Author: Jeanne Paul, Safety Management Specialist


Image: 34th Anniversary of the Piper Alpha Disaster - Learning Lessons from the Past




6th July 2022 marks the 34th anniversary of the Piper Alpha accident and it remains a tragic but timely reminder that there is no place for complacency in safety. We owe it to all those who have been affected, by this terrible disaster and other tragic organisational accidents over the years, to honour them by genuinely learning lessons from the past. Now more than ever, traditional ways of managing the hazards and risks that threaten safety and the effectiveness of organisations’ Safety Management Systems (SMS) should be challenged robustly.

It does not take a safety professional to see that, in the aftermath of a global pandemic, the breeding ground for unforeseen, unfamiliar, unpredictable hazards is rife. Hazards are like loose threads in a safety fabric that has, until now, reliably held an organisation together for years; threads which are continuously being pulled one-by-one to the point where that once tightly knit fabric may be on the brink of tearing. If only we knew the extent of the latent damage and which thread would cause the whole safety net to unravel.

We are now in a previously unchartered post COVID era, compounded by Brexit and the Russian invasion of the Ukraine, and so conditions are favourable for the holes in James Reason’s ‘Swiss Cheese Model’ to almost magnetically align triggering the next headline organisational accident. Can an organisation that has made it safely through today necessarily guarantee, or be justifiably confident, of being safe tomorrow? Would your organisation’s SMS provide you with the legal accountability to defend yourself in a court of law after an accident? The unnerving reality is that any safety-critical industry could be in the cross-hairs of the next big organisational accident: aviation, nuclear, oil and gas, rail, space, marine, medical – the list goes on. What does it take in today’s volatile political, social and economic climate to be able to manage safety effectively and protect your organisation against the unthinkable?

As the world evolves to cope with life post COVID, surely in the spirit of continuous improvement and the very essence of an SMS - it is time to consciously advance safety management. Advanced, more perceptive people-centred, proactive and performance-based safety management is more resource efficient, financially viable, helps inform better decisions and drives the right behaviours across an organisation.

Nine years ago, to mark the 25th anniversary of Piper Alpha, The Hon. Sir Charles Haddon-Cave delivered a speech at the ‘PIPER 25’ Oil & Gas Conference in Aberdeen entitled: ‘Leadership & Culture, Principles & Professionalism, Simplicity & Safety – Lessons from The Nimrod Review’. Haddon-Cave conducted a 2 year inquiry (2007-2009) at the request of the Secretary of State for Defence after RAF Nimrod XV230 suffered a catastrophic mid-air fire whilst on a routine mission over Helmand Province in Afghanistan on 2 September 2006. This led to the total loss of the aircraft and the death of 14 service personnel on board. It was the biggest single loss of life of British service personnel in one incident since the Falkland Islands.

During his speech, Haddon-Cave makes the very poignant observation that Nimrods were circling over Piper Alpha on the fateful day of the disaster, helping to co-ordinate the rescue mission.

In The Nimrod Review, Haddon-Cave looked carefully at the underlying organisational causes and found a fundamental failure of Leadership, Culture and Priorities. The findings echoed those of numerous other catastrophic accidents over the past few decades; in particular, Haddon-Cave found 12 uncanny, and worrying, parallels between the organisational causes of the loss of XV230 and the loss of the NASA Space Shuttle ‘Columbia’.

If current Safety Management System models are ‘doing what they say on the tin’ then why do organisational accidents keep recurring?

It is time to stop nodding sagely after the event lamenting the old adage that ‘There are no new accidents’. Such hindsight bias is unhelpful to those affected by the accident; the question we should be asking is ‘Why are those lessons not actually being learnt?’ Worse still, instead of ‘lessons learnt’, they are often referred to as ‘lessons identified’ almost in anticipation of a lack of learning! So how do we prevent a similar accident, with uncannily similar organisational causal and contributing factors, from happening again… And again… And again? To answer this question, we need to first look at the definition of an SMS and the traditional framework currently being employed by organisations worldwide; then ask the all-important question ‘Why?’ in order to propose improvements aimed at managing safety in a much more people-centred, proactive, resource efficient and cost-effective way.

