Safety management practices have changed significantly over time
Why learn about the history of safety?
It is useful to briefly describe the history of safety management to understand ARPANSA’s aims and objectives in promoting Holistic Safety.
What should be clear from the following is how the overall aim to improve safety and prevent accidents has influenced how safety management is applied and what approach is adopted. This can even be traced back to the second millennium BC, where Babylonian King Hammurabi set laws to execute masons whose constructed houses fell and killed the owners or occupants.
The following aims to provide a brief chronology of the major changes in safety management that have occurred since its inception. These are discussed in terms of the different phases or ‘ages’ of safety management: The ‘technological’ age; the ‘human’ age; the ‘organisational’ age; and the ‘systems' or 'holistic’ age.
First age of safety management — the technology
The first age of safety started with the Industrial Revolution in 1750-1760 and the invention of the steam engine.
Most accidents were from the technology failing, injuring workers and the public. The focus of safety management was to ensure the technology was safe to use.
‘if the technology is safe, then we will be safe’.
This view of safety management became part of what known as the ‘technical age’ or the age of the technology.
This technical age saw improvements in the ability to identify the ‘broken part’—the part of the technology that failed—and avoid single component failures. Sophisticated techniques (such as probabilistic risk assessment) for managing risky technology were developed for this purpose.
Technological failures, problematic for so long, could now be ‘engineered out of the system’. This is what most people thought until the meltdown of the Three Mile Island reactor (TMI).
The accident came as a surprise to engineers and managers. Despite all the risk assessments and technological safety features, the reactor nevertheless melted down. The President’s Commission into TMI found the causes to be “people-related problems and not equipment problems”.
As hardware and software had become increasingly more reliable, the human contribution to accidents had become ever more apparent.
In response, it was necessary for the focus of safety management to expand so that the human element (the human factor)—as well as the technology—was addressed thus creating the second age of safety management—the human factors age.
Second age of safety management — the human
This age of safety management expanded to focus on the human (human performance) as well as technology.
Systems were designed to be human error tolerant so neither human action nor single faults would result in accidents. Much of this work focused on man-machine interfaces and workspace layout.
‘if the human is safe, then we will be safe’
This view of safety management continued until accidents such as the Challenger space shuttle accident and Chernobyl reactor meltdown. Safety practitioners were again required to rethink their approach to managing safety. More than simply technical faults or human error, the Presidential Commission into Challenger found a “propensity within management to contain potentially serious problems”.
The IAEA reported similar findings and provided recommendations that addressed more than simply the technology or the people operating the reactor.
“creation and maintenance of a nuclear safety culture”
These accidents and others (such as the crash of Air Ontario Flight 1363 and the Exxon Valdez oil spill) sparked another paradigm shift in safety management. No longer was it enough to simply focus on the technology or the human. Organisational factors (such as management and safety culture) also needed to be addressed to maintain safe operations. This signalled the start of the third age of safety management—the organisational age.
Third age of safety management — the organisation
This age of safety management expanded to focus on the organisation as well as the human and technology.
Safety management in this organisational age saw human error and technical failures more as a consequence than a cause. Errors were viewed as the ‘tip of the iceberg’ for more serious latent conditions and problems higher up in the organisation e.g. poor leadership for safety or safety culture.
Without removing these problems and others existing higher up in the organisation, failures at the ‘sharp-end’ would continue e.g. without removing the ‘parent problems’, ‘progeny’ errors and technical failures will continue to appear. New safety management models and assessments appeared which enabled safety managers to find and then remove weaknesses higher up in the in the organisation (e.g. safety culture or climate surveys) that could lead to serious accidents in the future.
‘if the organisation is safe, then we will be safe’.
This view continued until accidents such as the 2003 Columbia Space Shuttle disaster. More than simply isolated failures at the organisational level or clear human and technological failures, the Columbia Accident Investigation Board (CAIB) found causes in the complex and interdependent interactions of the technology, human and organisation present at the time of the accident.
‘systems fail in complex ways’
By trying to accurately describe this complexity, the CAIB considered that control measures could be better designed to prevent such accidents happening again.
This accident and others sparked another paradigm shift in safety management. No longer was it enough to simply focus on technological, human and organisational factors in isolation. The complex interaction and interdependency also needs to be described, signalling the birth of the current age of safety management—the holistic or systems age.
Fourth age of safety management — the systems/holistic age
This holistic approach aims to understand the complexity of day-to-day work by describing the often complex interrelationships and interdependencies between the technology, human and organisation.
This allows the description of the organisation to more closely reflect the true reality today’s work which can often be complex e.g. people working together using complex technology across multiple locations and divisions within the organisation.
Without using this Holistic Safety approach, we are effectively only seeing part of the picture, or only a few pieces of the ‘puzzle’.
Adopting the holistic approach means seeing more clearly how each piece of the puzzle fits in, affects, and is and dependent upon other pieces.
This not only provides a more complete or ‘real’ picture of the context but also means control measures and steps taken will be both more efficient and effective at avoiding accidents. This is different to the other ages of safety where:
- isolated or component failures are identified e.g. blaming the person last in line of the accident ‘chain’—people at the ‘sharp-end’
- identifying upstream, contextual factors as erroneous (e.g. poor safety culture) without actually describing why they appear.
This is why Holistic safety is now widely regarded as best practice, and why ARPANSA encourages licence holders to adopt a holistic approach to safety management.