In 1993 I read a UK Government publication called “Organising for Safety“, published by the Advisory Committee on the Safety of Nuclear Installations (ACSNI). This was the third report by the ACSNI Human Factors Study Group. Dr Donald Broadbent, an influential psychologist well-known to many graduates in psychology like myself, was the Chairman of this Study Group. Dr Broadbent died shortly after completion of this report in 1993.
At the time, I was working as an Ergonomist for a company that produced health and safety training videos, when VHS tapes were still current (showing my age here). I’ve recently been thinking how relevant this Report still is today. “Organising for Safety” was an early discussion of the role of organisational factors in enhancing safety. It had quite an impact on my career.
In particular, the following conclusion of the Study Group caught my attention:
“Different organisations doing similar work are known to have different safety records, and certain specific factors in the organisation are related to safety”
There are two key aspects in this quote:
- different organisations, doing the same kind of things, can have significantly different safety performance
- there are ‘specific factors’ responsible for these different safety rates.
It occurred to me that if these specific factors could be identified and managed, then safety could be improved. So, over 20 years ago, my journey to understand human and organisational factors began.
As an example to support the above conclusion from the Study Group, the figure below shows the personal safety performance across several different sites. This shows that, in the same year, the different sites (all doing the same activities) had safety performance that varied from zero reported incidents at 15 locations, to a recordable injury rate of 3.50 (injuries per million hours worked). Even accounting for differences in reporting rates, this is a large variation in safety performance.
Over the years these organisational failures have revealed themselves, incident by incident. During my career in human factors, many major incidents have occurred, not just in the nuclear industry for which this Report was originally written, but across a range of industries. I have reviewed (and sometimes contributed to) incident investigations for events such as the NASA shuttle disasters, Herald of Free Enterprise, Piper Alpha, Kegworth, Longford, Texas City, Buncefield, Deepwater Horizon/Macondo, Nimrod and various rail disasters.
Besides these high-profile events, there have been several organisational ‘disasters’ in sectors such as healthcare and finance. These include the inadequate care during children’s heart surgery at Bristol Royal Infirmary over a ten-year period and the serious incidents during maternity services over many years at Morecambe Bay NHS Trust. And of course most readers will be familiar with the systemic failures that enabled a trader to cause the collapse of Barings Bank in 1995.
One of my professional interests is sharing the lessons from other industries. I have often found that pivotal incidents from one industry may be unknown in another. The technical specifics may be unique, but the organisational issues are not. A failure to learn from other industries may be the greatest organisational failure of all.
In a previous blog post I discussed the similarities between the 2006 RAF Nimrod XV230 incident and the healthcare sector. The key lessons from Nimrod XV230 also apply to healthcare for the simple reason that the Nimrod disaster was not purely due to technical failures. There were systemic failures of leadership, culture and priorities. These organisational issues apply equally well to the healthcare and other sectors.
Whether you’re trying to keep stuff in the pipes, keep trains on the tracks, aircraft in the sky, or prevent adverse events in healthcare, the organisational factors are largely similar. Organisational failures are key because they can influence everyone’s behaviour and override other positive influences on behaviour.
On humanfactors101.com I have summarised the key lessons from selected major incidents. Reviewing these incidents (and many more) shows that there are some common threads. “Organising for Safety” suggests that in seeking the causes to accidents, we should be looking at the organisation as a whole, rather than isolated parts (or individuals). In this 1993 Report, several of the ‘certain specific factors in the organisation’ that impact on safety (both personal safety and major events) were documented. It discusses the role of organisational factors such as:
- lack of leadership
- inappropriate targets/pressures/priorities
- insufficient resources (people/time/equipment)
- negative safety culture
- inadequate oversight and monitoring.
Since this Report was published 30 years ago, these organisational factors have been validated by numerous disasters in many industries. Following the investigations or inquiries, there is recognition that the causes were not new, statements that ‘this must not happen again‘ and appeals that the lessons must be learnt to prevent further incidents.
Sadly, the same proclamations and pleas will be made again.