VIEWPOINT Can We Have a ‘Safety Culture’ in the Tunnelling Business ? John Anderson Jno term ‘safety culture’ ’ight or could ‘mean for the construction industry has the subject of some interest in the UK and elsewhere in recent times. Might there really be some way in which the con- struction industry could go about its affairs to the extent that everyone was so signed up to safety that accidents and emergency incidents become a thing of the past? That really would be something worth celebrating! Ttistrue that our industry has made substantial progress inthe reduction of accidents, and there are driving forces at work to reduce accidents and ill health to even lower levels. ‘As the incidence of accidents reduces and solutions to traditional accident ‘black spots’ are well understood and applied in practice, it often becomes harder to devise new strategies for further reductions. The patterns and types of accidents may be more random in their occurrence, and hence more difficult to predict. This is the view of Jim Reason, a researcher in human error in the world of indus- trial accidents, whose book Human Error [1] spans the disciplinary guif between psychological theorists and those at the ‘sharp end’ concerned with maintaining the integrity and reliability of complex and hazardous technologies. ‘The possibility of human error can add to the existing level of physical risks and may, in critical situations, lead todisaster. On the other hand, the ability of engineering minds to reason from facts, opinions and circumstances (often in fast moving and rapidly changing circumstances) can contribute to the improvement of safety and the redue- tion of risk. As engineering and safety systems improve, it seems reasonable to argue that the relative contribution by personnel to overall safety standards and safety perfor- mance has increased, and it would appear wise to look out for any safety critical processes where human error should it occur) could result in particular danger. In the tunnel- ling world, this could occur not only during the construe- tion processes but also during the planning and design stages (2). ‘The ‘traditional’ approach taken by some accident in- vestigators is often to attribute the primary cause of an accident to either a fault in human behaviour (unsafe or dangerous act — usually in contravention of established rules and procedures) or to some sort of shortcoming or dangerous aapect of the environment (i.e. an unsafe condi- Present addreases: John Anderson, 6 Queen's Park Road, Chester (CH4 TAD, United Kingdom. John Anderson sa consulting engineer anda former Vice Animateur of the ITA Working Group “Health and Safety" ‘Ars eer Pitas rteimss- 8 tion, such as unstable ground). ‘This is an unduly narrow perspectivein that, for example, it eaves out the contribu- ion others may have had (or not had) to the ‘upstream circumstances’ and to the creation of the climate in which the accident occurred. This is especially the case in tunnel- ling, where dosign is s0 very closely integrated with con- struction. Signposts to Safety Culture ‘Some past research and a few publications have given us some possible signposts on this issue, In the early 1970s, there was a definitive review [3] of the UK legisla- tion on occupational health and safety. The committee charged with the task came to the view that detailed government rules and regulations were not wanted, and that legislators “. .. should be predominantly concerned with influ- cencing attitudes and creating a framework for better, health and safety organisation by industries them- selves ‘This committee was clearly in favour of self-regulation, and took the view that prescriptive regulations (dothis, do that’) promoted, at best, unthinking compliance. What was really needed was more team considerations closely linking solutions to circumstances, and more joint action by all involved based on proportionality. (In other words, the greater the risks, the more effort should be made to devise effective risk control measures — don’t waste time ‘and energy on trivial risks.) What they were saying was that it would be better to be prescriptive in the require- ‘ment to undertake the processes of risk assessment, and objective setting in requiring at the end of this process a safety place of work. Precisely this strategic approach came into being in the Member States of the European ‘Union from 1989 [4]. Meanwhile, the nuclear incident at Chernobyl Nuclear Power Plant in the Ukraine had occurred, and an analysis, [6] of the circumstances stated that “... the operator errors were not sins of omission or commission or misunderstandings or errors of com- ‘munication, but errors which were systematic, per- sistent and conscious violations of clearly siated safety rules.” ‘Te questions were asked: how could this happen? could other operators in similar safety-critical environments ‘become complacent or arrogant and deliberately and sys- ‘tematically flout operating rules? The event led to the publication of a document. (6), ‘Safety Culture’, by the International Atomic Energy Agency (Vienna) in 1991, inwhich ‘safety culture’ was described as being essentially intangible, but something which has desirable and tan- gible outcomes or benefits. This was followed in the UK by ‘a key publication (7] from the Health and Safety Executive (HSE), Organising for Safety. The text of this valuable document has wide application to the management of risk and the place of safety culture in that processiin all manner of complex and hazardous technological processes, includ- ing tunnelling. “The authors put forward the following as a definition of ‘safety culture’ “The safety culture of an organisation is the product of individual and group values, attitudes, percep- tions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation's health and safety management. Organisations with a positive safety culture are