Aviation: National Transportation Safety Board and Organizational Culture Essay

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The Role of Organizational Culture, Safety Culture, and Safety Climate in Aviation and Aerospace Safety

Robert L. Sumwalt




The lack of organizational focus on safety has been a factor in several accidents in the aviation and aerospace industry, as well as other socio-technical industries such as the nuclear power industry, oil and gas drilling and refining, and other transportation modes. Although accidents in these industries may have different physical causes, the root cause of many these accidents are often related to organizational factors. Safety climate provides a snapshot of employee perceptions of an organization’s safety focus, or the lack thereof, and can be a valuable predictor of safety culture. Striving for a safety culture is a continuous journey that involves nine milestones along the way.



In the early morning hours of February 1, 2003, Space Shuttle Columbia disintegrated over the skies of the southwestern United States while re-entering the earth’s atmosphere. The lives of all seven astronauts were lost. Many will recall that leading to the accident was foam that dislodged and struck Columbia during launch, which damaged critical heat tiles. However, the
Columbia Accident Investigation Board (CAIB), the Board appointed by President George W.
Bush to investigate the accident, found that “NASA’s organizational culture and structure had as much to do with this accident as the External Tank foam (CAIB, 2003, p. 177).
This was not the first fatal space shuttle accident experienced by NASA that involved organizational issues. Sixteen years earlier, Space Shuttle Challenger exploded shortly after launch. As in the Columbia accident where many will remember the technical problem - in
Challenger’s case it was O-rings that failed, allowing hot gasses to penetrate the solid rocket boosters and explode – the Challenger accident also involved organizational issues. “Economic strain on the organization together with safety rule violations suggested that production pressures caused managers to suppress information about O-ring hazards, knowingly violated safety regulations in order to stick to the launch schedule” (Vaughan, 1997, p. xii). von Thaden, Wiegmann, and Shappell (2006) identified 70 organization cause factors in
60 aviation accidents they examined. Organizational factors been implicated in accidents in other socio-technical industries, as well. For example, the U.S. Chemical Safety and Hazard
Investigation Board (CSB) determined that a 2005 oil refinery explosion that claimed 15 lives and injured 180 was an “organizational accident” (CSB, 2007). The International Atomic Energy
Agency (IAEA) stated the Chernobyl nuclear power plant meltdown “flowed from a deficient safety culture, not only at the Chernobyl plant, but throughout the Soviet design, operating, and regulatory organizations for nuclear power” (International Atomic Energy Agency, 1992, pp. 23-



24). The National Transportation Safety Board (NTSB) classified the 2010 Pacific Gas and
Electric Company gas pipeline explosion in San Bruno, CA, as an organizational accident
(NTSB, 2011). That accident that claimed eight lives, destroyed 38 houses, damaged 80 additional houses (NTSB, 2011). NTSB (2010) also found organizational issues to be causal in the 2009 multi-fatality subway accident in Washington, DC. The NTSB’s report of that accident stated “the NTSB has on a number of occasions recognized the lack of an organizational culture of safety within a transportation agency as having contributed to an accident” (NTSB, 2010, p.
The purpose of this paper is to examine how organizational factors can influence safety – either in a positive or negative fashion and discuss ways that organizational influence can be used to increase safety in the