One of the best definitions of an SMS, albeit not the most recent, is Transport Canada’s TP 13739 E (04/2001):

‘A safety management system is a business-like approach to safety. It is a systematic, explicit and comprehensive process for managing safety risks. As with all management systems, a safety management system provides for goal setting, planning, and measuring performance. A safety management system is woven into the fabric of an organization. It becomes part of the culture, the way people do their jobs.’

Most traditional SMS in use today are versions of the International Civil Aviation Organisation (ICAO) ‘4-Pillar’ SMS framework comprising 12 elements under 4 main components:

• Safety Policy and Objectives • Safety Risk Management • Safety Assurance • Safety Promotion

Based on my background, ex-RAF engineer and aviation safety consultant with both military and civil experience, I believe there are 4 key areas where this traditional ICAO SMS framework could be significantly enhanced by focussing on:

1. Innovating Safety Leadership and Safety Culture

Understanding the people at the heart of managing safety

2. Developing a Safety Vision & Strategy

Advancing a smarter business-like approach to improve cost-effectiveness

3. Asking the right Safety Key Performance Questions (SKPQs)

Creating a more accurate risk picture to prioritise resources

4. Adopting a Kaizen closed-loop approach

Perpetuating a cyclical process to continuously learn and then improve

Key Safety Management Principles

In the ‘PIPER 25’ speech, Charles Haddon-Cave QC highlights 4 principles from The Nimrod Review which he regarded as a paradigm of importance: Leadership, Independence, People (not just Process and Paper) and Simplicity (LIPS):

Principle of Leadership: There must be strong leadership from the very top, demanding and demonstrating by example active and constant commitment to safety and risk management as overriding priorities.

Principle of Independence: There must be thorough independence throughout the regulatory regime, in particular, in the setting of safety and risk policy, regulation, auditing and enforcement.

Principle of People: There must be much greater focus on people in the delivery of high standards of Safety and Airworthiness (and not just on Process and Paper).

Principle of Simplicity: Regulatory structures, processes and rules must be as simple and straightforward as possible so that everyone can understand them.

Haddon-Cave summarises the LIPS Principles with a quote from E.F. Schumacher:

‘Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius – and a lot of courage – to move in the opposite direction.’

Whilst these LIPS Principles are inherently assumed within the ICAO ‘4-Pillar’ SMS framework, because of their subjective seemingly intangible nature, they do not receive the attention they deserve. In general, Leadership, Independence, People and Simplicity are not treated in the same way as other safety hazards in terms of being identified, assessed, mitigated and controlled. There is a tendency - a human factor – which makes us far more comfortable dealing with quantitative safety data and technical issues rather than addressing the qualitative ‘big hitters’ that invariably make the headlines of every organisational accident that has occurred over the past few decades; fundamental failures of Leadership, Culture and Priorities.

People: Leadership and Culture

Why do we need greater focus on: ‘Innovating Safety Leadership and Safety Culture – Understanding the people at the heart of managing safety’?

The importance of engendering an engaged Safety Culture is set in stone in the annals of Safety Management 101 but is rarely achieved to the extent that we should really be aspiring to:

‘If you are convinced your organisation has a good safety culture, you are almost certainly mistaken. Like a state of grace, a safety culture is something that is striven for but rarely attained. As in religion, the [journey] is more important than the product. The virtue – and the reward – lies in the struggle rather than the outcome.’

- James Reason, 1997

People are at the heart of an organisation’s Safety Culture and therefore, people should be at the core of its SMS. Currently the Leadership and People LIPS Principles are inherently assumed, like undercurrents ebbing beneath the surface of the ‘4-Pillars’ ICAO SMS framework. To robustly challenge this traditional framework, there is no doubt in my mind that people and the effectiveness of human performance should be at the very heart of an SMS where they rightfully belong – pumping the lifeblood of Safety Leadership and Safety Culture around the organisation.

