Overview Introduction Human error has been shown to be the single largest contributing factor in aviation, transportation, high-technology, and industrial mishaps (
1). A great deal of attention has been paid to understanding human error in complex systems, including issues related to design, communication, and judgment. However, less attention has been paid to the impact of organizational influences on safety and performance. These surveys examine the organizational climate using a human factors framework.
Background An early model depicting organizational influences on loss control was introduced by Frank Bird (1974). His "Domino Theory" model posited that loss (i.e., a mishap) resulted from a sequence of events, each influencing the next (similar to that of falling dominos with each domino having a cause and effect on the next in the series).(
2) Figure 1 depicts the steps in Domino Theory.
In the ensuing years, several other researches expanded upon Bird's work. Turner (1978) observed that organizational factors leading to a mishap could go unnoticed for long periods by system's designers or users. He defined this dormant period of unforeseen disaster as an "incubation period" which could persist for years before a "triggering event" generated a mishap. Turner indicated this triggering event could be confused as a "causal factor" of the mishap rather than the last event in the sequence of events leading to the mishap.(
3)
Perrow (1984) contended that as organizations and their technologies become more complex, they also become vulnerable to accidents [mishaps] stemming from unforeseen or misunderstood events. He termed this type accident a "normal accident" in the sense that it is an inherent part of complex systems that they will eventually fail. Perrow highlighted the essential role that organizations and management have in managing these systems.(
4)
James Reason (1990) built upon earlier error management research. He divided errors into two categories: (1) "active errors" that are almost immediately recognizable, and (2) "latent errors" that might lie dormant for a period of time until some precipitating event triggers the mishap (similar to Turner's incubation period). Reason introduced the "Swiss cheese" model of mishap causation. Figure 2 depicts the four tiers of Reason's model.
Breakdown in interactions between these tiers results in "holes" in their respective defenses. It is these holes in the layered defenses that gives the name "Swiss cheese" to the model.(
5)
Wiegmann and Shappell (1996) fleshed out Reason's human error model by providing and defining subordinate categories to each of the model's four tiers. Their contribution resulted in the development of the Human Factors Analysis and Classification System (HFACS) - a model now recognized throughout DoD and becoming generally accepted in industry (refer to Figure 3).(
6)
During the same time frame as the evolution of human error research, other academicians were investigating issues regarding organizational climate and culture. Zohar (1980) described "organizational climate" as the shared perceptions employees have about their organization. He believed that organizations create several distinct climates simultaneously (e.g., motivational, creative, safety climates, etc.). His work primarily focused on "safety climate" which refers to the organizational members' shared perceptions that their leaders are genuinely committed to safety and have taken appropriate measures to communicate safety principles and to ensure adherence to safety standards and procedures.(
7)
Schein (1990), a pioneer in "organizational culture" theory, asserted that as a result of adaptation within an organization, a system of shared beliefs, values, attitudes, and norms emerge that govern individual and group behavior. Culture becomes a driving force that provides the criteria for measuring progress and methods for correcting deviations from expected outcomes. Culture is passed on to successive generations of organizational members through the process of socialization of new members into the group. (pp. 115-116).(
8)
In separate research, Roberts (1990a) identified key attributes of organizations that were successful in reducing risks associated with hazardous operations, and termed these organizations "high reliability organizations" (HROs). She chronicled several different types of organizations ranging from nuclear power plants to Navy aircraft carriers.(
9) Roberts (1990b) described responses that served to lessen negative impacts on HROs including: intensive training, open hierarchical communication, redundancy, and instilling a high reliable culture.(
10) In related work, Libuser (1994) proposed five factors regarding the effectiveness of organizations in managing risks: process auditing, reward systems, quality of operations, risk perception, and command and control.(
11)
Ciavarelli and Figlock (1997) developed the Model of Organizational Safety Effectiveness (MOSE) using the framework for HROs as outlined by Robert and Libuser, then adapted it for Naval Aviation use by incorporating standard naval language and safety practices.(
12) They then built an on-line survey process to measure organizational effectiveness within the scope of the MOSE model. Follow-on research by Baker(1998) and Figlock (2002) led to refinements in the MOSE model, including the addition of a sixth factor - "Communication/Functional Relationships."(
13),(
16) Several analyses of the Naval Aviation survey data with Naval Aviation aircraft mishap data demonstrated a statistically significant relationship between survey results and subsequent mishap rates.(
14)
Schmidt (1999) developed a maintenance derivative of the HFACS model, expanding it to provide a comprehensive examination of maintainer human factors. He titled this model the "HFACS-Maintenance Extension" (HFACS-ME). HFACS-ME was subsequently incorporated into the Naval Aviation mishap reporting.(
15)
Factor analyses of Naval Aviation safety climate survey data have been conducted. These factor analyses point to survey item categorization that aligns well with the top two tiers of the DoD HFACS model (
Organizational and
Supervisory factors). Thus, these two tiers are used to categorize Naval Aviation survey data (refer to Figure 3) with human factors-related survey items developed using the refined MOSE model.
