The SHE culture

The TRIPOD model includes SHE culture elements (Reason, 1991). In an accident investigation, the model is used to classify top management commitment on a scale from 1 (pathological) to 7 (generative-proactive). We will treat this aspect of the TRIPOD model in more detail in Section 6.5. 

1 Traditional occupational safety management cultme, i.e., a cultme where the causes of errors and accidents are attributed to inattention and carelessness on behalf of the workers. Disciplinary measures will dominate the remedial actions. 

2 Risk management culture, where an engineering view of human error causation is dominant. Errors and accidents are analysed in terms of mismatches between the operator and his environment. Remedial actions typically include design changes and provisions of procedural support. 

3 Systemic safety management culture, where the causes of errors are analysed in relation to the total work context. Not only are traditional causes such as poor design and procedures considered, but also such aspects as unclear responsibilities, lack of knowledge and a low morale. These in turn are traced back to management liability issues. 

It is relevant to apply the approaches by Reason and Lucas to cases where an independent body (e.g. an accident commission) carries out the accident investigation. The commission will ask questions about previous incidents of a similar type and the organisation s ability to learn from them. The commission may judge the failure to learn from previous experience as a root cause of the incident. 

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