‘Culture is the product of people’s choices. Some people are more influential than others but everyone makes a difference. People make choices. Choices make culture.’

- John Amaechi OBE

Safety Leadership drives the organisation’s Safety Culture but every single person within that organisation makes a difference. Leadership and Culture go hand in hand and whenever I’ve been asked to evaluate an organisation’s Safety Culture ‘failings’, the root cause goes straight back to a leadership issue.

A Business-like Approach

Why do we need to consider: ‘Developing a Safety Vision & Strategy – Advancing a smarter business-like approach to improve cost-effectiveness’?

Transport Canada’s definition of an SMS talks about ‘a business-like approach to safety’ and yet, where most organisations have a future vision and a business strategy describing how they intend to achieve their vision, there is no equivalent Safety-specific Vision & Strategy to align strategic safety objectives with the organisation’s overall business objectives.

James Reason’s Safety Space diagram conceptually describes a safe passage; the aim of any safety-critical organisation is to successfully navigate along its chosen path through the green Safety Space. Essentially, the more effective the SMS is, the easier and clearer it is to plot a chosen route. In practice, the route or routes might be different depending on what the organisation or different parts of the organisation do. For example:

(1) If you were a training organisation, you might want to keep well into the safe green zone to allow for a considerable margin of error away from the red catastrophe zone. The price for plotting a ‘cautious’ route is that the path is lined with resource-heavy protective defences and is therefore less efficient.

(2) If you were on military operations, you may want to navigate along a lower path very close to the red catastrophe zone by stripping back any extra defences for a short period of time - a riskier choice but more efficient.

These 2 illustrative examples are extreme paths running right along the edges of the 2 red zones ineffectiveness and catastrophe. The point is that to choose and judiciously navigate a desired path, you need an extremely effective SMS to know where you are and keep you on course in the safe green zone. The absence of an accident or near miss means that an organisation is anywhere outside the catastrophe red triangle… But where? Where is it heading? And where will it be tomorrow?

Setting the Safety Vision and Strategy

To adopt a business-like approach to managing safety, it is essential to have a Safety-specific Vision. A Safety Vision is about your safety goals for the future and how you will get there; a clear understanding of what success looks like at a point in the future (eg 5-10 years’ time) based on your safety goals, aspirations and resources.

A Safety Vision‘Point B’ on Reason’s diagram - will define a clear focus to stop wasteful meandering along the Safety Space or, worse still, heading in the wrong direction. It can unite, motivate, innovate, strengthen and empower an organisation to choose its own unique safety path through the green Safety Space and set its own bespoke compass direction to navigate the route. Just as the navigation routes may vary through the green Safety Space, Point B might be different for different parts of the organisation eg Point B’ and Point B’’ on the diagram.

It is important to remember that a Safety Vision is not the same as a promotional slogan like ‘Safety is our number 1 priority’ or ‘Safety is no accident’; a Safety Vision should be concise, clear, have a time horizon, be future-orientated, stable, challenging, abstract and inspiring.

The path you choose to navigate through the green Safety Space is your Safety Strategy ie the roadmap from Point A to Point B.

Strategic safety goals and objectives provide milestones or beacons along the way to ensure you are staying on course and are aligned with your target Safety Vision. Pioneering organisations with advanced SMS are already embracing the concept of treating safety management comparably to financial management. Hence the importance of having a Safety-specific Vision and a Safety Strategy which are deliberately separate and accountable in their own right but seamlessly align with your overall organisational vision, financial plan, core values and culture.

Asking the Right Questions and Measuring Performance

Why do we need greater focus on: ‘Asking the right Safety Key Performance Questions (SKPQs) – Creating a more accurate risk picture to prioritise resources’?

SMS assessments in both civil and military aviation, have repeatedly found that even organisations which had comprehensive Safety Management Plans with sophisticated and impressive Safety Risk Management (SRM) processes and analytical tools did not necessarily manage safety effectively. In fact, organisations like this are often seeking expert help because they had recently experienced a significant safety incident and/or narrowly avoided a major accident and could not understand why their SMS was ‘letting them down’. The problem is that in order to manage risk effectively, first and foremost you need to base safety risk management decisions on an accurate risk picture, otherwise you are wasting your time; quite simply, you can’t manage what you can’t see.

