Essay

Safety Management

Buildin ureur©

Three Practical Strategies By Earl H. Blair

The topic of safety culture hasreceived much attention, and forgood reason. Research and ex- perience demonstrate that the level of safety performance an organization can achieve is dictated by its culture. Peter- sen (2001) sums it up succinctly, "The culture of the organization sets the tone for everything in safety" (p. 123). Safety culture is an important subculture stem- ming from an organization's set of prac- tices and underlying assumptions.

Cultural Contributions to Disasters In the few decades, several spectacu-

lar and tragic events have occurred, fol- lowed by thorough investigations made available to the public. From these de- tailed reports, it has been recognized that organizafional culture and the resulting safety culture are often implicated as pri- mary causes in these incidents.

For example, the explosion of the space shuttle Challenger in 1986 demonstrated

Ijrl H. Blair, Ed.D., CSI', is an associate professor and director of the graduate safety management program at Indiana University, Bloom-

s' lngton. Blair is a former chair of the Department of Safety, Health and Environmental Health Sciences at Indiana State University, Terre

that even a sfafe-of-the-art organization had cultural is- sues that affected safety perfor- mance. The term safety culture had been recently coined, and the investigation revealed com- munication issues at NASA, including a top-down, com- mand-and-control culture that inhibited both engineers from communicating up the line and upper management from lis- tening to communication from lower levels in the organization.

The BP Texas City refinery explosion in 2005 was also thoroughly investigated. Hop- kins (2008) describes in detail the cultural issues that contrib- uted to the tragedy. It is possible that decisions made at the top levels of BP contributed more fo the explosion than did the proximal causes at the Texas City site. Furthermore, organizations appear

Haute. Before joining academia, Blair was a safety professional work- ing in the pharmaceutical, peti'oleum and chemical industries. He is a professional member of ASSE's Central Indiana Chapter.

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IN BRIEF •This article discusses practical strategies to de- velop safety culture, includ- ing short case examples to illustrate key points. «Focus is given to the most important actions leader- ship can take to build a safety culture. •Practical methods are provided to gain leadership support and enahle organi- zations to establish systems to enhance and sustain the safety culture. j

to have some difficultly learning from the past (e.g., BP's Deepwater Horizon explosion in 2010). A learn- ing culture is desirable for enhancing safety perfor- mance and prevenfing injuries.

The strategies for building safety culture are rel- atively simple. However, one should not confuse simple with easy. This analogy helps illustrate the distincfion: For overweight individuals, the con- cepts for losing weight are simple: use more calo- ries than you consume. However, the experience of many illustrates this is not necessarily easy to accomplish. Many distracters, variables and com- plexities make weight loss challenging for many people. Likewise, it can be challenging, yet worth- while, for an organization to systemafically devel- op its safety culture.

Three Practical Strategies for Building Safety Culture Strategy 1: Work Toward Being a 100% Reporting Culture

One reason organi- zations do not experi- ence higher numbers of reports on minor injuries and near-hits is that employees fear

subsequent blame and punishment. It is human nature to avoid being blamed and to try to stay out of trouble. For injury prevention, a reporfing culture should be more highly valued than a pun- ishing culture that is quick to administer discipline. Traditionally, many organizations have focused on reacfive discipline rather than on strategies and techniques to increase accurate reporting.

Disciplinary procedures are an example of why it is not easy to build a safety culture. Emphasiz- ing discipline over reporfing may not contribute to a better safety culture, since this focus may cause many incidents to go unreported. Underreporting may improve the safety record, but it does not con- tribute to a stronger safety culture.

Employees may also hesitate to report near-hits and minor injuries because of the extra time, work and perceived red tape involved. People tend to avoid extra work, especially if employees are not sold on the value of reporting for safety. If an or- ganization does not follow through and respond rapidly to reports, it devalues reporting. Thus, if an organization values reporting, it should establish and use a system that encourages reporting and appropriate follow-through.

Slogans such as "All injuries are preventable" create a major obstacle to employee reporfing. As Geller (2001) suggests, humans cannot be expected to be error-free. Consider these 12 additional rea- sons to avoid this slogan:

1) The focus is downstream (injuries). 2) It does not prescribe how to improve the safe-

ty process. 3) It can be a feel-good statement for manage-

ment. 4) M a n y employees do n o t believe it.