characterised by communications founded on mutual trust; by shared perceptions of the impor- tance of safety; and by confidence in the efficacy of the preventative measures to control risks”. ‘This implies that ‘safety culture’ exists on the indi- vidual, group and organisational level, and that itis not a philosophy but ultimately an action plan. It is founded on shared values, attitudes and beliefs — a ‘hearts and minds’ issue—and has had exponents in manufacturingindustry, particularly in the USA (8). Fully documented research into nuclear power plants with low accident records iden- tified the following characteristics: snior management team that was strongly com- mitted to safety, giving it high priority, devoting resources to it and actively promoting it personally; + a strong focus on safety by the whole organisation ‘and its members; + 2 high level of communication between and within levels ofthe organisation where exchanges were less formal and more frequent. Managers do more ‘walkabouts’ specifically on safety matters and are more ‘visible’ + a good ‘earning ability’ in the organisation, includ- ing a desire to avoid the mistakes of the past; and + a better quality of safety training. Itscoms reasonable to argue that our industry ought to be listening to these research findings, but just how rel- ‘evant might they be in the construction industry in general ‘and in tunnelling in particular? If any ‘culture’ comes to mind in tunnelling, it is (quite rightly) the culture of getting the job done, This ‘task culture’ is what we under- stand — completing the projectis normally the top priority. ‘The HSE document in looking at this particular issue does sound a note of caution: “The most familiar and certainly the most important point toemerge from our researches is the threaten- ing trade-off between production and safety. Exces- sive production pressures also creates an air of di traction and shortage of time that makes human error more likely. A positive safety culture is one where safety not only wins out if there is a conflict, but where everythings done to remove theconflictin the first place... ‘The conditions that make for safe operation are often those that make for a good organisational climate ‘and hence good output.” More recently in the UK, safety culture research has been undertaken in the offshore oil industry, and at a 1997 international conference in Aberdeen of safety culture enthusiasts [9], the HSE announced the availability of a new do-it-yourself software-based ‘safety climate survey tool’ suitable for all industries (10) 214 TunaveiLiNc ano Unnercrounn Space TecHNoLOGY Reason (1997) (11] argues that human errors are conse- quences and not causes, which are shaped and provoked by_ upstream workplace and organisational factors. Identify- ing a human error (he asserts) is merely the beginning of the search for the true cause. He ista what he describes as the ‘main principles of error management’, including: * the best people can sometimes make the worst errors; + short-lived mental states — preoccupation, distrac- tion, forgetfulness, inattention —are the last and the least manageable part of an error sequenc + people wll alwaye have the potential to make errors and commit violations (i.e. deliberate acts against known established rules and procedures), but wecan attempt to change the conditions under which they work to make these unsafe acts less likely; + errors also arise from informational problems, These are best tackled by improving the available informa- ic ither in the person’s head or in the workplace; * Violations (as defined above) are social and motiva- tional problems, and are best addressed by changing ’s norms, beliefs, attitudes and culture on the one hand, and by improving the eredibility, applica- bility, availability and accuracy of the rules and procedures on the other. ‘The Underground Perspective In published underground construction literature on accidents and ‘emergency events’ of one kind or another there is rarely any mention of human factors and their contribution to accidents. However, there are at least four texts of some interest: Lawrence (1974) [12]; Waninger (1982) {13}; Health and Safety Executive (1996) (14] and Anderson and Lance (1997) [15]. occurred in gold mines in South Africa. His investigations revealed a total of 794 human errors associated with the circumstances of 424 fatal accidents. ‘The ecale and detail of this research into human errors in underground work is, ‘unusual, and he found that the dominant human errors * failure to perceive warnings of danger (36%); and ‘+ the underestimation of the risks once the warning had been received (25%). Waninger carried out an extensive analysis of 425 underground tunnel construction accidents which had ‘been reportedto the German Tiefbau-Berufagenossenschat (underground construction insurance association). Hi report highlights stress on the workers and the role thi right have in influencing behaviour and the occurrence of accidents. He suggests that tunnelling workers’ stre levels are likely to be high due to: + environmental factors such as noise, water dirt/dust, polluted atmosphere * communications difficulties between persons; + working patterns involving changing shift patterns ‘and overtime; * hazards due to working with and in and around substantial moving mechanical equipment; ‘+ pressure of deadlines and the need to reach produc- tion expectations. ‘The UK HSE document looked in detail at the safety of the New Austrian Tunnelling Method (NATM), and there is ‘a section in this report entitled ‘Human factors in risk ‘management’. The HSE came to the view that the success- ful use of the NATM tunnelling method in soft ground was heavily dependent on avoiding human filure and asserted that Volume 13, Number 3, 1998‘... if NATMis to be undertaken safely itis essential that those managing the process understand how human failure