Mon 7 Feb 2005
An article in today’s New York Times reminded me of the appropriation of culture by NASA critics following the Columbia disaster of 2003. Investigators blamed the crash in part on a ‘broken safety culture’ in which the emphasis on safety was lacking and individual engineers’ ability to raise safety concern and make changes was hampered. At the time I was upset over the use of the term culture to encapsulate the problem, mostly because of the tendency for bureaucrats and administrators to imply that culture could be changed by fiat. But no company can change culture through administrative action - that much seems true two years later when, despite progress in the specific areas that caused the disaster, there are lingering questions from both inside and outside the agency regarding shuttle safety.
A recent letter in Discover magazine pretty much sums up the problem as I see it. The author wrote in response to Discover naming the winning of the X-Prize by Burt Rutan and Scaled Composites’ SpaceShipOne as the 2nd greatest SciTech achievement of 2004. In a nutshell, he argued that the push for government regulation of private spaceflight in the wake of the X-Prize is ridiculous because of the fallacy that government regulation somehow makes for safer practices. NASA seems to prove this. I think we can safely say that ethics, market success, and PR are all powerful incentives for a private company operation out from under the cloak of government to maintain rigorous safety practices while still innovating in a way that NASA is wholly incapable of.
April 8th, 2005 at 10:46 am
I disagree with the contention that safety culture can not be turned around effectively using administrative techniques. Too many of the past techniques have merely been “measuring tools” and not actual attempts to change the NASA culture.
I submitted the below patent application, which was recently printed by the Patent Office. A prototype or draft of the online approach is also available, on my nuclear safety culture webpage. I believe that this methodology could be fully implemented at NASA in about one week.
I am sure NASA has enough IT folks to handle the technical details for their network when a NASA decision maker tells them to implement it.
For NASA, the possible absence of a credible communications safety culture may itself preempt access for these methods, but I suspect that the time is ripe for someone inside NASA to advocate such inputs. The news media are still carrying negative stories about NASA’s safety culture, but that could be easily turned around with this approach.
Even the Nuclear Regulatory Commission and many nuclear utilities have trouble recognizing the need for such communications. Nevertheless, as I noted in my presentation on Nuclear Safety Culture at the American Nuclear Society 2002 Summer Meeting, when we built the USS NIMITZ, the lead ship of the two reactor class, such communications were key to our success. I was right in the middle of the NIMITZ Reactor Department during construction and testing and witnessed/participated in that culture for three years. The USA has now built about 10 of those advanced, nuclear powered aircraft carriers without any significant problems. If NASA were to pick up on these methods, I am sure such actions would be of further interest to the nuclear industry and NASA’s efforts and experience would be favorably discussed at the ANS 2005 Summer Meeting this June.
Thanks.
Charlie Jones
301-903-4421
====================================================
————————————————————-
United States Patent Application 20050055229
Kind Code A1
Jones, Charles Ray March 10, 2005
—————————————————————–
Automated issue-communication method that significantly improves an organization’s safety culture and corporate forthrightness by encouraging the communication of issues and concerns, circumventing middle-management filters while suppressing “whistleblower” creation
Abstract
This invention is a method for soliciting or requiring each individual in an organization (particularly organizations engaged in activities potentially impacting public safety, such as nuclear power plants, refineries, airlines, and space agencies) to report “up the organizational chain-of-command” his or her issues and concerns periodically as well as in specific instances to senior managers, to regulatory bodies, and/or to the public with minimal or no changes or filtering. Such information may be limited to concerns or issues but also might include up to the full range of routine and non-routine information falling within the knowledge or expertise of the individual, such as work completed and planned and any related obstacles to that work. This invention provides a method or approach that causes this range of data to not only bypass potential filters within middle management, it also provides peer validation and an archival record potentially important for the analysis of the root causes of accidents and incidents, for evaluations of regulatory compliance, and to motivate individuals to increase their productivity, personal integrity, and forthrightness. The work-related issues-and-concerns information may be collected, aggregated, integrated, stored, and analyzed as needed to evaluate potential safety, economic, regulatory, and political impacts associated with the issues and concerns raised. What separates this invention from previous art is primarily that it provides a credible, automated means for lower-level workers and managers to communicate effectively with senior managers without mid-level managers in the organization filtering, modifying, or delaying those communications and provides for concurrent peer-review validation of issues and concerns where those issues and concerns might (previously) have led to “whistleblower” status for the originator.
[Patent text omitted. Full text here.]