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5) It can make people who report minor injuries feel bad for being an exception to this "infallible truth."

6) It can lead to underreporting or even nonre- porting of injuries.

7) It may result in injury management instead of safety management.

8) It may provide a false image of a site's safety performance.

9) It can reduce risk percepfions. 10) It can hurt morale. 11) It may reduce employee efforts for safety

since perfection is outside their control. 12) In most cases, it probably is not achievable

over fime. A disfinction must be made between believing

that all injuries are preventable and repeating it as a slogan. It is acceptable to hold the belief that all injuries are preventable. If the belief inspires management's vision to strive for optimal perfor- mance, then it could influence positive results. Op- fimal performance and perfecfion are not the same thing. Since few employees believe the slogan, and perhaps many in management do not believe it ei- ther, the slogan becomes counterproductive.

Four factors encourage a reporting culture: 1) Indemnity: security against disciplinary acfion

as far as practical. 2) Confidentiality: deidenfification on incident

reports. 3) Ease of reporting: user friendly and limited red

tape. 4) Rapid feedback: follow-up and practical, mean-

ingful feedback to all concerned (Reason, 1997). If employees underreport or do not report inci-

dents, an organizafion may be unaware of many exposures and risks that exist. Integrity in report- ing allows an organization to solve the issues and be proactive in preventing future exposures and related injuries.

Strategy 2: Develop Safety Awareness With Meaningful Safety Rules

Hopkins (2005) re- lays the story of a train wreck that occurred near the Glenbrook Station in New South Wales (NSW) Australia

in 1999. Just beyond the station, the Indian Pacific train was stopped. A city commuter train com- ing through the station ran a red light and did not know the Indian Pacific was stopped just around the bend ahead. The commuter train slammed into the stopped train, killing seven passengers.

As with most tragic incidents, the investigation uncovered multiple causes and influences. Most immediately prior to the incident, investigators discovered casual and poor communicafion be- tween the driver and the signaler.

Several cultural deficiencies also allowed the tragedy to occur. Hopkins (2005) lists five cultures

fhat permeated NSW Railways and influenced the incident;

1) a culture of rules; 2) a culfure of blame; 3) a culture of silos; 4) a culture of on-time running; 5) a risk-hlind culture. The one positive culture was that of on-time

running. This level of service was a focal poinf and the railway reported a high percentage of success. However, fhe on-time culture was not counterbal- anced by a risk-aware culture.

Interestingly, Hopkins (2005) believes the culture of rules produced several negative outcomes, such as a deadened sense of risk awareness, a sense of employee disempowerment and a culture of blame. This incident is an example of excess regarding safe- ty rules. NSW Railways' rule-focused culture left its employees overwhelmed by eight volumes of rules. As Hopkins states:

This focus on rules tended to deaden awareness of risks. Moreover, when accidents occurred, the aim of accident investigations appeared to be to identify which rules had been violated and by whom. The obsession with rules led to a pronounced tendency to blame, (p. 28)

Specifically, the abundant safety rules presented several problems:

•The organization appeared to hold the illusory reliance on rules as a means of averting incidents, and seemed to believe that a rule could be devel- oped to cover every conceivable risky situation.

•The company had eight volumes of safety rules, and amendments were circulated weekly for recip- ients to update their manuals.

•The sheer volume of safefy rules made them virtually unknowable and impractical in daily use.

•The rules were not written in a user-friendly format. They were written in convoluted, complex language designed to cover all possible risks. Each rule covered several pages and read like a piece of legislafion, or was vague and difficult to interpret (e.g., used phrases such as "use extreme caution").

•Rules were cross-referenced in such a way that even the trainers often did not understand them. In one case, a person had to reference no fewer than 84 rules to select the correct course of acfion.

•The rules were written by people with no prac- tical experience in the topics about which they were writing. Consequently, many rules were to- tally impracticable.

•Based on all of these factors, mosf employees had liftle use for fhe safefy rules. They could see no relafionship between the content of training for safety rules and acfual task performance.

•Because the rules were impracfical, they were rarely enforced either internally or by rail inspectors.

Admittedly, this case study reflects fhe extreme. However, one may recognize symptoms that pre- vent an organization's safety rules from providing optimal impact:

1) Are safety rules used primarily to protect man- agement?

2) Are the rules cumbersome, impractical and not user-friendly?