happens; what can be done to prevent it; how it can be detected and corrected; and how to recover. Indeed failure to consider the issue is human ‘This report also takes the view that it is important to differentiate between the ‘rules’ which people have or de- velop for their own use in problem-solving, and the rules that may be imposed on them in the working environment Differing work rules may conflict; the rules may not be applicable to all situations; safety rules may conflict with a goal-driven desire; and certain rules may be seen to be undermined due to management inaction if they are breached. ‘Another HSE report {16] refers to the recorded experi- ences of the contractors working on the construction ofthe Channel Tunnel where, partway into the construction phase, there was succesful upgrading of the safety culture, with positive benefits. ‘Anderson and Lance advocate a risk-based approach to tunnel design and construction and outline four key factors that need to be part of any strategy to control risk and censure safety: + thedesign andimplementation ofenginceringeystems; + the design and development of engineering systems; + the adoption of appropriate procurement, organi- sational and management systems; and + the consideration of human factors issues. On this last point they pose the question: ‘If tunnel engineers need psychologists down the tunnel and in the design office to help assess and address human factors issues (including the likelihood of buman error) in the process of devising the right overall systemsforthe project, then why not?” ‘Where Now for Better Project Safety Performance? Accidents, ill health and losses will always remain pos- sible outcomes from failing to effectively control the inevi- table hazards, risks and dangers that are part and parcel of tunnel construction. There ean be no room for complacency. However it might be wise to admit that moving towards a ‘safety culture’, as has been defined by others in what could be regarded as ‘higher industries’, is not going to be easy, however desirable. Safety culture is not some magic potion that has the power to transform poorly performing individu- als or organisations. It has to be considered within an overall strategy for continuous improvement. Perhaps we need to first of all take a step back and examine our present position, and it does seem that certain factors conspire to create barriers to substantial improve- ‘ment. ‘Two of them have been mentioned already, namely: © possible overemphasis on production objectives tothe detriment of good health and safety performance; and * overcoming any apathy and/or complacency towards health, safety and risk issues that could exist in both persons and individual organisations. To these two, one might add: * the quality and commitment of some site manage- ment to give risk, health and safety the correct priority on a day-to-day basis; + shortcomings in education and training on riskiseues; Volume 13, Number 3, 1998 * contractual arrangements between the partios lack- ‘ng a central focus on risk management; and + the lack of sufficient effort in the design office to look forward to the foreseeable risks likely to be encoun- tered in the construction stage, and to do something positive about them. Advocates of more effort on risk management and the development of an industry safety culture, such as myself, argue that rewards await at the end ofthis rainbow. The potential prizes include: * significantly fewer accidents and cases of il health; + better productivity; + ess waste; * fewer losses; and * the potential for increased profitability. All prizes surely well worth working hard for. — Jon ANDERSON References 1. Reason, James. 1990. Human Error. Cambridge, UK: Cambridge University Press 2 Vlasov, S. N; Merkin, Y. Y; and Makovaky, L, V. 1997. Accident and emergency situations during the construction and operation of transportation and subway tunnels. (In Russian). Moscow: Russian Tunnelling Association 8. Committee on Safety and Health at Work (Robens Committee) 1972. Safety and Health at Work, London: HM Stationery Office 4. Buropean Council Directive of 12 June 1989 (89/39/EEC), 1989. On the introduction of measures to encourage improvements in the safety and health of workers at work 5. United Kingdom Atomic Energy Authority. 1987. Chernobyl and its consequences. London: UKAEA. 6, International Atomic Energy Agency, International Safety Advisory Group. 1991. Safety Culture. Vienna. 7. UK Advisory Committee on the Safety of Nuclear Installations, Human Factors Study Group. 1999. Organising for safety. Sudbury, Suffolk, UK: HSE Books. 8. Geller, B. Scott. 1996. The Prychology of Safety. Radnor, Pa, USA: Clinton Book Company, 9. International Conference on Safety Culture in the Energy Industries, 1997, University of Aberdeen, Scotland (organised ty Rneray Logitics International Lt, Cookham, Berks, 10, Health and Safety Executive. 1997. Health and Safety Climate Survey Tool. Sudbury, Suffolk, UK: HSE Books, 11. James Reason. 1997. Managing the riske of organisational accidents. Aldershot, UK: Ashgate Publishing Led. 12, Lawrence, A.C. 1974, Human error a8 a cause of accidents ingold mining. Journal of Safety Research 6:2(June), 18-88, Janinger,K. 1982. Accident black-spots associated with the ‘New Austrian Tunnelling Method’. In Tiefbau (2/1982) 14, Health and Safety Executive, 1996, Safety of New Austrian ‘Tunnelling Method tunnels. Sudbury, Suffolk, UK: HSE Books, 15, Anderson, J. M. and Lance, G. A. 1997. Necessity ofa risk. based approach to the planning, design and construction of NATM ‘tunnels in urban situations, In Proceedings of ‘Tunnelling 97° (London), 381-340, London: Institution of Mining and Metallurgy. 16. Health and Safety Executive. 1996, The Channel Tunnel — Aspects of health and sofety during construction. Sudbury, ‘Suffolk, UK: HSE Books, 1s. ‘TUNNELING AND UNDERGROUND Space TecHNOLOGY 215