological
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Sanction
‘organised’
reactive
‘credible’
calculative
‘trusting’
proactive
Direct
Encourage
Partner
‘disciplined’
generative
Champion
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Changing safety culture
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High-reliability organisations …

Have a collective preoccupation with the possibility of
failure

Expect to make errors and train their workforce to
recognise and recover them

Continually rehearse familiar scenarios of failure and
strive hard to imagine novel ones

Instead of isolating failures, they generalise them

Instead of making local repairs, they look for
system reforms
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High-reliability organisations …

Can reconfigure themselves to suit local circumstances

In their routine mode, they are controlled in the conventional hierarchical
manner

In high tempo or emergency situations, control shifts to the experts on
the spot

The organisation reverts seamlessly to the routine control mode once the
crisis has passed

Define their goals in an unambiguous way and, for these bursts of
semiautonomous activity to be successful, it is essential that all the
participants clearly understand and share these aspirations

Although high-reliability organisations expect and encourage variability of
human action, they also work very hard to maintain a consistent mindset
of intelligent wariness
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High-reliability organisations …






Are the prime examples of the system approach
Anticipate the worst and equip themselves to deal with it at all levels of
the organisation
It is hard, even unnatural, for individuals to remain chronically uneasy, so
their organisational culture takes on a profound significance
Individuals may forget to be afraid, but the culture of a high-reliability
organisation provides them with both the reminders and the tools to help
them remember
For these organisations, the pursuit of safety is not so much about
preventing isolated failures, either human or technical, as about making
the system as robust as is practicable in the face of its human and
operational hazards
High-reliability organisations are not immune to adverse events, but they
have learnt the knack of converting these occasional setbacks into
enhanced resilience of the system
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Same industry — same system failure
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