Organizations that do not internalize and apply the lessons gained from their mistakes relegate themselves to static, or even declining, levels of performance. Barriers to lateral communications (e.g., between work groups) can also impede the free flow of safetycritical information. This is done through established protocol, procedures, and norms that dictate the manner in which subordinates communicate with management, and the manner in which management receives and responds to the information. A dysfunctional organizational culture can discourage honest communications, despite formal appearances to the contrary. Ensuring Open and Frank Communications.Organizations that do not actively engage in qualitative and quantitative “what can go wrong?” exercises, or that fail to act on recommendations generated by the risk assessments that are done, miss the opportunity to identify and manage their risks. Without a complete understanding of risks, and the options available to mitigate them, management is hampered in making effective decisions. Performing Valid/Timely Hazard/Risk Assessments.The CAIB report makes a compelling argument for ensuring strong, independent “sanity” checks on the fundamental safety integrity of an operation. In the case where valid safety concerns are ignored, the success of the enterprise can be put in jeopardy. Establishing an Imperative for Safety. An organization that is focused on achieving its major goals can develop homogeneity of thought that often discourages critical input.When pre-established engineering or operational constraints are consciously violated, with no resulting negative consequences, an organizational mindset is encouraged that more easily sanctions future violations. This can occur despite well-established technical evidence, or knowledge of operational history, that suggests such violations are more likely to lead to a serious incident. Eliminating serious incidents requires constant reminders of the vulnerabilities inherent in hazardous activities. Operating diligence and management effectiveness can be easily dulled by a sense of false security – leading to lapses in critical prevention systems. Catastrophic incidents involving highly hazardous materials or activities occur so infrequently that most organizations never have the unfortunate, but educating, opportunity of experiencing one. Key organizational cultural themes emerging from the CAIB report include: Although NASA is a unique organization, with a focused mission, the organizational cultural failures that led to the Columbia disaster have counterparts in any operation with a potential for significant incidents. Through its report, the CAIB has provided a service to all organizations that operate facilities handling hazardous materials or that engage in hazardous activities.
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