Rail & Aviation Conference RAeS 21 st May 2009. Safety Culture and Safety Management. Jim Reason Professor Emeritus University of Manchester, UK. Overview. Organizational accidents The two faces of safety Safety culture Proactive process measures Error management.
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Some holes due
to active failures
Other holes due to
Successive layers of defences, barriers, & safeguards
Shared values (what is important) and
beliefs (how things work) that interact
with an organization’s structure and
control systems to produce behavioural
norms (the way we do things around here).
Respects, anticipates and responds to risks.
A just, learning, flexible, adaptive, prepared
& informed culture. Strives for resilience.
Aware that ‘latent pathogens’ and ‘error
traps’ lurk in system. Seeks to eliminate
them beforehand. Listens to ‘sharp enders’.
Systems to manage safety, often in
response to external pressures. Data
harvested rather than used. ‘By the book’.
Safety given attention after an event.
Concern about adverse publicity.
Establishes an incident reporting system.
Blame, denial and the blinkered pursuit of
excellence (Vulnerable System Syndrome).
Financial targets prevail: cheaper/faster.Cultural ‘strata’