Modify System/Process (if Needed)

If the status of a risk should change or the mitigating action does not produce the intended effect, a determination must be made as to why. It may be that the wrong hazard was being addressed, or the system/process needs to be modified. In either case, one would then re-enter the system safety process at the hazard identification step.

2.3. Creating Positive Safety Culture

2.3.1. Supportive Culture

The commitment of a company’s top management those who direct and control the organization at the highest level towards safety, safety practices and safety oversight will determine how business is conducted from a safety standpoint. The safety culture of the company underpins the entire safety achievement of the company and is crucial to its success. The ideal safety culture is one that is supportive of the staff and systems of work, recognizes that errors will be made and blaming some of the staff for those errors will not resolve the problems.

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Therefore, the supportive culture will encourage open reporting, seek to learn from its failures and be just in dealing with those involved. Punitive action must not follow automatically from the open acknowledgement of human error.

However, it must be made clear that indemnity will not be guaranteed where there has been gross negligence. The front line defence is that operating staff must not accept unsafe behaviour from their peers. Figure (2-11) shows the components of safety culture.

Figure 2.11: Components of Safety Culture [Global Aviation Information Network (GAIN), 2004]

2.3.2. Learning from Unsafe Acts

A Just Culture supports learning from unsafe acts. The first goal of any manager is to improve safety and production. Any event related to safety, especially human or organizational errors must be first considered as an opportunity to improve operations through experience feedback and lessons learnt.

Failures and ‘incidents’ are considered by organizations with good safety cultures as lessons which can be used to avoid more serious events to attaint his goal of learning from errors it is imperative to maintain a continuous recording of those errors and to subject them to study. Hence there is a strong drive to ensure that all

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incidents and accidents should be reported and investigated to discover the root causes, and that timely feedback is given on the findings and remedial actions, both to the work groups involved and to others in the organization or industry who might experience the same problem. This ‘horizontal’ communication is particularly important.

2.3.3. Benefits of Just Culture

A “Just Culture” refers to a way of safety thinking that promotes a questioning attitude, is resistant to complacency, is committed to excellence, and fosters both personal accountability and corporate self-regulation in safety matters.

A “Just” safety culture, then, is both attitudinal as well as structural, relating to both individuals and organizations. Personal attitudes and corporate style can enable or facilitate the unsafe acts and conditions that are the precursors to accidents and incidents. It requires not only actively identifying safety issues, but responding with appropriate action.

The benefits that can be gained from the creation of a Just Culture in an organization include measurable effects such as increased event reports and corrective actions taken, as well as intangible organizational and managerial benefits:

• A Just Culture can lead to not only increased event reporting, particularly of previously unreported events, but also the identification of trends that will provide opportunities to address latent safety problems.

• It has been estimated that for each major accident involving fatalities, there are as many as several hundred unreported incidents that, if properly investigated, might have identified an underlying problem in time to prevent the accident.

• A lack of reported events is not indicative of a safe operation, and likewise, an increase in reported events is not indicative of a decrease in safety. Event

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reporting illuminates potential safety concerns, and any increase in such reporting should be seen as a healthy safety indicator.

• It can be expected that a Just Culture will enhance the organization’s effectiveness by defining job performance expectations, establishing clear guidelines for the consequences of deviance from procedures, and promoting the continuous review of policies and procedures.

• Just Culture can allow an organization to be better able to determine whether violations are occurring infrequently or if deviation from established procedures has become normalized among its front-line employees and supervisors.

• Outdated or ineffective management structures can be manifested in many ways, as by operational inefficiencies, lost opportunities, or safety lapses.

While Just Culture is primarily implemented by a safety motive, it is recognized “that the same factors which are creating accidents are creating production losses as well as quality and cost problems.

2.4. Strategic Management

2.4.1. Strategic Management Elements

Strategic management can be defined as that set of managerial decisions and actions that determines the long-run performance of a corporation, also can be defined as the art and science of formulating, implementing, and evaluating cross- functional decisions that enable an organization to achieve its objectives.

Strategic management is one of the significant reasons that it can make a difference in how well an organization performs. Studies of the factors that contribute to organizational performance have shown a positive relationship between strategic planning and performance. Strategic management consists of four basic elements [Shams Eldein, 2004]:

30 1- Environmental scanning.