mercurydancer;
No one has died so whats the problem?
In flight safety work, this approach to risk is known by a number of terms beginning with "tombstone safety". Another term is "blood priority".
For your, and for postman23 and lomapaseo's benefit and hopefully others who have continued to read this thread, I want to reproduce (rather than just link) an article that covers all areas of interests expressed thus far. I think it answers the question, "How do we do that?"; I think it provides some basic notions on how serious flight safety work
must be done but too often isn't and I think it provides a positive way forward without a sense of pointing fingers or giving up in the face of daunting odds.
I have colored
blue those statements which I think are especially valuable and would apply equally to medicine as to other industries including of course, aviation from whence it came.
PJ2
http://www.fsinfo.org/docs/FSISpecial052603.pdf
Organizational Culture and Safety
The beginning of the organizational culture period of accident investigation and analysis can be traced back to the nuclear accident at Chernobyl in 1986 (Cox & Flin, 1998). On April 26 1986, two explosions blew off the 1000-ton concrete cap sealing the Chernobyl-4 reactor, releasing molten core remains into the vicinity and fission products into the atmosphere.
It was the worst accident in the history of nuclear power generation. It has so far cost over 30 lives, contaminated approximately 400 square miles around the Ukrainian plant and significantly increased the risk of cancer deaths over a wide area of Scandinavia and Western Europe (Read, 1990).
Poor safety culture was identified as a contributing factor in the Chernobyl disaster (Cox & Flin, 1998). Since then safety culture has been discussed in other major accident enquiries and analysis of system failures, such as the King's Cross Underground fire in London and the Piper Alpha oil platform explosion in the North Sea (Cox & Flin, 1998; Pidgeon, 1998).
According to Meshkati (1997), the most dramatic turning point for "safety culture" in the United States came with an aviation accident that killed 14 people -the in-flight structural breakup and crash of Continental Express Flight 2574 near Eagle Lakes, Texas, on September 11, 1991. As a member of the National Transportation Safety Board (NTSB) at that time, Dr. John Lauber suggested that the probable cause of this accident included "The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures" (Meshkati, 1997).
As a result of this and other similar aviation accidents, safety culture came to the forefront as the exclusive topic at the U.S. National Summit on Transportation Safety, hosted by the NTSB in 1997. The acknowledgment of the meaning of safety culture in preventing accidents has led to many studies attempting to characterize safety culture in a number of high-risk manufacturing companies. Cox and Flin state, there have been few attempts to examine the various definitions of safety culture that have been proposed in the literature, nor have there been any attempts to culture within organizations.
Furthermore, such terms as "safety climate" are often used in conjunction with safety culture, with little if any differentiation between the concepts (Cox & Flin, 1998). Consequently, while the concept of safety culture continues to attract more attention, "the existing empirical efforts to study safety culture and its relationship to organizational outcomes have remained unsystematic, fragmented and in particular under-specified in theoretical terms" (Pidgeon, 1998).
The first thing to recognize about Safety Culture is that it cannot be quantitatively measured. Instead, it is more appropriate to survey attitudes, and observe employee and management behaviors, and the quality of the work process. The rapid development of new technology has fundamentally changed the nature of work and has increased the complexity of systems within a variety of industries (Hendrick, 1991). Among these complex systems are those commonly known as "high-risk" systems, such as nuclear power plants, chemical processing facilities, and aviation operations that require a tight coupling between both technical and human subsystems. It is critical to have positive workplace attitude – from the president to the newest hire.
Management is the key to a successful safety culture. This positive attitude must flow from the top down. How may times have you heard the expression "flavor of the month" directed at a new organizational program or process? It’s common for corporations to adapt this lack-luster attitude and it is one of the largest mistakes made. Deliberate how safety programs are conventionally presented to would-be participants. A corporate administrator learns about a new safety program and orders the appropriate materials. Some companies go as far as to hire a trainer to teach the new step-by-step procedures to certain personnel. Then these employees demonstrate the new procedures to others while on the job, and thus a new safety program is implemented plant wide.
But to many this is just another set of temporary procedures, which attempt to reduce recordable injuries and make management look good. It is commonly believed that the new program won't really work to reduce injuries, and therefore it won't be long before it will be replaced with another "flavor of the month.” The "flavor-of-the month" attitude occurs when people are not taught the principles or rationale behind a program. They are just trained on how to implement the new process. They are not educated about the research-supported theory and corporate mission statement from which the program originated.