Safety Climate Assessment Surveys Naval Aviation's web-based Safety Climate Assessment Surveys process has evolved and expanded during its ten-year history. The initial Command Safety Assessment (CSA) survey served as a starting point for development of an Internet-based survey application for Fleet-wide use. Since the introduction of the CSA survey, a total of ten on-line climate surveys have been developed to assess different aspects of organizational safety:
- Command Safety Assessment (CSA)
- Maintenance Climate Assessment Survey (MCAS)
- Administrative Support Personnel Assessment (ASPA)
- Contractor Maintenance (CTR)
- Fleet Readiness Center (FRC)
- Higher Headquarters (HHQ)
- Private Motor Vehicle (PMV)
- Drinking & Driving (D&D)
- Motorcycle (MTRCYCL)
- Off Duty & Recreational Activity (OD&R)
Notes: (1) Duffey, R. and Saull, J. The probability and management of human error (Draft). Proceeding of 12th International Conference on Nuclear Engineering. April 25-29, 2004, Virginia. (2) Bird, F. (1974). Management guide to loss control . Institute Press, Loganville, Georgia. (3) Turner, B. (1978). Man-made disasters . Wykeham Publications, London, England. (4) Perrow, C. (1984). Normal accidents: Living with high-risk technologies . Basic Books, New York. (5) Reason, J. (1990). Human error . Cambridge University Press, New York. (6) Wiegmann, D and Shappell S. (1996). A human error approach to aviation accident analysis: The human factors analysis and classification system . Ashgate, Great Britain (7) Zohar, D. (1980). Safety climate in industrial organizations: Theoretical and applied implications. Journal of Applied Psychology, 65 (1), pp. 96-102. (8) Schein, E. (1990, February). Organizational culture. American Psychologist, 45 (2), pp. 109-119. (9) Roberts, K. (1990a). Some characteristics of one type high reliability organization. Organization Science, 1 (2), pp. 160-176. (10) Roberts, K. (1990b). Managing high reliability organizations. California Management Review, 32 , pp. 101-113. (11) Libuser, C. (1994). Organizational structure and risk mitigation . Dissertation, University of California, Los Angeles, California. (12) Ciavarelli A. and Figlock, R. (1997). Organizational factors in naval aviation accidents. Proceedings "Kickoff Conference" (pp. 36-46). Center for Risk Mitigation, Haas School of Business, University of California, Berkeley, California. (13) Figlock, R. (2002, June). Review and evaluation of a theoretical model of organizational safety effectiveness applied to naval aviation. Dissertation, Walden University, Minneapolis, Minnesota. (14) 1. Schimpf, M. (2004, June). Can squadron safety climate surveys predict mishap risk? 2. Schimpf M. and Kinzer, C. (2004, November). A study of the relationship between maintenance climate assessment (MCAS) and naval aviation mishaps. 3. Schimpf M. and Figlock, R. (2006, June). CSA and MCAS surveys and their relationship to naval aviation mishaps. Available at:
https://www.advancedsurveydesign.com/?page_id=87 (15) OPNAVINST 3750.6R, Naval Aviation Safety Program; 1 March 2001; Appendix O, pp. 15-20. (16) Baker,R. (1998) Cllimate Survey Analysis for Aviation Maintenance Safety. Masters Thesis. Naval Postgraduate School.