3) Does fhe organizafion fend to enforce safefy rules mosfly affer someone is injured?

The following suggestions for enhancing safefy rules are based on Reason (1997) and Hopkins (2005; 2008). Safety rules must be:

1) dynamic; 2) developed with input from end users; 3) practical and relevant; 4) effecfively communicafed; 5) monitored and enforced; 6) regularly modified and updafed; 7) confinually improved.

Strategy 3: Ensure That Leaders Under- stand How to Consis- tently Act to Develop Safety Culture

Schein (1992) r e - searched culfure and leadership exfensively and concluded fhat:

Culture and leadership are two sides of the same coin in that leaders first create cultures when they creafe groups and organizations. . . . The bottom-line for leaders is if they do not become conscious of the cultures in which they are im- bedded, those cultures will manage them. Cul- tural understanding is desirable for aii of us, but it is essential to leaders if they are to iead. (p. 15)

Schein (1992) also discusses how leaders embed and transmit culture. He lists six "primary embed- ding mechanisms" that create an organization's climate and six "secondary articulation and rein- forcement mechanisms" (pp. 230-231).

Primary Culture-Embedding Mechanisms 1) what leaders systematically pay attention to,

measure and control; 2) how leaders react to critical incidents and or-

ganizational crises; 3) observed criteria by which leaders allocate

scarce resources; 4) deliberate role modeling, teaching and coach-

ing; 5) observed criteria by which leaders allocate re-

wards and status; 6) observed criteria by which leaders recruit, se-

lect, promote, refire and excommunicate organiza- üonal members.

Secondary Articulation & Reinforcement Mechanisms

1) organization design and structure; 2) organization systems and procedures; 3) organizational rites and rituals; 4) design of physical space, facades and buildings; 5) sfories, legends and myths about people and

events; 6) formal statements of organizational philoso-

phy, values and creed. To develop a safety culture, emphasis should be

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The best way for

leaders to learn what is happen-

ing in the workplace is to walk

around, monitor

and listen.

to Schein's (1992) first primary mechanism: What leaders system-

atically pay attenfion to, measure and con- trol. Since organiza- fional culture and the resulting safety culture are primar- ily inOuenced by the organization's lead-

ers, this strategy is crifical. One responsi-

bility of SH&E profes- sionals is to give counsel

and advice to organiza- fional leaders. While leaders

are often intelligent and well educated, they may not automafi-

cally understand specifically how they can best influence the safety culture. Safety profession- als can give leaders specific information on how to best develop the safety culture.

From 2001 to 2004, a comprehensive study was conducted at Indiana University to cross-validate a safety climate survey (Seo, Torabi, Blair, et al, 2004). Perhaps the most significant finding of the research was that all other factors on the safety cli- mate scale were influenced by two factors: manage- ment commitment and supervisory support. "In terms of practical implicafions, this finding suggests that more emphasis should be made on the role of management commitment and supervisory support among various aspects of accident prevenfion ef- forts, considering their substanfial influence on oth- er dimensions of safety" (Seo, et al., pp. 442-443).

Stewart (2002) states: Management commitment is undoubtediy the foundation of safety. Without it, the rest of the agen- da for exceiience cannot be effective . . . it must be real, sustained, determined and beiievable. It means that the ieaders understand safety, believe in it with a passion, and see that their passion is embedded in the company's cuiture. (p. 185)

Since management commitment is intangible, the issue involves determining the visible mani- festation of management commitment? What behaviors and activifies can be, and should be, measured?

Stewart (2002) notes that safety improvement efforts often do not focus on the most important things. These are not necessarily the physical or system deficiencies that are the easiest to see. Rather, the most important things are the intangi- ble elements that may be difficult to see and mea- sure, such as lack of management commitment, a low level of worker involvement in safety acfivifies and a failure to enforce safety rules.

Leaders must focus on specific behaviors to strengthen safety culture (Blair, 2003). Part of the SH&E professional's role is to influence leaders to take the right acfions that will affect safety per- formance. The key is idenfifying what leader be-

haviors have the greatest impact on the journey to establish a strong safety culture.

How Can Leaders Enhance Safety Culture? Based on Komaki's (1998) leadership research,

two activities that disfinguish effective leaders from mediocre or lackluster leaders are the amount of fime spent monitoring worker performance, partic- ularly via work sampling, and providing all kinds of consequences (posifive, neutral, negative); and lis- tening to employees by providing a milieu that pro- motes construcfive performance-related dialogue.

