Department of Consumer and Employment Protection Resources Safety 1 Please read this before using presentation This presentation is based on content presented at the 2007 Mines Safety Roadshow held in October 2007 It is made available for non-commercial use (eg toolbox meetings) subject to the condition that the PowerPoint file is not altered without permission from Resources Safety Supporting resources, such as brochures and posters, are available from Resources Safety For resources, information or clarification, please contact: or visit

Toolbox presentation: Safety culture – part 2 What does safety culture mean for mining? October 2007

Department of Consumer and Employment Protection Resources Safety 3 Safety culture toolbox series 1.Integrating human factors and safety management systems 2.What does safety culture mean for mining? (Author: Martin Knee, State Mining Engineer) 3.Safety culture in practice in Australian mining

Department of Consumer and Employment Protection Resources Safety 4 Safety culture A big round of applause please! Here is the man who set up our Safety Culture!!

Department of Consumer and Employment Protection Resources Safety 5 Safety culture

Department of Consumer and Employment Protection Resources Safety 6 Safety culture – What is it? “The safety culture of an organisation is the product of individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety programmes. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.”

Department of Consumer and Employment Protection Resources Safety 7 Safety culture – What is it really? “What people at all levels in an organisation do and say when their commitment to safety is not being scrutinised — what they do when no-one is watching.”

Department of Consumer and Employment Protection Resources Safety 8 What are we up against?

Department of Consumer and Employment Protection Resources Safety 9 Active failures Active failures are the unsafe acts committed by people who are in direct contact with the system They take a variety of forms: slips lapses fumbles mistakes procedural violations

Department of Consumer and Employment Protection Resources Safety 10 Latent conditions Latent conditions are the inevitable “resident pathogens” within the system They arise from decisions made by designers, builders, procedure writers, and top level management Such decisions may be mistaken, but they need not be All such strategic decisions have the potential for introducing pathogens into the system

Department of Consumer and Employment Protection Resources Safety 11 Latent conditions cont. Latent conditions have two kinds of adverse effect. 1.They can translate into error provoking conditions within the local workplace such as: time pressure understaffing inadequate equipment fatigue inexperience

Department of Consumer and Employment Protection Resources Safety 12 Latent conditions cont. 2.They can create long lasting holes or weaknesses in the defences such as: untrustworthy alarms and indicators unworkable procedures design and construction deficiencies

Department of Consumer and Employment Protection Resources Safety 13 Latent conditions cont. Latent conditions — as the term suggests — may lie dormant within the system for many years before they combine with active failures and local triggers to create an accident opportunity Unlike active failures, whose specific forms are often hard to foresee, latent conditions can be identified and remedied before an adverse event occurs Understanding this leads to proactive rather than reactive risk management

Department of Consumer and Employment Protection Resources Safety 14 Our safety cultures …

Department of Consumer and Employment Protection Resources Safety 15 … are poles apart

Department of Consumer and Employment Protection Resources Safety 16 Gas? What gas?

Department of Consumer and Employment Protection Resources Safety 17 For electrical safety — always pool your resources

Department of Consumer and Employment Protection Resources Safety 18 What makes you think it came from our mine?

Department of Consumer and Employment Protection Resources Safety 19 Do you really have to leave us?

Department of Consumer and Employment Protection Resources Safety 20 At least the ashtray is close to the sign!

Department of Consumer and Employment Protection Resources Safety 21 Well, at least while I’m smoking I can’t use my mobile phone

Department of Consumer and Employment Protection Resources Safety 22 Error management Two possibilities: 1.limiting the incidence of dangerous errors and — since this will never be wholly effective 2.creating systems that are better able to tolerate the occurrence of errors and contain their damaging effects

Department of Consumer and Employment Protection Resources Safety 23 Human fallibility Two approaches to the problem of human fallibility: the person the system The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects High reliability organisations — which have less than their fair share of accidents — recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure

