Identifying vulnerabilities

Identified recurring factors have been grouped under ten headings or repeating ‘themes’ which were observed in the events studied:

1. Leadership issues
2. Operational attitudes and behaviours (operational ‘culture’)
3. Safety management systems
4. Impact of the business environment (often commercial and budgetary requirements)
5. Oversight and scrutiny
6. Competence and training (at all levels)
7. Risk assessment and management (at all levels)
8. Organisational learning
9. Communication failures
10. Supply chain (management of contractors)

Shortfalls in safety leadership have been a precursor to nearly all events studied. If excellence in safety is to be achieved, it is vital that leaders at all levels ‘set the tone at the top’ and reinforce this through their own actions and visible commitment. In many, commercial pressures (such as the need to complete a project to a very tight schedule or carry out major organisational change) have led to shortcuts being taken and other deficiencies.

Good safety performance requires the presence of a well-understood management system that makes clear who is accountable for what and where the workforce follows clear and respected procedures. In some of the events studied, a culture of ‘casual compliance’ has developed over time without management awareness or action. Even where procedures are followed, however, there is a danger that errors have built up in them often as a consequence of changes elsewhere in the plant or process. This calls for continuous vigilance with a good understanding of the wider system.

The build-up of problems such as these commonly reflects a shortfall in safety culture within the organisation. This is often characterised by a failure to adopt a questioning attitude, breakdowns in communication and a failure to learn from events both within and outside the organisation. It has also led to a failure to assess risks in plant or system design and construction as well as in operations. These shortcomings have frequently been exacerbated by reductions in training and competence, often a result of budgetary pressures.

In some of the events studied, contractors have been used to carry out major tasks. Contracts have not always been formulated in such a way as to encourage the reporting of emerging issues and the client-contractor interface has been poorly managed.

Finally, providing strong oversight and scrutiny in the organisation should allow the shortfalls discussed above to be addressed before major problems develop. In many cases, this has been absent or weak, or findings have not been addressed or fully implemented.

These ten themes are being followed-up by developing statements of good practice designed to provide a basis for organisations to compare their own ‘expectations’ for performance in each area. The intent is that these are put into operational practice at all levels from the boardroom to the workplace. To check that this occurs, ‘penetrating’ questions are being developed to enable organisations to explore whether ‘reality aligns with expectation’. Use of these statements and questions will help organisations to identify their vulnerabilities.

Addressing vulnerabilities

New systematic approaches are also needed to address these vulnerabilities. However, the analysis shows that these will need to model complex processes. Contributory factors exist within a complex network of causes and thus, what appears to be a straightforward change (such as improving a procedure) can lead to unintended consequences.

A simple example illustrates this. A technique known as Causal Loop Modelling is used to depict the interactions between causal factors and the potential consequences of intended changes. It can explain why consequences can be subtle or hidden, how time lags can be important, and expose unforeseen long-term trends.

The figure below shows how the approach can be used to analyse the possible consequences of actions to improve learning by increasing the number of ‘events’ being reported.

The arrows represent causality. An ‘S’ means a similar change is caused (i.e. an increase causes an increase and a decrease causes a decrease). An ‘O’ means an opposite change is caused. The right-hand loop shows that more reporting leads to more investigations and more corrective actions. Unless carefully controlled, prioritised and resourced, this may lead to a significant increase in the workload and as this increases, the number of visible improvements and completed actions may go down because people cannot cope. This can lead to disillusion, cynicism from the workforce and a decrease in efforts to report events. Thus a worthwhile initiative can leave the organisation worse off than before it was launched, unless actions are taken at the outset to mitigate these unwanted consequences.

Diagnosing current vulnerabilities based on the ‘library’ of findings obtained from the events studied, combined with new approaches to plugging vulnerabilities, can help to make organisations more resilient to major events in all ‘high hazard’ industries.