THE ORGANIZATIONAL ACCIDENT .1 BASIC SAFETY CONCEPTS

2-6 Safety Management Manual SMM 2.4.6 Decisions by line management may result in inadequate training, scheduling conflicts or neglect of workplace precautions. They may lead to inadequate knowledge and skills or inappropriate operating procedures. How well line management and the organization as a whole perform their functions sets the scene for error- or violation-producing conditions. For example: How effective is management with respect to setting attainable work goals, organizing tasks and resources, managing day-to-day affairs, and communicating internally and externally? The decisions made by company management and regulatory authorities are too often the consequence of inadequate resources. However, avoiding the initial cost of strengthening the safety of the system can facilitate the pathway to the organizational accident. 2.4.7 Figure 2-3 portrays the Reason model in a way that assists in understanding the interplay of organizational and management factors i.e. system factors in accident causation. Various defences are built deep into the aviation system to protect against fluctuations in human performance or decisions with a downside at all levels of the system i.e. the front-line workplace, supervisory levels and senior management. Defences are resources provided by the system to protect against the safety risks that organizations involved in production activities generate and must control. This model shows that while organizational factors, including management decisions, can create latent conditions that could lead to breaches in the system’s defences, they also contribute to the robustness of the system’s defences 2.5 THE ORGANIZATIONAL ACCIDENT 2.5.1 The notion of the organizational accident underlying the Reason model can be best understood through a building-block approach, consisting of five blocks Figure 2-4. Figure 2-3. A concept of accident causation Latent conditions trajectory Defences People Accident Workplace Organization Techn ology Train ing Regu lation s Errors and violatio ns Workin g conditio ns Manag ement decisio ns and organ ization al proces ses Chapter 2. Basic Safety Concepts 2-7 Figure 2-4. The organizational accident 2.5.2 The top block represents the organizational processes. These are activities over which any organization has a reasonable degree of direct control. Typical examples include: policy making, planning, communication, allocation of resources, supervision and so forth. Unquestionably, the two fundamental organizational processes as far as safety is concerned are allocation of resources and communication. Downsides or deficiencies in these organizational processes are the breeding grounds for a dual pathway towards failure. 2.5.3 One pathway is the latent conditions pathway. Examples of latent conditions may include: deficiencies in equipment design, incompleteincorrect standard operating procedures, and training deficiencies. In generic terms, latent conditions can be grouped into two large clusters. One cluster is inadequate hazard identification and safety risk management, whereby the safety risks of the consequences of hazards are not kept under control, but roam freely in the system to eventually become active through operational triggers. 2.5.4 The second cluster is known as normalization of deviance, a notion that, simply put, is indicative of operational contexts where the exception becomes the rule. The allocation of resources in this case is flawed to the extreme. As a consequence of the lack of resources, the only way that operational personnel, who are directly responsible for the actual performance of the production activities, can successfully achieve these activities is by adopting shortcuts that involve constant violation of the rules and procedures. 2.5.5 Latent conditions have all the potential to breach aviation system defences. Typically, defences in aviation can be grouped under three large headings: technology, training and regulations. Defences are usually the last safety net to contain latent conditions, as well as the consequences of lapses in human performance. Most, if not all, mitigation strategies against the safety risks of the consequences of hazards are based upon the strengthening of existing defences or the development of new ones. Organizational processes Workplace conditions Latent conditions Active failures Defences 2-8 Safety Management Manual SMM 2.5.6 The other pathway originating from organizational processes is the workplace conditions pathway. Workplace conditions are factors that directly influence the efficiency of people in aviation workplaces. Workplace conditions are largely intuitive in that all those with operational experience have experienced them to varying degrees, and include: workforce stability, qualifications and experience, morale, management credibility, and traditional ergonomics factors such as lighting, heating and cooling. 2.5.7 Less-than-optimum workplace conditions foster active failures by operational personnel. Active failures can be considered as either errors or violations. The difference between errors and violations is the motivational component. A person trying to do the best possible to accomplish a task, following the rules and procedures as per the training received, but failing to meet the objective of the task at hand commits an error. A person who willingly deviates from rules, procedures or training received while accomplishing a task commits a violation. Thus, the basic difference between errors and violation is intent. 2.5.8 From the perspective of the organizational accident, safety endeavours should monitor organizational processes in order to identify latent conditions and thus reinforce defences. Safety endeavours should also improve workplace conditions to contain active failures, because it is the concatenation of all these factors that produces safety breakdowns Figure 2-5. Figure 2-5. The perspective of the organizational accident R e in fo rc e Organizational processes Workplace conditions Latent conditions Active failures Defences Improve Identify Monitor C o n ta in Chapter 2. Basic Safety Concepts 2-9 2.6 PEOPLE, CONTEXT AND SAFETY — THE SHEL MODEL 2.6.1