Safety, Culture, and Blame

Shein divides culture into three levels (figure 13.2) [188]. At the top are the surface-level cultural artifacts or routine aspects of everyday practice including hazard analyses and control algorithms and procedures. The second, middle level is the stated organizational rules, values, and practices that are used to create the top-level artifacts, such as safety policy, standards, and guidelines. At the lowest level is the often invisible but pervasive underlying deep cultural operating assumptions 

Upon which actions are taken and decisions are made and thus upon which the upper levels rest. 

Safety culture is primarily set by the leaders of the organization as they establish the basic values under which decisions will be made. This fact explains why leadership and commitment by leaders is critical in achieving high levels of safety. 

Unhealthy work atmospheres with respect to safety and communication are not limited to NASA. Carroll documents a similarly dysfunctional safety culture at the Millstone nuclear power plant [33]. An NRC review in 1996 concluded the safety culture at the plant was dangerously flawed it did not tolerate dissenting views and stifled questioning attitudes among employees. 

For both the Challenger and Columbia accidents, as well as most other major accidents where decision making was flawed, the decision makers saw their actions as rational. Understanding and preventing poor decision making under conditions of uncertainty requires providing environments and tools that help to stretch our belief systems and to see patterns that we do not necessarily want to see. 

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