To create an accurate risk picture, you need to look at your SMS holistically, not just in silos or pillars – especially when there is a tendency to rely heavily on the Safety Risk Management (SRM) pillar in the traditional ICAO ‘4-Pillar’ SMS framework. As the holistic effectiveness of an SMS increases, the pixels increase and create a risk picture with sharper focus. Enhancing the quality of the risk picture is enabled by asking the right Safety Key Performance Questions (SKPQs) and then developing relevant Safety Key Performance Indicators (SKPIs) to answer them and move forward.

To illustrate this point, this is a typical bar chart used by many aviation organisations to demonstrate the effectiveness of their Human Factors (HF) Training:

What does this graph actually tell you about the effectiveness of the organisation’s HF training and how does this impact its overall safety performance? Without context, this type of quantitative data is meaningless. The real SKPQ that should be asked is ‘How effective is the HF training - and does it improve safety behaviour in the workplace?’ The answer to this question requires a combination of quantitative and qualitative information to answer properly.

Incident reports are another very common Safety Performance Indicator (SPI) generating copious amounts of work for organisations – often snowballing into a well-intentioned but misguided cottage industry of data collection, over-analysis and graphical interpretation categorized by complex taxonomies and ‘ages of reporting’. Unfortunately it is human nature to collect data which is easy to count and measure then place too much faith in what that data is actually telling you without retaining the all-important context; this phenomenon is described by Marr (2013) as ‘ICE’:

If it is human nature to fall into the ‘ICE’ trap, how do we focus on measuring the things that are really important, even if they seem to be difficult to measure, and how do we retain that all-important context? What I recommend is: start by asking the right questions (SKPQs) instead of coming up with data-driven SPIs which persuasively lure you into the ‘ICE’ trap! Ask yourself what you really want to know – then, and only then - do you come up with a performance indicator that answers your question. It’s only when you have an accurate risk picture, that you can manage your unique set of risks in a professional, competent way, supported by all the other elements of an effective holistic SMS. Ultimately, developing a true and accurate risk picture enables you to: make well-informed risk-based decisions; prioritise limited resources by focusing on what really matters; and avoid chasing ghosts arising from seemingly state-of-the art but all too often over-complicated risk management processes.

Continuously Learning and Improving

Why do we need to consider: ‘Adopting a Kaizen closed-loop approach – Perpetuating a cyclical process to continuously learn and improve’?

Kaizen is a term that refers to on-going or continuous improvement. The definition of kaizen comes from two Japanese words: ‘kai’ meaning ‘change’ and ‘zen’ meaning ‘good’. The Japanese philosophy was first introduced by Toyota back in the 1980s and has since been adopted by thousands of companies around the globe. This lean transformation encourages an improvement culture that gradually increases quality, efficiency, and profitability:

‘KAIZEN™ means improvement. Moreover, it means continuing improvement in personal life, home life, social life, and working life. When applied to the workplace KAIZEN™ means continuing improvement involving everyone – managers and workers alike.’

- Masaaki Imai, Founder of Kaizen Institute

The kaizen concept posits that there is no perfect end and that everything can be improved upon. People must strive to evolve and innovate constantly. The basic principle of kaizen is that people who perform certain tasks and activities are the most knowledgeable about that task/activity; including them to effect change is the best strategy for improvement. Progress in safety management, particularly engendering an engaged Safety Culture, does not happen overnight or in a single year or even in 5 years; it is a process of deliberate, patient, continual refinements. It is the very essence of a kaizen approach.

Michael Crichton illustrated the meaning of kaizen very neatly in his novel Rising Sun:

‘Americans are always looking for the quantum leap, the big advance forward. Americans try to hit a home run – to knock it out of the park – and then sit back.

The Japanese just hit singles all day long, and they never sit back.’

