Recognition of management’s role in systemic failure
Dr. Deming, our well-known quality guru cited frequently in this text, estimated that 85 percent of quality problems are created by management. He professed that the vast majority of behavior and performance comes from the system, not the individual. So, if we want to change our circumstances, we must change the system, not the worker. Who controls the system? Management! Managers must recognize that the system is the culprit, and that they alone can change the system.
As discussed earlier in Chapter 1, aviation accident investigations in the past were characterized by ﬁnding the cause and blaming the individual(s) involved, usually the pilot. Of course, we now know that this long-standing but misguided approach to improving safety had multiple deleterious consequences, including discouraging individuals in the system from reporting anything for which they might be subject to blame, and failure to improve the system in which the event occurred.
Management plays a vital role in establishing a safety ethos. Safety culture is discussed throughout this book,
Management is vested with the authority and responsibility for managing safety risks in the company. This is best accomplished through a robust quality management-based risk management system. Management controls the resources, so it is management’s job to ensure that the safety function has what it needs in terms of personnel, expertise, funding, time, and organizational support to satisfy its vital function.