A few years ago, management by walking around became popular. Perhaps leaders can best accomplish these two activities with leadership by walking around (LBWA). Leaders cannot effective- ly perform these activities from their offices. Also, this is not leadership by wandering around; it is walking around with purpose. That purpose is to enhance the safety culture, to talk with employees about safety, to listen to their concerns and to fol- low up when corrective actions are needed.

Most companies that practice some form of be- havioral safety recognize that they must address behavior at all levels to be effective. Often, employ- ees provide peer safety coaching and feedback to improve safe work on the job.

The behaviors prescribed for leaders and man- agement are more about supporfing the company's safety efforts, since managers generally do not per- form work on the floor or in the field. Therefore, it is often suggested that management develop self- managed checklists for these supporfive behaviors, and that they be measured on achieving the be- haviors as they would be measured for producfion, quality and cost control.

These checklists can be customized to play to the strengths of individual leaders, and can help ensure that they practice LBWA. Consider these examples of high-leverage activifies for leadership:

1) Conduct safety walkarounds that involve a) discussing safety with employees; b) asking how they can help make people safer; and c) focusing on acfively caring for employees (Geller, 2001).

2) Confirm that safety-related corrective actions are closed out, and develop a measurement system to track.

3) Promote and conduct safety coaching. Figure 1 presents an example of a leadership

self-managed checklist. Based on McSween (2003), this checklist illustrates different activities or be- haviors that management can perform to influence safety culture. Keep in mind the checklist is sim- ply a guide and should be customized as needed. Checklist measures should be simple and realistic.

The timefiame for LBWA is contingent on the industry and should be reasonable. For example, 1 to 2 hours per week, or about 5% of a leader's time could be devoted to such an activity. This decision depends on individual context and circumstances. It may take more fime than this to be most effec- tive. Leaders are encouraged to view this as an in- vestment in safety culture rather than as a cost to the organizafion. Paperwork should be minimized

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r Name:

(e.g., if could be added to scorecards if fhe organizafion employs a balanced scorecard approach).

Consider three additional suggestions for using the self-managed checklist:

1) The checklist in Figure 1 is an ex- ample of behaviors that could be select- ed. It is recommended that pinpoints or behaviors be limited to 3 to 5 behaviors instead of 10 (or more).

2) An organization should implement a system to track and confirm that lead- ers are actually performing the safety- related activities they have agreed to perform.

3) Selected behaviors should be tar- geted for a specific dmeframe (e.g., three walkarounds per week). The measure- ment could include a weekly or month- ly ratio of the number of implemented behaviors to the number of expected or planned behaviors.

Leadership by Walking Around: Benefits for Site Leaders

Leaders can reap safety benefits as well as benefits beyond safety perfor- mance when they practice LBWA. For example:

1) They have a concrete opportunity to demonstrate that they care.

2) It will help to ensure that outstand- ing safety challenges are resolved.

3) Employees will see that leaders are genuinely committed to safety since they are demonstrating visible, ongoing sup- port for safety.

4) The practice establishes a hands-on safety ex- ample for supervisors.

5) Employees will develop greater trust in their leaders.

6) Leaders have multiple opportunities to en- force and reinforce the safety process.

7) Leaders will leam what they do not know. Regarding the last point, the best way for leaders

to learn what is happening in the workplace is to walk around, monitor and listen. This is far superi- or to sitting at a computer and reviewing statistics. At a minimum, it reinforces and adds to collected knowledge. Most importantly, it develops the rela- tionship between leaders and field employees.

As noted, the amount of time spent walking around and engaging in dialogue about safety need not be lengthy. Each organization and leader can establish guidelines for their specific situation. Remember, these activities should be viewed as in- vestments in safety, nof as costs.

To keep this in perspective, consider how much a serious injury or poor employee morale costs because leadership has not developed a culture of safety. Leaders must have realistic and effective measures of how they support safety, otherwise they are guilty of short-term thinking that ignores safety culture.

