Several of the other speakers spoke about the “Safety Culture“ critically necessary in their industry and their own minor safety lapses.
One presenter spoke about NASA’s recent Columbia accident as well as the 1986 Challenger accident and the degradation of their safety culture and the loss of many lessons learned from 1986 due to continuous pressures regarding meeting schedules and catching up to schedules that had been slipping. The lesson is and has been clear to the US nuclear industry. And their safety systems and programs and training held up when put to the test when the North American’s electrical grids system’s failure caused a major blackout across the northeast this last August.
It is interesting to note, as presented by another speaker that the United States Navy’s nuclear program has not had any such incidents since the program began in 1948. Of course the USN has a very strong, traditional culture where “there is a right way and a wrong way and the Navy way”…and they do things the Navy way. Admiral Rickover’s legacy in the Nuclear Navy is much broader than safety, but safety was paramount.
Back in 1998, on the occasion of the 50th anniversary of the establishment of the Naval Nuclear Propulsion Program, Congress passed a resolution that commended the Navy and its nuclear propulsion program for its unblemished safety record and key role in the military.
Of course they live in a world where the consequences are much larger than simply a nuclear disaster, as big as that is all by itself. There is a nation at stake and the lives and freedom of 292 million, if you don’t add up all of the other free nations and their people on this planet. Huge stakes. Huge consequences.
One of the MNTA speakers spoke of sitting with a regulatory group and examining their own “Safety Culture” and their attempts to define it. Ever vigilant was one attribute. I appreciate that, as do many of you. Their early drafts included other words such as “behaviors, attitudes, compliance, and independent oversight.” But as he spoke I picked up on some other things that really resonated with me due to my work in developing my own EPPI (Enterprise Process Performance Improvement) models. In that EPPI model one of the environmental enablers of peak performance is the right “Culture/Consequences.” To me, culture is/are simply “the consequences.”
To the individual performer, or team, or department, function, business unit, enterprise, and industry, culture is established by human beings at the higher levels. It is established by the consequences applied by and from “above.” Not by their words, but by their deeds. Those above have a heady responsibility to establish the appropriate balance of consequences, guided by the probability and severity of ALL of the risks and rewards involved.
Pushing schedule adherence over safety as a convoy of military vehicles rushes to the front lines due to the stakes of potentially losing a major battle may indeed be a justified and appropriate risk. Pushing to adhere to a schedule in the case of a space shuttle, or a nuclear power generating installation, or a nuclear submarine refueling efforts is not. But why might they push the limits and incur such a risk?
Consequences. The rewards and punishments; the reinforcers or extinguishers of behaviors and cognition. Whether stated or not, whether formal or not. The reality of the culture of a society or an enterprise lies in what is really rewarded and punished. Of course the more immediate and sure the consequence, the more effective.
For they control the consequences.
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