The Nimrod Review - Official Documents

The Nimrod Review
20.12
20.13
490
10 In the Baker Report into the BP U.S. Texas City Oil Refinery Incident, recommendations were made in
10 areas:
(1) Process safety leadership.
(2) Process safety management.
(3) Process safety knowledge and expertise.
(4) Process safety culture.
(5) Clearly defined expectations and accountability for Process Safety.
(6) Support for line management.
(7) Leading and lagging process safety performance indicators.
(8) Process safety auditing.
(9) Board monitoring.
(10) Industry leader.
The phrase ‘Process Safety’ is used in contra-distinction to ‘Personal Safety’. The former is aimed at wider
organisational issues. I prefer, however, to avoid using the word ‘Process’ so generically because of the dangers
of emphasising the ‘processes’ of safety at the expense of the end product and of encouraging ‘comfort in
compliance’ with process.
Recommendation: Adoption of FOUR KEY PRINCIPLES
In the light of the lessons learned from previous Chapters, I recommend that the MOD should promulgate
and adhere to the following Four Key Principles, in order to help assure and ensure an effective Safety
and Airworthiness regime in the future:
✓
✓
✓
✓
Leadership
Independence
People (not just Process and Paper).
Simplicity
20.14 I outline these Four Key Principles in further detail below.
✓ Leadership
20.15 Principle of Leadership: There must be strong leadership from the very top, demanding and
demonstrating by example active and constant commitment to safety and Airworthiness as overriding
priorities.
20.16
Leadership is the most common principle emphasised time-and-time again in reports into major incidents and
other materials:
“[T]he first priority for a successful safety culture is leadership” (Lord Cullen, Ladbroke Grove Rail Inquiry,
2001) 11
“Leaders create culture. It is their responsibility to change it.” (Columbia Accident Investigation Board,
2003). 12
10 The Report of the BP U.S. Refineries Independent Safety Review Panel, January 2007, headed by former US Secretary of State, James A. Baker III.
The Panel focused on the wider picture of ‘Process Safety’ rather than what it referred to as merely ‘Personal Safety’.
11 Ladbroke Grove Rail Inquiry Part 2 Report (2001), Chapter 1, paragraph 1.11.
12 Columbia Accident Investigation Board Report, 2003, page 203.