Department of Consumer and Employment Protection Resources Safety 24 Fallibility management Person approach directs most management resources at trying to make individuals less fallible or wayward System approach strives for a comprehensive management programme aimed at several targets: the person the team the task the workplace the institution as a whole with a view to setting up a “resilient” or “high-reliability” organisation

Department of Consumer and Employment Protection Resources Safety 25 Types of human error We distinguish intentional and unintentional behaviour Slips are unintended actions Lapses are unintended failures to act Mistakes are intended, but the result is not what was really meant Violations are intentional failures Violations can be seen as a form of mistake (I’ll get away with it)

Department of Consumer and Employment Protection Resources Safety 26 To err is human Types of human error

Department of Consumer and Employment Protection Resources Safety 27 Taking chances — making judgments Expected benefits of comparatively risky behaviour alternatives Expected costs of comparatively risky behaviour alternatives Expected benefits of comparatively safe behaviour alternatives Expected costs of comparatively safe behaviour alternatives

Department of Consumer and Employment Protection Resources Safety 28 Challenges for high-reliability organisations Managing complex, demanding technologies so as to avoid major failures that could cripple or even destroy the organisation concerned Maintaining the capacity for meeting periods of very high peak demand, whenever these occur

Department of Consumer and Employment Protection Resources Safety 29 How do organisations cope? TypeVulnerableRule followersRobustEnlightenedResilient CharacteristicsIn denial Messengers ‘shot’ Whistleblowers dismissed or discredited Protection of the powerful Information hoarded Responsibility shirked Failure punished or covered up New ideas crushed Deal ‘by the book’ Conform to rules Target = ‘zero’ Reactive Repair not reform Information neglected Responsibility compartmentalis ed New ideas = ‘problems’ Develop risk management capacity Enhance systems Improve suite of performance measures Develop action plans Monitor/review progress Clarify/refine objectives Active leadership Safety management plan widely known Competent people with experience Accountabilities understood Advanced performance measures Regular reviews Range of emergency responses catered for Strive for resilience of systems Reform rather than repair Responsibility shared Actively seek new ideas Messengers rewarded Proactive as well as reactive Failures prompt far-reaching inquiries Flexibility of operation Consistent mindset = ‘wariness’ Descriptor ‘in disarray’ pathological ‘organised’ reactive ‘credible’ calculative ‘trusting’ proactive ‘disciplined’ generative StrategySanctionDirectEncouragePartnerChampion

Department of Consumer and Employment Protection Resources Safety 30 Changing safety culture

Department of Consumer and Employment Protection Resources Safety 31 High-reliability organisations … Have a collective preoccupation with the possibility of failure Expect to make errors and train their workforce to recognise and recover them Continually rehearse familiar scenarios of failure and strive hard to imagine novel ones Instead of isolating failures, they generalise them Instead of making local repairs, they look for system reforms

Department of Consumer and Employment Protection Resources Safety 32 High-reliability organisations … Can reconfigure themselves to suit local circumstances In their routine mode, they are controlled in the conventional hierarchical manner In high tempo or emergency situations, control shifts to the experts on the spot The organisation reverts seamlessly to the routine control mode once the crisis has passed Define their goals in an unambiguous way and, for these bursts of semiautonomous activity to be successful, it is essential that all the participants clearly understand and share these aspirations Although high-reliability organisations expect and encourage variability of human action, they also work very hard to maintain a consistent mindset of intelligent wariness

Department of Consumer and Employment Protection Resources Safety 33 High-reliability organisations … Are the prime examples of the system approach Anticipate the worst and equip themselves to deal with it at all levels of the organisation It is hard, even unnatural, for individuals to remain chronically uneasy, so their organisational culture takes on a profound significance Individuals may forget to be afraid, but the culture of a high-reliability organisation provides them with both the reminders and the tools to help them remember For these organisations, the pursuit of safety is not so much about preventing isolated failures, either human or technical, as about making the system as robust as is practicable in the face of its human and operational hazards High-reliability organisations are not immune to adverse events, but they have learnt the knack of converting these occasional setbacks into enhanced resilience of the system

Department of Consumer and Employment Protection Resources Safety 34 Same industry — same system failure