Publications

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Workplace safety has been historically neglected by organizations in order to enhance profitability. Over the past 30 years, safety concerns and attention to safety have increased due to a series of disastrous events occurring across many different industries (e.g., Chernobyl, Upper Big-Branch Mine, Davis-Besse etc.). Many organizations have focused on promoting a healthy safety culture as a way to understand past incidents, and to prevent future disasters. There is an extensive academic literature devoted to safety culture, and the Department of Energy has also published a significant number of documents related to safety culture. The purpose of the current endeavor was to conduct a review of the safety culture literature in order to understand definitions, methodologies, models, and successful interventions for improving safety culture. After reviewing the literature, we observed four emerging themes. First, it was apparent that although safety culture is a valuable construct, it has some inherent weaknesses. For example, there is no common definition of safety culture and no standard way for assessing the construct. Second, it is apparent that researchers know how to measure particular components of safety culture, with specific focus on individual and organizational factors. Such existing methodologies can be leveraged for future assessments. Third, based on the published literature, the relationship between safety culture and performance is tenuous at best. There are few empirical studies that examine the relationship between safety culture and safety performance metrics. Further, most of these studies do not include a description of the implementation of interventions to improve safety culture, or do not measure the effect of these interventions on safety culture or performance. Fourth, safety culture is best viewed as a dynamic, multi-faceted overall system composed of individual, engineered and organizational models. By addressing all three components of safety culture, organizations have a better chance of understanding, evaluating, and making positive changes towards safety within their own organization.

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Despite continuing efforts to apply existing hazard analysis methods and comply with requirements, human errors persist across the nuclear weapons complex. Due to a number of factors, current retroactive and proactive methods to understand and minimize human error are highly subjective, inconsistent in numerous dimensions, and are cumbersome to characterize as thorough. An alternative and proposed method begins with leveraging historical data to understand what the systemic issues are and where resources need to be brought to bear proactively to minimize the risk of future occurrences. An illustrative analysis was performed using existing incident databases specific to Pantex weapons operations indicating systemic issues associated with operating procedures that undergo notably less development rigor relative to other task elements such as tooling and process flow. Future recommended steps to improve the objectivity, consistency, and thoroughness of hazard analysis and mitigation were delineated.

The purpose of this study was to investigate the impact of instructions on aircraft visual inspection performance and strategy. Forty-two inspectors from industry were asked to perform inspections of six areas of a Boeing 737. Six different instruction versions were developed for each inspection task, varying in the number and type of directed inspections. The amount of time spent inspecting, the number of calls made, and the number of the feedback calls detected all varied widely across the inspectors. However, inspectors who used instructions with a higher number of directed inspections referred to the instructions more often during and after the task, and found a higher percentage of a selected set of feedback cracks than inspectors using other instruction versions. This suggests that specific instructions can help overall inspection performance, not just performance on the defects specified. Further, instructions were shown to change the way an inspector approaches a task.

Despite extensive safety analysis and application of safety measures, there is a frequent lament, "Why do we continue to have accidents?" Two breakdowns are prevalent in risk management and prevention. First, accidents result from human actions that engineers, analysts and management never envisioned and second, controls, intended to preclude/mitigate accident sequences, prove inadequate. This paper addresses the first breakdown, the inability to anticipate scenarios involving human action/inaction. The failure of controls has been addressed in a previous publication (Forsythe and Grose, 1998). Specifically, this paper presents an approach referred to as "surety." The objective of this approach is to provide high levels of assurance in situations where potential system failure paths cannot be fully characterized. With regard to human elements of complex systems, traditional approaches to human reliability are not sufficient to attain surety. Consequently, an Organic Model has been developed to account for the organic properties exhibited by engineered systems that result from human involvement in those systems.