The Nimrod Review - Official Documents

27.6
(1) Compliance with applicable standards and procedures.
(2) Right first time, i.e. insistence on getting things right first off.
(3) Not accepting poor standards of work, i.e. a zero tolerance policy.
Chapter 27 – New Safety Culture
(4) Understanding that: (a) the overall risks that are being managed; (b) risk is not constant; and (c) new
hazards need to be captured and managed as they arise.
(5) Learning from incidents and near misses to improve the safety of work and overall safety of the railway;
(6) Sharing information so that your maintenance staff become the eyes and ears necessary to detect things
that are wrong; and
(7) Action where something is found to be wrong.
The ‘Yellow Book’ stresses three points in particular:
(1) It should be recognised that that there can be a tendency for a Safety Culture to deteriorate, particularly
where repetitive tasks can result in perceived familiarity and a false sense of security.
(2) It is essential to put measures in place that minimise the potential for complacency, such as varying people’s
tasks and encouraging ownership.
(3) The starting point for a good Safety Culture is a commitment on the part of management. This is best
expressed by the setting of a safety policy, endorsed by the board of directors. A safety policy should state
the organisation’s aims for achieving safety. 7
Challenger and Columbia
27.7 On 28 January 1986, NASA Space Shuttle “Challenger” was lost on take-off as a result of a failure of an ‘O-ring’
Thiokol seal in the Solid Rocket Motor. 17 years later, NASA8 Space Shuttle “Columbia” was lost on re-entry on
1 February 2003 as a result of a failure in its wing foam thermal protection system. 9 The Challenger Presidential
Commission10 made recommendations in 1986 regarding improvement to NASA’s Safety Organisation. The
Columbia Presidential Commission (CAIB) 11 found that, although changes had been made to NASA’s Safety
Organisation following Challenger, many of the organisational failures which led to the Columbia accident
echoed organisational failures in the Challenger accident because NASA had failed to alter its essential
organisational Safety Culture in the 17 years between the two major accidents. Professor Diane Vaughan12 attested to the difficulty that NASA had had in addressing the fundamental organisational and cultural problems
in the intervening years.
27.8
I was, therefore, interested to learn what steps have been taken by NASA to improve its Safety Culture in the
light of the CAIB report post-Columbia, particularly given the striking parallels between the organisational
causes of the losses of Challenger and Columbia and the organisation causes contributing to the loss of XV230
(see Chapter 17).
NASA’s approach to Safety Culture
27.9
I have received valuable assistance from Lieutenant Colonel Tracy Dillinger of the NASA Office of Safety and
Mission Assurance. 13 Tracy Dillinger worked on the CAIB and was seconded by the US Air Force Safety Center to
NASA to oversee improvements in Safety Culture within NASA post-Columbia. Tracy Dillinger explained to the
Review how NASA has addressed the challenge of developing an effective Safety Culture by reference to the
NASA Safety Programme and the NextGen Project referred to below.
7 Ibid, paragraph 6.2.4.
8 US National Aeronautics and Space Administration.
9 See Chapter 17.
10 The Rogers Commission was set up by President Ronald Regan and reported in June 1986.
11 The Columbia Accident Investigation Board (CAIB) was set up by President George W. Bush and reported in August 2003.
12 Professor, Columbia University Sociology.
13 Lieutenant Colonel Tracey Dillinger, PsyD, Office of Safety and Mission Assurance, NASA Headquarters Washington DC.
571