“Leadership is progressively being recognized as a key** factor in supporting successful performance across a range of domains. . . . the decisions and actions that characterize safety leadership thus become important emergent properties in the prevention of incidents, which should be considered within the context of the broader organizational system and not merely constrained to understanding events or conditions that shape performance at the ‘sharp end’.” [emphasis added]
The authors go on to analyze decisions and actions after a mining incident (landslide) using a combination of three different schemes: Rasmussen’s Risk Management Framework (RMF) and corresponding AcciMap, and the Critical Decision Method (CDM).
The RMF describes work systems as comprised of various levels and argues that safety performance is affected by decisions and actions at all levels from politicians in the external environment down through company executives and managers and finally to individual workers. Rasmussen’s AcciMap is an expansive causal diagram for an accident or incident that displays the contributions (or omissions) at each level in the RMF and their connections.
CDM uses semi-structured interviews to obtain information about how individuals formulate their decisions, including context such as background knowledge and immediate influencing factors. Consistent with the RMF, case study interviews were conducted with individuals at different organizational levels. CDM data were used to construct the AcciMap.
We won’t go into the details of the analysis but it identified over a dozen key decisions made at different organizational levels before and during the incident; most were connected to at least one other key decision. The AcciMap illustrates decisions and communications across multiple levels and thus provides a useful picture of how an organization anticipates and responds to an unusual situation.
The authors argue, and we agree, that this type of analysis provides greater detail and insight into the performance of an organization’s safety management system than traditional accident investigations (especially those focused on finding someone to blame).
This article does not specifically discuss culture. But the body of decisions an organization produces is the strongest evidence and most visible artifact of its culture. Organizational decisions are far more important than responses to surveys or interviews where people can report what they believe (or hope) the culture is, or what they think their audience wants to hear.
We like that RMF and AcciMap are agnostic: they can be used to analyze either “what went wrong” or “what went right” scenarios. (The case study was in the latter category because no one was hurt in the incident.) If an assessor is looking at a sample of decisions to infer a nuclear organization’s culture, most of those decisions will have had positive (or at least no negative) consequences.
The authors are Australian academics but this short (8 pages total) paper is quite readable and a good introduction to CDM and Rasmussen’s constructs. The references include people whose work we have positively reviewed on Safetymatters, including Dekker, Hollnagel, Leveson and Reason.
Bottom line: There is nothing about culture or nuclear here, but the overall message reinforces our beliefs about how to think about Nuclear Safety Culture.
* S-L Donovana, P.M. Salmonb and M.G. Lennéa, “The leading edge: A systems thinking methodology for assessing safety leadership,” Procedia Manufacturing 3 (2015), pp. 6644–6651. Available at sciencedirect.com; retrieved Jan. 19, 2017.
** Note they do not say “one and only” or even “most important.”