A true safety culture is established when safety is valued consistent with productivity and profitability. Managers and supervisors need to be held accountable for safety in the same manner as production and profitability.
Paul O’Neill, U.S. Secretary of the Treasury, as printed in the Industrial Safety and Hygiene News (ISHN), March 2001, explains: “Many companies still see safety management as a costly legal requirement with no real business benefits, but this is not the case. He explains that all truly great organization must be aligned around values that bind the organization together." “This is how companies withstand competitive pressures and operate consistently on a far_flung global basis.”
He stated that: great organizations have three characteristics:
• Employees are treated with dignity and respect.
• They are encouraged to make contributions that give meaning to their lives.
• Those contributions are recognized.
According to O'Neill: "Safety is a tangible way to show that human beings really matter." He continues to state that: "Leadership uses safety to make human connections across the organization. Stamping out accidents (which at Alcoa O'Neill called "incidents"), and telling employees we can get to zero incidents is a way to show caring about people. This is leadership."
Leadership accepts no excuses, and does not excuse itself, when safety problems arise.
• Simply caring about safety is "not nearly enough, not nearly enough,” He continues to say: "At the end of the day, caring alone is not enough to make sure that an incident never happens again."
• What's needed is for "safety to be as automatic as breathing," "It has to be something unconscious almost."
• This won't happen by leadership simply giving orders. "You need a process in place to get results." A process based on leadership, commitment, understanding, and no excuses.
• "Safety is not a priority at Alcoa, it is a precondition. If a hazard needs to be fixed, it's understood by supervisors and employees that "you do it today. You don't budget for it next year."
He continues by stating: How do you get an organization to believe this? "You always must be constantly thinking about ways of refreshing the organization's thinking about safety."
O'Neill outline five steps he took soon after coming to Alcoa. He called in the safety director to review the company's performance.
O'Neill was told Alcoa's rates were below industry average. "That's good," "But the goal is for no Alcoan to be hurt at work," he told his safety director. No injuries down to first aid cases. "The only legitimate goal is zero." Otherwise, who's going to volunteer to be that one annual case, or whatever?
Getting to zero is a journey of discovery, O'Neill said, and at no point can you stop and say, "We've reached the point of diminishing returns and can't afford to get better."
O'Neill met with employees and gave them his home phone number. "I told them to call me if their managers didn't fix safety problems.
What I was doing was making a point to my managers." O'Neill had 26 business units. Vice presidents call him personally whenever their group experienced a lost workday case. "This constantly engaged them about safety," he said. It forced them to confront themselves: "Why do I have to make this call I hate to make?"
When Alcoa launched an internal computer network, safety information came online first, before marketing, sales or finance, according to O'Neill. Just another way to keep safety in front of employees and managers and reinforce that it is a precondition, he explained.
O'Neill told his financial people, "If you ever try to calculate how much money we save in safety, you're fired." Why? He didn't want employees looking at safety as a "management scheme" to save money.
"Safety needs to be about a human value. Cost savings suggest something else. Safety is not about money; it's about constantly reinforcing its value as a pre-condition."
OSHA strongly believes that an effective safety and health program is the answer and results are the proof. After focusing on its safety and health program, an Atlanta company reported that, from 1994 to 1996, their annual Workers' Compensation claim costs fell from $592,355 to $91,536, a savings of $500,000. After implementing a 100% fall protection program and supervisory accountability for safety, Horizon Steel Erectors, Inc., had a 96% reduction in its accident costs per person per hour, from $4.26 to $0.18 (Mallon, 2001).
To go along with the “flavor of the month syndrome”, a lot of companies cannot release the Blood Priority or otherwise known as the Tombstone Safety Program. Mr. Richard Wood, author of “Aviation Safety Programs,” states that Tombstone Safety refers to the idea that it’s a lot easier to get something corrected if you just had an accident or killed someone - there is literally blood on the accident report.” The result to this is that it is difficult to get something corrected if it has not caused an accident.
This is the, “If it ain’t broke, don’t fix” attitude. This type of attitude is taught, and it comes from the top down. If the corporation has the Tombstone Safety Program, then that’s what the employee’s will do…Tombstone Safety!
