Developing a Safety Culture in High Risk Environments

The U.S. government has failed more than one would like to know to protect the public from situations that it knew - or should have known - could lead to tragic loss of life. In many cases, unless something actually causes an incident, it isn’t a safety issue.  That’s how things have worked at NASA with the space shuttle and Apollo 1, so it is hardly a shock that the same methods are found in other places as well.  When a Safety Culture is in place however, an organization can manage risks and prevent accidents, mistakes and disasters.

The confidential President's Daily Brief (PDB) for August 6, 2001 contained a two-page section entitled "Bin Ladin Determined to Strike in US," and refers to possible hijacking attempts by Osama bin Laden disciples and the existence of about 70 FBI investigations into alleged al-Qaeda cells operating within the United States. The August 6 PDB was presented to Bush while he vacationed at his ranch in Crawford, Texas. The digest is prepared by the Central Intelligence Agency, an official from which briefs the president on the report's contents.   

Condoleezza Rice later testified that this was only historical information based on old reporting. There was no new threat information.   Really - that would be a short view of history I would say.  And it is evading the issue, it doesn’t matter how old the information was, the real question is what were people doing about it.

From the viewpoint of the president, apparently not much.

The book's [The One Percent Doctrin] opening anecdote tells of an unnamed CIA briefer who flew to Bush's Texas ranch during the scary summer of 2001, amid a flurry of reports of a pending al-Qaeda attack, to call the president's attention personally to the now-famous Aug. 6, 2001, memo titled "Bin Ladin Determined to Strike in US." Bush reportedly heard the briefer out and replied: "All right. You've covered your ass, now.''

Obviously an attitude problem existed with this person, so let's look at civil aviation and see how incidents are treated there.  In the United States, the Federal agency responsible for investigating transportation accidents of all kinds, determining causes and making recommendations designed to prevent events with the same antecedents from occurring in the future is the National Transportation Safety Board or NTSB.  Sometimes these investigations span years and more than one incident.  The rudder issues with the Boeing 737 are an example.   

The NTSB has no enforcement powers though; that is the responsibility of the Federal Aviation Administration.  In a real world situation, sometimes it would be very expensive for airlines and the aircraft industry to immediately implement the safety requirements set by the NTSB.  So it is common for the FAA to give the industries a certain amount of time to incorporate the safety recommendations that NTSB investigations may require.  Sometimes these recommendations are procedural and are related to airline or aircraft operations.  Other times they are design defects in the aircraft or spacecraft.  At times during NASA's existence, it seems to have perpetrated or accepted things that fall into both categories.  

The NTSB does follow up on its safety findings and issues progress reports.  Phrases like "unacceptable response" or "improvements languish" are often found in these reports. 

This is from a highly interesting article on safety issues the NTSB and FAA are working on.

NTSB Member Deborah Hersman pointed out that the FAA is recording three operational errors each day, and one severe operational error every nine days. "I think one severe high- risk event every nine days warrants a higher priority, and to provide direct warning to pilots," she said.

NTSB investigations always have an element of human tragedy and yet it is exceedingly rare for them not to find the specific cause(s) of an accident.  I now want to briefly look at NASA's history in putting humans into space.  

Putting human beings into space is a dangerous and complex procedure.  Nevertheless, the physics was understood since the early 20th Century.  Developing the technology was more difficult and there wasn't a serious effort made  until the 1950s.  Both the Soviet Union and the United States were able to put satellites into earth orbit by the late 1950s.  The "rocket science" knowledge to send humans beyond earth orbit was not particular difficult and the Saturn 5 rocket performed flawlessly in sending Americans to the moon.  Today the avionics used seem very primitive and one wonders how they ever accomplished it. 

The space shuttle is a more complex vehicle but its design is a product of the 1970s.  In less than 150 launches, there have been two incidents of loss of vehicle and crew.  Needless to say, there were investigations.  The Challenger incident has been well documented and can be found in many places.  Preventing the disaster would have been simple, it should never have been launched in the conditions it was in at the time the launch occurred. 

The loss of the Columbia was somewhat different but reflects the same absence of a true Safety Culture inherent in NASA.  Since all launches are recorded, video analysis immediately revealed that a chunk of frozen material fell off of the external fuel tank and hit the leading edge of the left wing of the orbiter and damaging its heat shielding.  This "hit by frozen foam" was not an unusual event on launches and obviously it had never caused an accident before.  However NASA engineers expressed the opinion in emails that, after video review, in this case it could have damaged the wing so severely to make a safe reentry into the earth's atmosphere impossible.  The result can be seen in the Kirtland Image which is attached to this story. 

However their expert cautionary warning was ignored by the bureaucratic decision makers in NASA.  This information is contained in the 6 volume CAIB Report.   As a result of the investigation, persons found their careers ended because of the decisions that were made.  

In my career as a Technical Architect, creating a Safety Culture was synonymous with quality.  There existed several power point presentations that I frequently used to make the characteristics of a corporate culture that put safety and quality as it primary concern.  Such a culture has these fundamental characteristics:

• Informed – managers should know what is going on in their organisation and the workforce should be willing to report their own errors and near misses;

 • Wary – the organisation and its constituent individuals should be on the lookout for the unexpected, maintaining a high degree of vigilance;

• Just – the organisation should operate a ‘no blame’ culture within the constraint that some actions can be agreed by all to be totally unacceptable and worthy of approbation;

• Flexible – such organisations can operate according to the demands, so they can provide both high tempo and routine modes of operation and can change when required by circumstances;

• Learning – organisations should be ready to learn in order to improve and be capable of implementing what needs to be done to reform.

Successful organizations know that this is a means to an end, namely organizational achievement and the inverse of failure.  I've always found this to be a highly desirable goal but it can only be fully accomplished in gradual steps. Everyone has to participate and organizations that stress cooperation rather than competition will find this much easier to create and maintain.  And what that does is permit an organization to operate within a narrower margin of error.

Realizing that mistakes are accidents and accidents diminish productivity is a beginning.  Adopt these attitudes and a true Safety Culture may result.  The indications are that the tragic loss of Challenger and Columbia has resulted in a Safety Culture in NASA.  With risks as high as are found in space flight, it simply must exist.  Fortunately the space shuttle has only a few missions left and will be replaced with a system that should be safer and more capable for space exploration.  This was NASA's purpose in the beginning.

Here I have simply explored how mistakes happen, what attitudes lead to mistakes, and what the consequences can be in high risk activities.  This is only prerequisite.  I may return to this subject at a later date.