| Popis: |
Over the last few decades, safety risk management has been built on increasingly more cumbersome and complicated systems. Notably, incident investigations include assessments of these safety systems with limited attention to culture and behaviours. While the safety systems approach significantly reduced accidents, a few major incidents in high-risk industries in the past decade blamed, amongst others, a “wrong safety culture”. The most striking increase in the behavioural safety literature since 2015 calls for a change in approach. The study reported here used an incident report where behaviour and culture were implicated as possible leading causes: the sinking of the BP Deep Water Horizon rig in 2010. A decade later, the authors have analysed this comprehensive report using a new sociotechnical safety questionnaire that represents the latest shift in safety investigations. Items related to safety systems yielded no additional insights into the incident, neither did the personal situation of workers help due to a lack of information reported. However, four categories of questionnaire items proved most useful to obtain new insights into the incident: perspectives of the workers’ own experiences, of colleagues, of management and lastly of taboo topics such as fear, judgements, blaming and hiding of critical information. A “do-not-go-there” culture driven by management resulted in inadequate communication on key risks identified by experts. This study highlights individual behaviour and group culture concerns in several job positions in contrast to what was reported in earlier accounts. These include the role of contractors where they constituted most of the workforce, the role of technical experts that dealt with major uncertainty yet remained outside standard procedures, and the actions of management driven by cost and time constraints to the detriment of safety. The sociotechnical safety questionnaire creates the opportunity for future incident investigations to follow a new line of inquiry to improve analyses of cultural and behavioural causes of safety incidents. |