Whilst the aim of an effective SMS is to continually improve safety performance, the ‘4-Pillar’ somewhat stove-piped set up of today’s ICAO SMS framework does not naturally lend itself to a closed-loop, continuous improvement process. In contrast, the Shewhart Cycle (Plan-Do-Study-Act) does reflect the closed-loop, continual, iterative and cyclical nature of safety management. The Shewhart Cycle reinforces the underlying assumption that safety performance improvement requires a kaizen approach. The implication is that the end state is virtual, that is it needs constant, unrelenting effort to perpetually strive for; a concept echoed in James Reason’s earlier description of Safety Culture: ‘As in religion, the [journey] is more important than the product. The virtue – and the reward – lies in the struggle rather than the outcome.’

Often when an organisation feels that their SMS has ‘let them down’ it is because they are not completing the continuous improvement cycle - closing the loop. This is a vital step in any cyclical improvement process to ensure that lessons identified are actively turned into lessons learnt. To keep advancing by continual refinement in a Plan-Do-Study-Act Shewhart Cycle takes unrelenting energy, effort, absolute commitment and time: The Japanese just hit singles all day long, and they never sit back.’

What is ASPECT®? And WHY could it help you?

ASPECT® is an advanced pioneering approach to achieving cost-effective, resource efficient and simple safety management by enhancing the focus on:

1. Innovating Safety Leadership and Safety Culture

Understanding the people at the heart of managing safety

2. Developing a Safety Vision & Strategy

Advancing a smarter business-like approach to improve cost-effectiveness

3. Asking the right Safety Key Performance Questions (SKPQs)

Creating a more accurate risk picture to prioritise resources

4. Adopting a Kaizen closed-loop approach

Perpetuating a cyclical process to continuously learn and improve

ASPECT® is an advanced people-centred performance-based SMS framework and evaluation tool innovatively designed to:

  • Invest in people to create an engaged Safety Culture at the heart of enhancing organisational safety performance
    • Enable the Accountable Executive to be truly accountable and optimise return on investment in managing safety by:
      • Creating a Safety Vision & Strategy specifically for managing safety strategically in a complex dynamic environment
      • Enabling clear ownership, leadership and investment in safety management in a proactive resource-efficient way
      • Creating a more accurate risk picture for managing safety risk to deliver cost-effective prioritisation of resources
      • Offering a valuable opportunity to set people up for success in a resourceful, proficient and pioneering way
    • Provide an unabiased and independent performance-based perspective on SMS effectiveness across ASPECT’S 10 core elements and 50 sub-elements
    • Avoid outsourcing by enabling organisations to organically develop and continuously improve their own bespoke SMS

    By answering a simple set of Safety Key Performance Questions (SKPQs), the ASPECT® software provides a comprehensive written report across each of the 10 core elements (each sub-divided into 5 sub-elements) or whatever combination of elements you wish to evaluate. In addition, a bar chart of results is available to help you determine the holistic effectiveness of your SMS and identify shortfalls. This enables organisations to prioritise different aspects of their SMS depending on their bespoke safety targets and objectives; the areas that you want to prioritise and improve. Repeating the evaluation process against the same scale enables you to benchmark your starting point, Point A, and then keep measuring progress (including return on investment) against your key strategic safety milestones on the roadmap to your Safety Vision, Point B.



    And finally, to close the loop on the 34th anniversary of Piper Alpha, it is time not only to reflect but also to act - to truly honour all those affected by such a terrible disaster. People are - and always will be - at the heart of managing safety effectively:

    ‘People make choices. Choices make culture.

    What are the choices that you made today? And what choices will you make tomorrow?

    The answers to those questions matter. Don’t kid yourself to believe they don’t.’

    - John Amaechi OBE

    So today, what choices will you make to challenge the way you have always managed safety? How will you advance safety management in your organisation today, tomorrow and continually every day to proactively learn the painful lessons of the past?

    Musketeer are here to help...

    Need some advice on our services or products call us on 01733 391495 or email us

    Our accreditations