Attitude

Human Factors Risk Culture : 

Human Factors Risk Culture James Reason Emeritus Professor University of Manchester Management of Human Factors Risk in Safety-Critical Industries Royal Aeronautical Society, 11th May 2006

Expanding focus of safety concern across industries : 

Expanding focus of safety concern across industries 1955 2005

The importance of culture : 

The importance of culture Only culture can reach all parts of the system. Only culture can exert a consistent influence, for good or ill.

Culture: Two aspects : 

Culture: Two aspects Something an organisation is: shared values and beliefs. Something an organisation has: structures, practices, systems. Changing practices easier than changing values and beliefs.

A safe culture: Interlocking elements : 

A safe culture: Interlocking elements

Cultural ‘strata’ : 

Cultural ‘strata’

Some barriers to cultural progression : 

Some barriers to cultural progression Blaming Denial Silence Fixes Tradeoffs

Culture change: a continuum : 

Culture change: a continuum Don’t accept the need for change. Accept need, but don’t know where to go. Know where to go, but not how to get there. Know how, but doubt it can be achieved. Make changes, but they are cosmetic only. Make changes, but no benefits—model doesn’t align with real world. Model aligns today, but not tomorrow. Successful transition—model keeps in step with a changing world.

Contrasting perspectives on the human factor : 

Contrasting perspectives on the human factor Person model vs system model Human-as-hazard vs human-as-hero ‘Reliability (safety) is a dynamic non-event’ (Karl Weick)

Getting the balance right : 

Getting the balance right Both extremes have their pitfalls. Blame Deny Isolate Learned helplessness

On the front line . . . : 

On the front line . . . People at the sharp end have little opportunity to improve the system overall. We need to make them more risk-aware and ‘error-wise’ – mental skills that will: Allow them to recognise situations with high error/risk potential. Improve their ability to detect and recover errors that are made.

Risk-awareness on the front line:Lessons from various industries : 

Risk-awareness on the front line:Lessons from various industries Western Mining Corporation: ‘Take time, take charge’. Thinksafe SAM: Steps are S=spot the hazard, A=assess the risk, M=Make changes. Esso’s ‘Step back five by five’. Defensive driver training. Three-bucket assessments

The 3-bucket model forassessing risky situations : 

The 3-bucket model forassessing risky situations 1 2 3 SELF CONTEXT TASK

How the model works : 

How the model works In any given situation, the probability of unsafe act(s) being committed is a function of the amount of bad stuff in all three buckets. Full buckets do not guarantee an unsafe act, nor do empty ones ensure safety. We are talking probabilities not certainties. But with foreknowledge we can gauge these levels for any situation and act accordingly. Don’t go there—challenge assumptions, seek help.

Preaching risk awareness is not enough—needs system back up : 

Preaching risk awareness is not enough—needs system back up Western Mining Corporation Each day supervisors ask workers for examples of ‘take time take charge’. What makes this happen is that, at weekly meetings with managers, supervisors provide examples of ‘take time take charge’. Feedback to original reporters. A manager at corporate level whose sole task is to make the process work.

Resilience : 

Resilience World Individual mindfulness Collective mindfulness System Resilience Local risk awareness Turbulent interface between system & world ‘Harm absorbers’ Activities Frontline operators Management

Slide 17: 

Human as hazard Errors & violations Human as hero Adjustments, compensations & improvisations Systemic factors revealed Systemic factors concealed A B C D Reduced variability cycle

Something to aim for? : 

Something to aim for? It is hoped that as an organization learns and matures, variability will diminish. The tensions and transitions implicit in the cycle will remain, but the perturbations should be less disruptive. Eventually (one hopes), the person and system models will operate cooperatively rather than competitively. Enhanced resilience (one hopes) will be an emergent property of this greater harmony.

Summary : 

Summary In all hazardous industries, there has been an increasing involvement of systemic/cultural factors in the understanding of safety. It was argued that a balance needs to be struck between system & person models. The person model usually means ‘human as hazard’. But there is also ‘human as hero’. Speculative cycles around two-sided person & system axes are outlined.