ORGANISATIONAL AND CULTURAL CAUSES OF ACCIDENTS - A PILOT STUDY

A team from the Safety Systems Research Centre at the University of Bristol have recently completed a major study of the organisational and cultural precursors leading to ten major events which have occurred across a range of industries. The work was funded by the Health and Safety Executive (Nuclear Installations Inspectorate) and, initially, by British Nuclear Fuels Limited (BNFL). One of the main conclusions of the study was that the precursors to the events were strikingly similar, whatever the industry and the nature of the process being managed. These precursors have been grouped under seven general headings: Leadership; Operational attitudes and behaviours; Commercial pressures/business environment; Learning from events; Competence; Risk assessment and management; and Oversight, scrutiny and audit. For each of these areas, the relevant findings were analysed and a series of statements of good practice formulated which, it was argued, would have provided defences against the events. From each of these statements, a series of more penetrating questions were developed, and are currently being trialled, which attempt to evaluate whether an organisation has embedded systems and behaviours which are likely to achieve the good practices, and to provide an understanding of the 'real situation' in the organisation. This paper describes a short pilot study - undertaken in two phases - in which the statements and associated questions from the Bristol University research were tested in an industrial context, in this case a large integrated energy company (Centrica plc). The statements were tested at both a corporate, or Group, level and within an operational business. The findings from Phase 1 of the study are presented in terms of the learning for the company, i.e. potential improvements to organisational resilience.