jOHN fARLEY
MR HADDON-CAVES REPORT page 570:
5. In my view, there are five elements required for building an Engaged Organisation and SafetyCulture:
A Reporting Culture: an organisational climate where people readily report problems, errors and near misses.
A Just Culture: an atmosphere of trust where people are encouraged and even rewarded for providing safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour.
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining its focus on safety.
A Learning Culture: the willingness and competence to draw the right conclusions from its safety information and the will to implement major safety reforms.
A Questioning Culture:1 It is vital to ask “What if?” and “Why?” questions. Questions are the antidote to assumptions, which so often incubate mistakes.
6. The role of Leadership is critical in Safety Culture.
7. I make appropriate Recommendations with a view to building an Engaged Organisation and Safety Culture for the Future.
I hope you can see he has covered this but it has to be implimented .