Thursday, November 20, 2008

The Hawthorne Effect

I had cause to refer to this recently, and struggled to remember the name. Hopefully a summary here will help me remember in future.

Studies carried out at the Hawthorne Works (outside Chicago) between 1924-1932 showed that changes in the working environment could improve productivity. But the improvement was only short lived, leading to the conclusion that people were responding because something had changed, and not to the change to the environment itself.

There is an article on Wikipedia

Tuesday, November 18, 2008

Floods, fire and theft rank with ill-advised cost-cutting

Article in Risk Management suplement of the Financial Times By Andrea Felsted on 18 November 2008

"As the economic outlook for the UK becomes more gloomy, so the risks that businesses face multiply because, according to Peter Jackson, sales and marketing director for Aon Risk Services in the UK, "when times are tougher, the worst is more likely to happen."

One reason the risks are higher is because business have more stock because it is difficult to shift. Because of financial constraints they may wish to cut back on insurance, but actually lose more if there was a fire or through theft.

Other cost saving may be cutting back on maintenance, equipment may be replaced less regularly, or plant may be repaired rather than replaced. Directors need to be particularly aware of the risks as they may be held personnaly responsible if someone dies as a result of that equipment failing. Companies should have a clear idea of the minimum level of maintenance spend they can live with rather than just incrementally cutting and seeing what goes wrong.

John Scott, head of risk insight at Zurich Financial Services UK, says that when companies cut costs “management often take their eye off the ball on the simple, really key stuff around health and safety. We often see an increased trend of workplace injuries. That is something that is a consequence of tightening belts. Well-managed companies try to do both. They try to cut back but without jeopardising staff safety.”

Research commissioned by FM Global, an insurer of commercial and industrial property, suggests that risk management is not an area where costs should be cut.

Some 71 per cent of UK investment analysts it polled believed that companies should pay more attention to their risk management activities during the next five years.

Thursday, November 13, 2008

Just culture

A flow chart of an individual's culpability following an unsafe act has been around for some time. I think it was developed by Professor James Reason, and I know a few companies use it (or at least claim to ) to guide their disciplinary processes.

Anyway, I was looking for a copy of the chart, which was proving difficult. Eventually found it in the following paper from Titled 'A roadmap to a just culture: enhancing the safety environment' and published September 2004. It was prepared by the Global Aviation Innovation Network (GAIN) working group for safety information sharing.

I think the paper's forward by Reason gives a very good account of the issues:

"The term ‘no-blame culture’ flourished in the 1990’s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a proportion of unsafe acts were ‘honest errors’ (the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators. But the ‘no-blame’ concept had two serious weaknesses. First, it ignored - or, at least, failed to confront - those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome. Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts."

Andy Brazier

Thursday, November 06, 2008

Report into Morecambe offshore helicopter crash

Accident occurred on 27 December 2006 whilst the helicopter was approaching a gas platform in Morcambe Bay. The two pilots and five passengers were killed.

Report No: 7/2008. Report on the accident to Aerospatiale SA365N, registration G-BLUN, near the North Morecambe gas platform, Morecambe Bay on 27 December 2006.
Report published 23 October 2008 by the Air Accident Investigation Board and available at their website.

The report suggests the co-pilot who was flying the helicopter on its approach to the gas platform became disorientated, probably due to darkness and weather. Handover of control to the pilot was not precise and the pilot himself was not ready to take control. This meant there was not enough to time to work out what to do before the helicopter hit the water at a speed that was not survivable.

This is a difficult accident to comment on. We usually look for root causes in systems and organisations so that we can make good recommendations. This accident is an example of how individuals can fail, and sometimes those failures will result in accidents. In others words, if we accept risk we sometime have to accept tragedy.

The report makes six recommendations, but none in my mind are particularly earth shattering, asking for reviews of standard operating procedures and suggesting some areas for research. A comment is made that a simulator was available for training, but had not been used. No recommendation is made, and given the level of experience of the pilots in this case it is difficult to see whether such training would have had much impact on the risks.

Andy Brazier