Thursday, May 26, 2011

Upper Big Branch 1

A few days ago the Governor’s Independent Investigation Panel issued its report on the Upper Big Branch coal mine explosion of April 5, 2010.  The report is over 100 pages and contains considerable detail on the events and circumstances leading up to the disaster, coal mining technology and safety issues.  It is well worth reading for anyone in the business of assuring safety in a complex and high risk enterprise.  We anticipate doing several blog posts on material from the report but wanted to start with a brief quote from the forward to the report, summarizing its main conclusions.

“A genuine commitment to safety means not just examining miners’ work practices and behaviors.  It means evaluating management decisions up the chain of command - all the way to the boardroom - about how miners’ work is organized and performed.”*

We believe this conclusion is very much on the mark for safety management and for the safety culture that supports it in a well managed organization.  It highlights what to us has appeared to be an over-emphasis in the nuclear industry on worker practices and behaviors - and “values”.   And it focuses attention on management decisions - decisions that maintain an appropriate weight to safety in a world of competing priorities and interests - as the sine qua non of safety.  As we have discussed in many of our posts, we are concerned with the emphasis by the nuclear industry on safety culture surveys and training in safety culture principles and values as the primary tools of assuring a strong safety culture.  Rarely do culture assessments focus on the decisions that underlie the management of safety to examine the context and influence of factors such as impacts on operations, availability of resources, personnel incentives and advancement, corporate initiatives and goals, and outside factors such as political pressure.  The Upper Big Branch report delves into these issues and builds a compelling basis for the above conclusion, a conclusion that is not limited to the coal industry.


*  Governor’s Independent Investigation Panel, “Report to the Governor: Upper Big Branch,” National Technology Transfer Center, Wheeling Jesuit University (May 2011), p. 4.

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