Blowing Up Safety Culture - The Lure and Trap of Accident Investigation and Continuous Improvement

Harold S. Blackman, Boise State University


Safety culture is clearly recognized as an important element of any organization. This is of particular importance for high-risk industries where complex sociotechnical systems exist. In many industries a great deal of energy, time and money continues to be expended in trying to get the culture right. Active safety programs such as the Voluntary Protection Program, peer observation programs such as behavior-based safety, planned audits and inspections from a variety of bodies both internal and external to the organization, as well as audits by regulatory bodies are regularly employed. And when something bad happens there are standard protocols for investigating accidents leading to corrective actions that seek to prevent another occurrence. This coupled with the fact that for decades there have been countless programs directed at quality and continuous improvement has led to situations where we can become captured by quality and we are led away from understanding the greater situational context. This paper describes how this may occur and then presents a case study where an intervention was applied to “blow up” and then reset the safety culture of an operational facility where this “quality capture” had occurred.