Safety Culture Rewind

As the saying goes, safety starts at the top. And it’s absolutely true; without management?buy-in?and commitment, safety will not be effective at the lower levels of the organization, and programs that depend on a?healthy safety culture,?such as SMS and Human Factors, will be bound to fail. Accidents are typically not caused by a single errant individual, but rather a chain of events that may have been hiding dormant in the system for months or even years (also known as latent conditions). The individual who causes the accident may simply?be the "trigger puller" for a chain of systemic failures.

There were several sentinel events that occurred in high-risk industries that precipitated the need to address safety culture; foremost, the world's worst nuclear power plant accident that occurred at Chernobyl in 1986. That same year, NASA lost the Challenger space shuttle shortly after liftoff. Through intensive investigations, it was revealed that both of these accidents had human factors and safety culture-related underpinnings that attributed to the trigger events. However, it was not until the inflight breakup of Continental Express Flight 2574 in 1991 that the aviation industry, specifically, began to take notice of how a pathogenic safety culture could contribute to an aircraft accident. Among the findings of the National Transportation Safety Board (NTSB) investigation of Flight 2574:

The failure of Continental Express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane's horizontal stabilizer deice boots that led to the sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose-down pitchover and breakup of the airplane. Contributing to the cause of the accident was the failure of Continental Express management to ensure compliance with the approved maintenance procedures, and the failure of the FAA surveillance to detect and verify compliance with approved procedures (NTSB, 1992).

This report revealed, among other things, deficiencies in management oversight. However, what was not stated in the Probable Cause was the role that corporate culture played in the accident chain. This was not elucidated until John Lauber (then NTSB board member) offered a dissenting opinion. Lauber believed that the Probable Cause was shortsighted, due to the fact that a poor corporate culture was not included as part of the Probable Cause. In his dissenting opinion letter, Lauber suggested that the Probable Cause should be rewritten as follows:

The National Transportation Safety Board determines that the probable causes of this accident were (1) the failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures, and (2) the consequent string of failures by Continental Express maintenance and inspection personnel to follow approved procedures for the replacement of the horizontal stabilizer deice boots. Contributing to the accident was the inadequate surveillance by the FAA of the Continental Express maintenance and quality assurance programs (NTSB, 1992).

It was this dissenting opinion by Member Lauber that set the wheels in motion for the proposition that a pathogenic (or non-existent) safety culture can have a significant contributing effect on accident causation. This subsequently led to the development of a Corporate Culture checklist, which the NTSB uses as part of accident investigations in the current day.

Upcoming?Human Factors Courses

Human Factors Train-The-Trainer: January 22-26, 2024

Human Factors Initial: January 22-23, 2024

Human Factors Recurrent: January 23, 2024

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Dr. Bob Baron ?conducts aviation safety training, consulting, and program implementation for aviation operators on a global basis.

Sensitive and knowledgeable about various cultures, Dr. Baron uses his 35+ years of academic and practical experience to assist aviation organizations in their pursuit of safety and quality excellence. He has extensive experience working with developing nations and island countries. He also provides training and consulting to some of the largest airlines and aircraft manufacturers in the world, as well as civil aviation authorities and accident investigation bureaus.

If your aviation organization is interested in improving its culture, implementing programs such as Human Factors, SMS, SSP, or LOSA, or have an external, unbiased safety audit/Gap analysis, please get in touch.

Dr. Baron’s company, TACG, provides numerous training, consulting, and auditing services. For more information, please go to https://www.tacgworldwide.com