Safe Science Promoting a Culture of Safety in Academic Chemical Research (2014) / Chapter Skim
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2 Safety Systems and Cultures
2 Safety Systems and Cultures
Pages 21-44
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Next, consideration is given to several different industries that have made good use of modern safety concepts and practices in the face of obvious and significant hazards to people and property. The chapter concludes with a brief discussion of organizational change processes.
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Many of today's work environments are highly complex, making it difficult to anticipate all possible interactions and possible failures among multiple components and multiple human operators.5 The traditional view that accidents can be understood in terms of simple linear chains of events has been gradually replaced by a broader systems perspective.6 The Second Epoch: The Systems Perspective The systems perspective represents the second epoch of safety and views accidents and other losses as arising from causal factors that reside at multiple levels within complex sociotechnical systems.7,8 The concept of human–systems integration (HSI) is central to the systems perspective.
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Systems safety also makes use of safety audits and other techniques that can be used to monitor system performance and provide early detection of changes in key system parameters. The Third Epoch: Safety Culture The emphasis on culture, specifically safety culture, represents the third epoch of modern safety management.
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Safety culture, as typically defined, refers to the organization's shared values, assumptions, and beliefs specific to workplace safety, or more simply, the relative importance of safety within the organization. Numerous attempts have been made to identify the key attributes or characteristics of a positive safety culture, and although the various frameworks differ in the details, there are clearly more similarities than differences.16,17,18 For example, virtually all discussions of safety culture highlight the fundamental importance of management commitment and active involvement.
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Positive safety cultures also place high importance on hazard identification and control as well as continuous learning and improvement. To a considerable extent, achieving a safety culture that emphasizes learning and improvement requires a culture that seeks and values information and that assigns greater importance to problem solving than blame assignment.
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A framework for understanding the develop ment of organisational safety culture. Safety Science 2006; 44(6)
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Situational awareness relates more to achieving immediate tactical objectives than to long-term objectives. The development of sense-making requires situational awareness.
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Flin. Safety climate, safety management practice and safety performance in offshore environments.
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Highperformance work systems and high-involvement work processes (HIWPs) are two approaches that have received considerable research attention.
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in aviation45 directly foster team skills, including assertiveness, maintaining shared situation awareness, and communication. Considerable research, much involving cockpit crews, but also some in health care, underscores the importance of group processes and group cohesion in overall safety.46,47 KNOWLEDGE FROM OTHER SAFETY SYSTEMS This section describes and discusses several examples of industries that have adopted many of the principles and approaches described above with the primary goal of improving safety performance.
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The importance and usefulness of reporting and tracking near misses has gained broad recognition in many areas of safety practice. Near miss reporting can be a useful part of the surveillance and monitoring component of a comprehensive safety management system.
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This system, the Aviation Safety Reporting System (ASRS) , allows pilots and other personnel to confidentially report near misses and other close calls.
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2000 publication of To Err Is Human,53 the health care community has given a great deal of attention to patient safety. To Err Is Human and its 2001 follow-up publication, Crossing the Quality Chasm,54 both concluded that health care is not as safe as it should be and suggested that between 44,000 and 98,000 patients are killed in hospitals in the United States every year -- medical errors that could have been prevented.
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These organizations constantly entertain the thought that they may have missed something that places patients at risk. Near misses are viewed as opportunities to improve cur rent systems by examining strengths, determining weaknesses, and devoting resources to improve and address them.
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HROs pay close attention to their ability to quickly respond to and contain errors and recover when difficulties occur. Thus, systems can function despite setbacks.57 The health care industry engages in other activities designed to promote patient safety, such as the National Patient Safety Foundation and the Lucean Leape Institute.
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These facilities are also required to follow OSHA's § 1910.119, Process safety management of highly hazardous chemicals (aka Process Safety Standard) , if they utilize processes that involve specific chemicals above the threshold quantities listed in the standard.
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Since then, consensus standards have been developed that incorporate many of the principles laid out by OSHA in its proposed rulemaking. Most notably, the American Industrial Hygiene Association served as secretariat in cooperation with the American Society of Safety Engineers to publish ANSI Z10, American National Standard for Occupational Health and Safety Management Systems, and a number of cooperating national standards bodies from around the world assisted in the development of OHSAS 18001, Occupational Health and Safety.59 Many industrial research facilities have voluntarily adopted these standards because (1)
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Indeed, this very problem was an important contributing factor in the Three Mile Island incident. Initial approaches to controlling risk in the nuclear industry primarily focused on providing defense in depth, redundancies, and wide safety margins.
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The nuclear industry, along with other high-hazard industries, has also come to realize the importance of "upstream" organizational and managerial factors in accident causation and safety performance.62,63 The safety culture concept originated in the nuclear industry in the aftermath of the Chernobyl disaster in 1986.64 As discussed previously, in 1991, the International Atomic Energy Agency (IAEA) issued a comprehensive report on safety culture, defining it for the nuclear industry.
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This statement includes a definition of safety culture and enumerates nine traits of a positive safety culture. Nuclear safety culture was defined as "the core values and behaviors resulting from a collective commitment of leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment."67 The nine traits were (1)
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However, some organizational research has shown that employees are not always automatically ready to participate at the levels required, and efforts may be needed to build capacity in order to achieve the level of participation desired.74,75,76 Indeed, the perceived lack of psychological safety can easily create anxiety and resistance among employees concerning anticipated changes, discourage them from participating, and ultimately defeat the entire change process. The second stage of the change process focuses on learning and behavior change.
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Consistent top management expectations and support are very important, but this change process almost always requires a well-executed, multicomponent plan that involves consistent messages through multiple channels, well-designed training activities, employee involvement, new methods and standards of evaluation, investment in new equipment and systems, and the use of role models or program champions. Changing safety culture involves altering the process of social exchange between employees and the organization.
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Studying organisational cultures and their effects on safety. Safety Science 2006; 44(10)
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