Team Building and Safety Culture Building a safety culture is not a safety function, but a project management function. And no one person can do it alone. Kenneth Blanchard, author of the “One Minute Manager Builds High Performing Teams,” states, “Not one of us is as smart as all of us put together.”
Empower the employee’s and getting them involved is exactly Paul O’Neill done at Alcoa. He built a high performing team that was focused on safety culture. To do this one must be totally involved and empower the workforce. However you manage your other projects, you need to build a safety culture in a particular way.
Consider the ATTAM approach: Assess, Train, Teach, Assign, and Monitor.
Assess. Observe people working, and take notes. What are the recurring unsafe acts? Record each unsafe act as it occurs. Once employees notice you in an area, they put on a face of safety and limit your ability to observe. That's the time to ask, "Why are these unsafe acts occurring?" Assess your people to determine who can champion the correcting of attitudes, behavior, and ignorance. Who are the key players? Usually, they are crew leaders, supervisors, and others with authority. Identify the people, and then identify their attitudes and basic safety knowledge.
Train. Once you've selected your safety champions, you must do
more than just tell them, "Now I am making safety part of your performance evaluation." They must learn the causes of injury and alternatives to practicing those causes. You must train everyone that safety is equal to or greater than all other goals, including production. Safety champions are teachers, but they are only as effective as their training and the backing of management allow them to be. Consider purchasing "train the trainer" safety programs.
Teach. Your trained safety champions teach safety to the rest. The simple teaching method has three parts. First, stop when you enter an area. Scan the area, then look, listen, smell, and feel for unsafe conditions. Look for such things as improper tool use. Listen for high ambient noise. Smell for gasoline fumes. Feel for high heat. When you notice an unsafe act, approach the worker, making him or her aware of the unsafe practice. Then you must follow up to ensure that worker corrects it. You also teach by looking for safe acts. For example, if you see an employee- working overhead and wearing a safety belt, let that person know you recognize and appreciate his or her attention to safety.
Assign. Some unsafe acts wouldn't happen if you could correct environmental problems. For this, you must hold individuals responsible. If it's nobody's job, nobody will do it. Make specific work assignments and hold individuals accountable for certain safety objectives. • Assign individuals to inspect equipment and work areas for problems such as poor lighting, missing guards, damaged equipment. • Assign ownership of an individual problem to an individual (who may lead a group in resolving it). • Assign individual safety ownership of specific power distribution equipment, so such activities as breaker testing and transformer inspection actually happen. • Assign someone to audit inspections, safety tours, safety meetings, and other activities.
Monitor. Check your safety culture progress by asking key questions. How are employees responding? How are your teachers carrying out their duties? Do they need more training? What are the recurring types of unsafe behavior? When did you last observe people working? Are safety inspection reports precipitating action? Is it easy to report unsafe conditions or equipment? Are you replacing unsafe equipment? Are you rewarding your employees for safe or unsafe acts?
Everything boils down to two questions: Do your employees know how much you value safe behavior? Are you sure you want them to know?
Safety Culture vs. Tombstone Safety By Gary L. Hanes
44 Flight Safety Information Journal - May 2003 www.FSinfo.org
References
Blanchard, K. (2000). One-Minute Manager Builds High Performing Teams. Retrieved May 7, 2003:
Ken Blanchard Companies
Cox, S.; Flin, R. (1998). Safety culture: Philosopher's Stone or man of straw. Retrieved April 18, 2003:
http://www.aviation.uiuc.edu/new/htm...shamithf02.pdf
Read, P. (1998). Ablaze, The story of the heroes and victims of Chernobyl
Retrieved April 19, 2003: http://www.ceet.niu.edu/faculty/vanmeer/chernob.htm
Meshkati, N. (1997). Chernobyl Accident. Retrieved April 20, 2003: http://www.worldnuclear.
org/info/chernobyl/inf07.htm
Hendrick, W. (1991). Ergonomics in organizational design and management. Retrieved April 20, 2003:
www.ehs.cornell.edu/Geneva/safety_manual.pdf
O’Neill, P. (2001). Safety Exchange of America. Retrieved April 25, 2003:
http://www.emeetingplace.com/Culture...roduction/Part 2.htm
Mallon, J. (2001). Nine Oklahoma Companies Earn 2002 Safety Award. Retrieved April 29, 2003:
http://www.state.ok.us/~okdol/press/pr042202.htm