Figure 1

Self-Managed Safety Behavior Checklist

haged Checklist

Date:

Choose 3 to 5 Measures to Focus on

1) Perform safety walkabouts to discuss safety

2) Ensure the closeout of safety-related corrective actions

3) Conduct safety coaching

4) Promote safety coaching

5) Attend safety related training with team

5) Recognize employees for working safely

7) Provide at least one positive safety feedbaci<

8) Review observation data and its importance in safety meetings

9) Actively participate in safety activities

10) Compieted checklist turned in at the end of every work week

Yes No N/A

Leaders who are passionate about improving safety performance should read Roberto's (2010) Know Wliat You Don't Know: How Great Leaders Pre- vent Problems Before They Happen. Safety is all abouf prevention, and Roberto shows with case studies and research that the best leaders do not simply respond to problems, they discern problems before they become big issues. Roberto demonstrates that the best way to discover the symptoms that pro- duce bigger problems is to spend purposeful time on the floor and in the field, walking, monitoring, asking, listening and anficipating issues.

Evaluate Existing Safety Culture Manuele (2008) clarifies a prime way to evaluate

and improve a safety culture. Specifically, Manuele examines cultural implications that may impede ef- fective incident investigations, the quality of which he identifies as an indicator of safety culture.

Siiice I believe that effective incideiit investiga- tion and analysis are vitai to obtaining superior safety results, i continue—with compassion—to encourage safety professionals to undertake improvements in the investigation process. Condoning inadequate incident investigation detines a safety cuiture probiem, one that wili not be easily overcome . . . in some organiza- tions a "blame cuiture" has evolved whereby the focus of their investigations is on individuai

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human error and the corrective action stops at that level. This approach avoids collecting data on and improving the management systems that may have enabled the human error, (p. 344)

In making this case, Manuele (2008) borrows from Whittingham (2004) and illustrates how a culture of fear can arise from the system of expect- ed behavior that management creates.

An electrocution occurred. As required in that organization, the corporate safety director visited the location to expand on the investigation. Dur- ing discussion with the deceased employee's im- mediate supervisor, it became apparent that the supervisor knew of the design shortcomings in the lockout/tagout system, of which there were many at the location. When asked why the design shortcomings were not recorded as causal fac- tors in the investigation report, the supervisor's response was, "Are you crazy? I would get fired if I did that. Correcting all these lockout/tagout problems will cost money and my bcss doesn't want to hear about things like that." (p. 345)

For improvement, Manuele (2008) recommends starting with a self-evaluation of the culture, and he suggests commencing with the first step of the plan-do-check-act process by denning the prob- lem. He suggests starting with a sample of com- pleted investigation reports, and counsels to limit the scope to only those incidents that result in seri- ous injury or illness. Manuele believes that such a study need not be time-consuming since the data already exist.

A safety professional who undertakes such a study should keep in mind that its outcome is to be an analysis of the:

•activities in which serious injuries occur, for which concentrated prevention efforts will be beneficial;

•quality of causal factor determination and corrective action taking;

•culture that has been established over time with respect to good or not so good causal fac- tor determination and corrective action taking;

•organization levels that are to be influenced if improvements are to be made.

From that analysis, a plan of action would be drafted to influence the safety culture, to the ex- tent that is necessary. Thus, the plan of action must be well crafted to convince management of the value of making the changes proposed. . . . It is much easier for me to write all this than it will be for safety professionals to get it done. Chang- es in culture are not easily accomplished. They require considerable time and patience, and may only be achieved in small steps, (pp. 346-347)

Gain & Sustain Management Support Upper management usually says the right words

about safety in company policies and daily rhetoric, but the disconnect for many employees is the be- lief that management does not walk the talk. In fact, in the author's experience, safety perception sur- veys often reveal a discrepancy between how much management thinks it is committed to safety (such

as 90% strongly agree) and how much employees perceive that management is committed to safety (such as 30% agree). Although managers may feel they are personally highly committed to safety, em- ployee perceptions are their reality. If leaders follow the recommendations for walking around, moni- toring, coaching, listening and resolving safety is- sues, then employees will believe that management walks the talk, genuinely cares about them and is committed to safety.

As noted, safety professionals can influence leaders about the things they should do to enhance safety culture. Sometimes, leaders simply do not know what they should be doing regularly to im- pact safety. Based on their own experience, some leaders may believe that a good safety program consists of slogans, posters and incentives.

