Safety Culture and the Reporting program.
The safety culture of an organization is dependent on many variables and it is imperative
to the safety health of an organization. An important tool in improving safety culture is
the reporting program. This program supplies the information required to improve the
organizations safety and help identify any problem areas with a thorough incident
investigation. Safety culture and the reporting program both rely on each other to ensure
efficiency. Both entities collectively improve each other and they must complement each
other. A reporting system therefore cannot imply solely that the safety culture is mature
as it must exist even in the formative stages of a safety culture in order to reach a
What is Safety Culture?
The term ‘safety culture’ was first coined after Chernobyl power plant accident in 1986
and is used regularly now 1 . ‘Safety culture is the ‘engine’ that drives the system towards
the goal of sustaining the maximum resistance towards its operational hazards’. (James
Reason 1991) 2 Chernobyl, the sinking of the Free Enterprise and the Piper Alpha
disasters are some examples that highlight the importance of a mature culture. Safety
culture is distinguished ‘into its static and its dynamic components.’ (Patrick Hudson
1994)3 The static components are ‘the attitudes, beliefs, perceptions and values that
employees share in relation to safety’ (Cox and Cox 1991) 4 . The dynamic components
are the processes and procedures that define how an organization should conduct
everyday operations. It can be determined that all organizations have some sort of safety
culture from a pathological safety culture to a mature generative culture 5 . It is up to an
organization to develop and improve their safety culture but as ‘it is very hard to change
the attitudes and beliefs of adults by direct methods of persuasion’ (James Reason
1991)Error! Bookmark not defined.3 and it is better to engineer safety conscious actions.
Therefore it is the dynamic processes and procedures, that determine operational actions,
that can be controlled and in the process of doing the attitudes of adults can evolve. It is
through everyday operations that a change in beliefs and values can be influenced.
Characteristics of a Safety Culture.
Each organization has a certain level of safety culture and in order to improve their
resistance to hazards they must aim for the generative stage (Figure 1.1). The Westrum
Model (1991) demonstrates the need of an increase in informedness and trust in order for a
1 INSAG-7 The Chernobyl Accident: Updating of INSAG-1. International Atomic Energy Agency. (1992) Pg 22
Oganisational Accidents and Safety Culture - James Reason (1991) Pg 4
Safety Culture – Theory and Pract ice – Patrick Hudson (1994) Pg 8-2
4 The structure of employee attitudes to safety - a European example Work and Stress. Cox, S. & Cox, T. (1991)
- Pg 93 - 106
Aviation Safety Culture – Patrick Hudson (2001) Pg 5
safety culture to mature 6 . ‘Informedness follows from being informed (seeking
information) and reporting (providing information)’ (Patrick Hudson 2001) Error! Bookmark not
. The reporting program and subsequent investigation must support the safety culture
and vice versa. ‘The issue is not whether the organization has a reporting system; it is
whether, as a matter of practice, errors and near misses are reported. 7 ’ For a reporting
program to be effective it must be designed to compliment the characteristics of the ideal
safety culture as well as being driven by the safety culture.
The reporting program is the information flow from bottom to top but it also should enable
an information flow back to the employees. This will encourage a sense of informedness
through out the organization not just the managerial spheres. This will increase reporting as
the employees will see an action resulting from their reports. This helps to e ncourage an
informed and reporting safety culture. ‘A reporting culture depends, in turn, on how the
organization handles blame and punishment.7 ’ ‘To err is human’ and if all errors are
punished it will not encourage reporting. The same occurs if blame is not appointed to the
truly egregious errors as reporting will be seen as unproductive. Therefore a just culture is a
requirement of the reporting program in order to be productive. Then once the reports are
gathered they need to be investigated and therefore learning can occur. ‘Finally, a culture
of safety is flexible, in the sense that decision- making processes vary, depending on the
urgency of the decision and the expertise of the people involved.7 All these characteristics
of the safety culture and the reporting program are ‘organizational or collective practices’7 .
These are the practices that will affect the less tangible static components of the safety
culture. It is therefore clear that the safety culture and the reporting program must
compliment each other in order to improve an organizational culture and a standalone
reporting program is not enough to indicate a mature safety culture.
