Culture accidents

Many organizations that have evolved over a long period of time come to believe that the system of safety rules that they have developed is invulnerable to human error. The existence of a "rule book" culture can produce a complacent attitude which assumes that if the rules are followed then accidents are impossible. This is based on the belief that a rigid set of rules will cover every contingency and that interpretation by individuals to cover imanticipated situations will never be required. Of course, all rules will at some time require such interpretation, and the need for this should be accepted and built into the system. 

The first area focuses on the cultural and organizational factors that will have a major influence on the effectiveness of a human error data collection system and how well the information derived from such a system is translated into successful error reduction strategies. Regardless of how effectively the technical issues are dealt with, the system will not be successful imless there is a culture in the organization which provides support for the data gathering process. No data collection system aimed at identifying human error causes of accidents will be workable without the active cooperation of the workforce. 

The type of data collected on human error and the ways in which these data are used for accident prevention will vary depending upon the model of error and accident causation held by the management of an organization. This model will also influence the culture in the plant and the willingness of personnel to participate in data collection activities. In Chapters 1 and 2 a number of alternative viewpoints or models of human error were described. These models will now be briefly reviewed and their implications for the treatment of human error in the process industry will be discussed. 

In some organizations, designated individuals have specific responsibility for eliciting detailed information from operational staff on the immediate and underlying causes of incidents. An example is the Human Performance Evaluation System (HPES) developed for the nuclear industry, which is described in Bishop and Larhette (1988). These coordinators provide a certain level of guaranteed irrununity from sanctions which allows individuals to be frank about the contributory causes that they may not be willing to discuss in an open forum. As discussed earlier, the need for this approach is a consequence of the fact that in many organizations a blame culture exists which is likely to inhibit a free flow of information about the causes of accidents. 

With regard to evaluating these factors, it is recommended that structured checklists be used, such as those provided by the HFAM method described in Chapter 2. These checklists provide an explicit link between the direct causal factors and management policies. Figure 2.12 shows how these checklists could be used to investigate possible procedures deficiencies, and the policies that led to the deficiencies, as part of the incident investigation. Similar checklists can be used to investigate possible culture problems (e.g., inappropriate trade-offs between safety and production) that could have been implicated in an accident. 

A 43-year-old male in the surgical ICU after exploratory laparotomy following a motor vehicle accident develops fever that is unresponsive to broad-spectrum antibacterial therapy (piperacillin-tazobactam 3.75 g every 6 hours, gentamicin 120 mg every 8 hours, and vancomycin 1 g every 12 hours). The patient has a central venous catheter and a Foley catheter. Blood cultures are negative at the time, but the patient has yeast growing in the sputum and urine. Laboratory studies reveal a white blood cell count of 11,300 cells/mm3 (11.3 x 109/L). 

Other accidents could have introduced early cultures to the hallucinatory effects. While harvesting the plant for seeds (for oil) or fiber, accidental fires could have produced a resinous smoke, which was then inhaled. The smoke would have also appealed to the magicoreligious practices of native shamans (30). The smoke itself is inherently evocative of visions and mystery—a natural medium for shamanism It contained a property that could induce a form of trance it was readily consumed by the cleansing power of fire its smoke rose to the abode of the gods and it allowed dreams to be materialized. 

The treatment for most of these attitudes is the developement of an effective loss prevention team culture within the company, (i.e., led by senior management, with employee involvement), that demostrates the mutual benefits of an accident free environment. 

Thus, the American Lawn is a political and economic (and not solely cultural) object that by its design (and not by any form of ecological accident) demands inputs. Many of these inputs are hazardous, and knowledge of these hazards is easily available to lawn people. 

Many archaeological sites are discovered by accident. Rome, for example, is a city in Italy that has been occupied for nearly 3,000 years. This city was the cultural and political center of the Romans, a people whose... 

I consider three sources of variation in behavior across societies. First, societies may exhibit different behaviors because for historical reasons they have ended up in different coordination equilibria. In theory, the United Kingdom and the United States could be identical in all respects except that people drive on the left in the first country and on the right in the second, together with features that flow directly from this difference. Differences in metric systems, number systems, and calendars can also generate differences in behavior that need not reflect anything but accidents of history. Second, behavioral differences may be due to different norms and values. I especially emphasize the importance of social norms in explaining cultural variation. Norms, in turn, are backed by... 

Traditional accident models were devised to explain losses caused by failures of physical devices (chain or tree of failure events) in relatively simple systems. They are less useful for explaining accidents in software-intensive systems and for non-technical aspects of safety such as organizational culture and human decision-making. Creation of an infrastructure based on which safety analysis can function efficiently and effectively is needed. A so called safety culture for a development company and processes associated with routine tasks there, in general, is now identified as an area of root cause of accidents and that there is the greatest... 

A cell culture laboratory, in which activities are restricted to manipulation of established or pathogen-free derived cell lines, is a relatively safe workplace. Major risks are related to potential injuries resulting from liquid nitrogen manipulation or glassware accidents. 

The material in this long chapter may not cover the needs of every chemical plant and every petro-chemical plant, but the ten or fifteen Management of Change procedures developed by major corporations and reviewed by me did not seem to exactly fit the needs or culture of my own organization. Trevor Kletz has said many times that improper plant modifications have been a major cause of chemical plant accidents. I have been working in a process safety function for three decades and my experiences have been similar. It just seems appropriate to repeat the first three paragraphs of the second section of this chapter, as a fitting close. 

---