A primary role of safety professionals is to give advice on how to anticipate, identify and control hazards and exposures. The safety professional is a consultant and the best s/he can do is convince up- per management about the high-leverage activities that should be measured and regularly reviewed. It is effective to emphasize the expected benefits for the organization. SH&E professionals also should seek to spark leaders' passion for safety. Bench- marking performance against other companies or industries that have a strong safety culture is one place to start.

Crafting a Report to Describe Why & How Leadership Builds the Safety Culture

The primary way to gain management support for safety culture is to influence them through commu- nication. Doing so effectively may be a challenge. However, if leaders claim that safety is a value, then they should be willing to listen and act on a safety professional's relevant recommendations.

This communication can consist of a written re- port, face-to-face meetings or both. The report must be clear, concise and succinct, focused on no more than three priorities. Rather than overwhelm participants with a long list of needs, be willing to start small. The SH&E professional might consider developing a presentation that summarizes or illus- trates key points in the written report as well.

Strategically, the safety professional must gain management support and buy-in before such a meeting. This involves identifying the leaders who are the most passionate about safety. Meet with these individuals and describe needs. Having an advocate can go a long way toward ensuring that individuals are assigned safety supportive respon- sibilities and held accountable for follow-through.

The following strategies may be applied to make the communication effort more eftective. Safety professionals can select those strategies that are ap- propriate in their situation (Blair & Spurlock, 2013).

1) Emphasize the organization's legal and ethi- cal responsibilities regarding safety. Most organi- zation leaders will respond to information that can negatively or positively affect company image. The concept of a strong safety culture is becoming more visible and more desirable.

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2) Discuss a tragic event in the industry or a similar in- dustry. As noted, incident in- vesfigations often reveal that basic causes relate to a poor safety culture. Be proactive. One does not want to end up discussing an event that oc- curred in his/her organization due to cultural deficiencies.

3) Develop a sense of ur- gency for safety. Organiza- tions naturally become urgent about safety when a fatality or tragedy occturs, but this is reactive. Safety profession- als add value to their orga- nizations by helping them be proactive and more urgent about taking preventive measures.

4) Speak management's language. Focus on the costs of poor safety management, such as work- ers' compensation costs and indirect costs. Some cost reduction may be accomplished through case management, but a soHd safety management sys- tem that exists in the culture and not just on paper will lead to fewer injuries and lower costs.

Conclusion To successfully implement and sustain efforts

to develop safety culture, each organizafion must customize techniques to accomplish their chosen strategies. A starting point for safety profession- als is to gain upper management support for these strategies. Managers and employees are likely to support the strategies if the safety metrics and key performance indicators are designed to develop the culture and relationships, and to hold people accountable for supporting safety.

Three pracfical strategies to enhance safety cul- ture have been discussed. While a company can take many other acfions to develop safety culture, these are three powerful strategies to consider for enhancing a safety culture:

1) Work toward becoming a 100% reporting cul- ture.

2) Develop safety awareness with meaningful safety rules.

3) Ensure that leaders understand how to de- velop safety culture and consistently act to do so.

Each strategy assumes follow-up to sustain and infuse it in the culture. Even if employees report most incidents, little benefit is derived if proactive measures are not taken to prevent future incidents. Leaders are less likely to pracfice leadership by walking around if the company does not system- atically measure the acfivity.

The concluding question for many readers at this point could be. Would one or more of these strate- gies be more powerful for long-term performance than the current safety strategies being used by the organization? PS

Sustaining the Effort to Build a Safety Culture

1) Establish and maintain a safety Scoreboard focused on leading safety metrics. These are acfivity measures of fhe safety process and the measures of support for safety that build safety culture. Ef- fective scoreboards include trailing measures, are kept current, and are simple to read and understand.

2) Use a risk assessment matrb( to determine priorities for safety acfions and interventions.

3) Design ways to insfitutionalize or systematize these culture development strategies.

4) Consider a system to maintain focus on the important goals, establish accountability and provide regular ongoing dialogue for improvement (FranklinCovey, 2006).

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Roberto, M. (2010). Know what you don't know: How great leaders prevent problems before they happen. Upper Saddle River, NJ: Wharton School of Publishing.

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Seo, D.C., Torabi, M.R., Blair, E.H., et al. (2004). A cross-validation of safety climate scale using confirma- tory factor analytic approach, journal of Safety Research, 35, 427-445.

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Whittingham, R.B. (2004). The blame machine: Why human error causes accidents. New York, NY: Elsevier Butterworth Heinemann.

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