Aviation Safety Culture – Patrick Hudson (2001) Pg 5
7 Safety Culture, Mindfulness and Safe Behaviour: Converging ideas?
– Andrew Hopkins (2002) Pg 7
Figure 1.1 – The Evolution of Safety Cultures Error! Bookmark not defined.6
The Dynamic Components.
The dynamic components are the characteristics of the safety culture, the SMS and the
reporting program which are all practices. These are used to shape organizational culture
more so than trying to change the elusive values and beliefs directly. The Safety
Management System (SMS) ‘is a businesslike approach to safety. It is a systematic,
explicit and comprehensive process for managing safety risks.’ 8 It incorporates the
organization’s philosophy, policies, specifies the roles and responsibility of all employees
through specified procedures and practices8 . It should be integrated into everyday
operations in order to become effective. With managements commitment to the SMS it
will become incorporated with daily operations and by ‘acting and doing, shaped by
organizational controls, lead to thinking and believing.’ Error! Bookmark not defined.8 The
reporting program should also become integrated into an organization’s processes. Both
the SMS and reporting program help to form an organisational culture but it is the safety
culture that will drive the personnel within the organization to adopt these processes Error!
Bookmark not defined.8
. The SMS and reporting system need to be present in all stages of the
safety culture where all components must work together in order for the organization’s
safety health to evolve. The confidential reporting system is part of the processes that
develop the safety culture. It should come into existence in the beginning of the
organization advancement not at the end. Therefore again it cannot be assumed that t he
existence of a reporting program quantifies a mature safety culture.
http://www.tc.gc.ca/ Civ ilAviation/systemSafety/pubs/tp13739/ SMS/what.h t m
Figure 1.2 – The Accident Pyramid 9
Why do we need to report?
James Reason (1990) 10 determined that there was not one single cause but a chain of
failures that lead to an accident. This chain included the defenses, or lack thereof, and
latent failures which are controlled by the managerial spheres as well at active failures.
The active failures occur at the sharp-end and this is usually the last point to ‘break the
chain’. The latent failures can remain dormant for days, weeks even years and are
inherited by the sharp-end. In the right circumstances accidents can occur when latent
conditions combine with active failures and other local triggering events to create an
accident trajectory. It is these trajectories that then bypass the defenses and cause an
occurrence. A small change in circumstance can be the only difference in a nil event or a
serious accident. This is demonstrated by the Accident Pyramid (Figure 1.2) where for
each accident there are multiple similar events. It is therefore imperative to determine the
contributing factors to stop history repeating itself with the possibility of more dire
consequences. This is done through gaining knowledge. ‘The best way to sustain a state
of intelligent is to gather the right kinds of data.’ Error! Bookmark not defined.9 As the people at
the sharp end are the inheritors rather than the instigators of the accident sequence (James
Reason 1991) then this is where the ‘right kind of data’ is held. It is with the active
failures or human error of the sharp-end that can be analyzed to determine the latent
failures. An investigator will ‘use the discovery of human error as the beginning of an
investigation, not as its conclusion.’ 11 It is therefore easy to see that the sharp-end must
be willing to report and even encouraged to report. Without their voluntary report the
situation will never be investigated and a future, possibly a more serious occurrence,
might not be avoided. A reporting system is important as enables an information flow
Beyond Aviaton Human Factors - Daniel E Maurion, James Reason, Neil Johnston, Rob B Lee. (1995)
Errors in our Understanding of Hu man Error: The Real Lesson from Aviat ion to HealthCare – Sidney
Dekker (2003) Pg 5.
that can help improve the safety health of an organization. Reporting program is
imperative but it must be designed to aid informedness and trust in order to help evolve
the safety culture.
Safety; A Dynamic Non-Event.
