James Reason, the organisation psychologist (1997), has a list of qualities that characterise good HES culture:
Reason’s research is supported by the fact that human behaviour is the single most important factor behind accidents. This applies to all fields and trades. The usual proportion is that 80 to 90 per cent of all accidents can be attributed to human mistakes.
Can I tell?
A reporting culture emphasises the need for mapping problematic incidents and accidents. It is dependent on the employees providing clear feedback on problematic incidents, and a proper reception and treatment of such feedback. It is also dependent on trust in the management and confidence among the employee that those who report problematic incidents won’t be punished for it. A reporting culture is geared towards learning from what happened, rather that ‘getting’ those who made a mistake. This is a vital prerequisite of a learning culture, and the survey on the risk level on the Norwegian continental shelf (RNNS) says that a third of those working offshore believe that reports are embellished. If this happens we risk missing out on important lessons.
”The accident happened just like I thought it would”
We’re all human. We all make mistakes. And when we make mistakes, should we be punished for doing our best? A comprehensive HES regime has to focus on the chance of people making mistakes. But sometime something happens that noone could have foreseen. We don’t often hear after an accident: “Oh yes, this accident happened just like I thought It would”. Accidents happen partly because we’re not prepared for them. We all have a responsibility, but it is important that this is a common responsibility. It’s okay to interfere, it’s okay to correct each other – and it’s okay to react. But such corrections and reactions have to be perceived as just.
This isn’t how we want it to be
How easy is it to be flexible and open to new suggestions? There are big differences in how organisations react to creative suggestions from the employees. Some organisations are good at making use of the wealth of experience their employees have, and open up for all to contribute to improving the HES culture and safety. We know that organisations that appreciate the employees’ input find it easier to exploit this knowledge in a chaotic situation. If the employees are respected and have been given the chance to make use of their own knowledge, their colleagues put greater faith and trust in each other’s experience and competence.
Finding out before it’s too late
Insufficient and inadequate communication and passing of information has been shown to be decisive factor behind unwanted incidents. In situations where important information has failed to reach the right person in time, serious accident can happen. How do we organise ourselves to ensure that information always goes where it should go? And who is allowed to talk about what? This is particularly challenging in cooperation between different units, or between different positions in a large company.