The Nimrod Review - Official Documents

The Nimrod Review
Professor Reason
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NASA has adopted a safety model of Professor James Reason (whom I had the privilege of meeting and whose
work on Accident Theory I outline in Chapter 18). In his seminal book, Managing the Risks of Organizational
Accidents, 14 Professor Reason identified the four critical sub-components which interact to create an “Informed
Culture”, namely a positive Safety Culture that effectively shares information throughout the organisation and
actively seeks maximum safety. The four key elements (or ‘sub-cultures’) are as follows:
A Reporting Culture: an organisational climate where people readily report problems, errors and near
misses;
A Just Culture: an atmosphere of trust where people are encouraged, and even rewarded, for providing
safety-related information; and it is clear to everyone what is acceptable and unacceptable behaviour;
A Flexible Culture: a culture that can adapt to changing circumstances and demands while maintaining
its focus on safety;
A Learning Culture: the willingness and competence to draw the right conclusions from its safety
information and the will to implement major safety reforms.
Tracy Dillinger explained to the Review that NASA has adopted Professor Reason’s model with one important
modification: instead of the phrase “Informed Culture”, Tracy Dillinger prefers the use of the phrase “Engaged
Culture”, because it is not sufficient for an organisation simply to be properly informed, it must act on the
information to promote and improve safety. Although Professor Reason makes clear that an effective organisation
must necessarily act on the information received, I agree with Tracy Dillinger that the phrase “Engaged Culture”
correctly emphasises the responsibility of an organisation actively to manage safety, i.e. not merely to gather
information, but to act on it.
JPDO NextGen Project
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The Review has also been briefed by NASA on the work on the US Joint Planning and Development Office
(JPDO) 15 . In 2003, the JPDO was tasked with producing a plan for safely implementing the Next Generation
Air Transportation System (NextGen) which must be capable of accommodating a threefold increase in air
traffic by 2025. The JPDO Safety Working Group’s Safety Culture Study Team is made up of representatives
from government, industry and aviation safety academia. On 30 July 2008, the JPTO Team produced its “Safety
Culture Improvement Resource Guide” (Resource Guide) which had gathered source material from 20 industry
and government sources worldwide. The JPTO Team concluded from the published data reviewed that there
was a clear relationship between a strong Safety Culture and improved safety performance.
The JPTO Resource Guide endorsed Professor Reason’s approach set out above and recommended that it form
the cornerstone to improving Safety Culture as part of the NextGen project. I outline the four elements of
Professor Reason’s model below.
A Reporting Culture
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A positive Reporting Culture helps to mitigate errors by encouraging employees to report information about
hazards or safety concerns that they encounter. It also enables trends to be picked up and acted upon.
It is only human nature, however, to be reluctant to report incidents which might involve a degree of personal
blame or blaming colleagues. Other impediments to adequate reporting include apathy (‘Will any good come
from reports?’), or scepticism that management will act on reports. There are five important factors in ensuring
the quality and quantity of incident reports: (1) protection from disciplinary proceedings where appropriate;
(2) confidentiality or anonymity where necessary; (3) separation of the agency or department that collects
and analyses reports from those with the authority to discipline; (4) rapid, useful, accessible and intelligible
14 Managing the Risks of Organizational Accidents, James Reason, December 1997, ISBN 1840141050.
15 The US Joint Planning and Development Office (JPDO) is the central organisation that co-ordinates the activities of the US Departments of
Transportation, Defense, Homeland Security, Commerce, FAA, NASA and the White House Office of Science and Technology Policy.