‘Safety culture is the ‘engine’ that drives the system towards the goal of sustaining the
maximum resistance towards its operational hazards’. 12 As this restatnce improves there
will be an increase in safety and this is described as a ‘dynamic non-event’2 (Karl Weick
1991) making safety hard to evaluate. It is therefore easy for an organization to become
complacent in a time of non-events. The reporting program becomes even more
important in this time as it should promote reporting of occurences that result in a nil
event. ‘Without a detailed analysis of mishaps, incidents, near misses, and "free lessons,"
we have no way of uncovering recurrent error traps or of knowing where the "edge" is
until we fall over it.’ 13 It is imperative that an orgainsation remains ‘wary’ during these
times. To do so the safety culture must be driving the organization to report and to
investigate. Complacency can cause a false sense of security which could result in an
organization taking greater risks then they should. If an organization becomes
complacent the safety culture can actually move backwards at a slow rate that may go
unnoticed as a normalized deviance sets in. Then even the best reporting program can
become void without the motivation to support it. If a normalized deviance occurs then
not only does a reporting program not imply a mature safety culture but it could actually
exist inefficiently in a diminishing safety culture.
Confidential reporting program protects the identity of the reporter. An ‘independent
‘safety broker’ 14 ’ gathers the reports and investigates the relevance and importance of the
report. ‘Reports that will be treated confidentially also differ in substance from other
forms of occurrence reporting—they typically hold greater candor and higher
psychosocial resolution’ (O’Leary & Pidgeon, 1995) 15 This improves not only the
quantity but also the quality of information. As ‘the best way to sustain a state of
intelligent is to gather the right kinds of data’ Error! Bookmark not defined.9 this type of reporting
system increases the ability of an organization to be informed, to learn and to report. For
reporters to feel entirely comfortable reporting, an exemp lary or a near perfect culture
must exist but in the formative stage and even in the most advanced safety culture this is
not realistic. In the place of an ‘exemplary open reporting culture’7 a confidential
reporting program can encourage reporting. ‘Systems that have shifted to confidentiality
all show a huge
increase in willingness to report as measured by the number of reports received’
(Madsen, 2001;Noerbjerg, 2004)15 . A confidential reporting program can help improve
reporting and therefore the safety culture can improve but the very nature of it being
confidential may imply an immature safety culture more so than a mature safety culture.
Oganisational Accidents and Safety Culture - James Reason (1991) Pg 4
Hu man error: models and management - James Reason (2000)
Road map to a Just Culture: Enhancing the Safety Env iron ment (2004) Pg 30, 31
Fro m Punitive Acition to Confidential Reporting – Sidney Dikker (2007) Pg 1
Either way it is an imperative part of the safety system that can help improve the general
safety health of an organization.
The SMS, safety culture and the confidential reporting program are all integrated. They
cannot exist efficiently without each other. Each component promotes and improves each
other. The SMS supplies the procedures and processes, the reporting program supplies
the information flow and the safety culture is the engine that drives the entire system. A
confidential reporting program can exist without a mature safety culture but it will not be
entirely efficient until the safety culture has evolved towards the pro-active or generative
stages. Instead the reporting program and the safety culture must work together to
improve the organizations resistance to hazards. A reporting program must have certain
characteristics that will compliment and emulate the ideal safety culture. Simply being in
‘existence’ does not imply a mature safety culture as the reporting system should be in
place at all stages of the development of the safety culture. This however does not negate
its importance in developing the safety culture.
INSAG-7 The Chernobyl Accident: Updating of INSAG-1. International Atomic Energy Agency. (1992)
2. Organizational Accidents and Safety Culture - James Reason (1991)
3. Safety Culture – Theory and Practice – Patrick Hudson (1994)
The structure of employee attitudes to safety - a European example Work and Stress.
4. - Cox, S. & Cox, T. (1991)
5. Aviation Safety Culture – Patrick Hudson (2001)
7. Beyond Aviation Human Factors - Daniel E Maurion, James Reason, Neil
Johnston, Rob B Lee. (1995)
8. Errors in our Understanding of Human Error: The Real Lesson from Aviation to
HealthCare – Sidney Dekker (2003)
9. Safety Culture, Mindfulness and Safe Behavior: Converging ideas? – Andrew
10. Roadmap to a Just Culture: Enhancing the Safety Environment (2004)
11. From Punitive Action to Confidential Reporting – Sidney Dikker (2007)