Safety Culture

["J. J. Rozental" <josrozen@netmedia.net.il>]

Dear Radsafers

1 - If we make an analysis about the reasons for most incidents or accident,
there is no doubt that the root is human error.

2 - Why experienced professional, with good historic record, in different
fields of application, suddenly commit very serious incident or accident?

3 - There are doubt about the errors in  TMI and  Chernobyl, were made by
experienced professionals?

4 - The Radiological Accident in Goiania, the most serious radiological
accident to have occurred to date, could never be happened in the  way that
it occurred, since the management of the facility was composed  of
radiotherapists, working with radioactive materials for about 20 years,
who  knew  the  legislation, and included also in the organization, by
norms, a physicist in radiation protection. It  is difficult to understand,
considering their  background, how could they leave,  totally insecure,  the
head  unit of  the Cs-137 source  in  a demolished hospital.

Lack of Safety Culture is the main commun point in all these incidents and
accident -- Why? -- Lack of perception of risk

More we study lessons learned, more we need to implement Safety Culture on
Nuclear Installations. In our area, Safety Culture is the key to human
factor. Why? -- Attitudes toward work 

All of us know what should to be done, as many of you wrote.However, as
mentioned above, more of all accidents with fatalities were due human error.
The great majority made by experienced professional? Why -- Lack of attitude
towards the organization, hierarchy, leadership, procedures and working habits.

The next serious incident or accident also will be due human error. Why? --
Lack of motivation to follow the above "Why"

 SAFETY CULTURE PROBLEM IDENTIFICATION,  SELECTED FROM  ACCIDENT IN THE LAST
DECADE	
  a)  Management: Where radioactive sources are being used or stored in a
site,  even a temporary site, e.g., industrial radiography cameras,
moisture-density gauges, well-logging gauges, brachyteraphy sources, the
organization should have specific control procedures, specially in the event
of an abnormal situation;
 
  b)  Training:	Even if the greatest care is taken, accidents  are sometimes
unavoidable and thus it is absolutely necessary to be well prepared to deal
with any that  may occur; 

  c)Competent Authority: Although a programme of  inspection is very
important,  it is only  effective if it is associated with some kind of
enforcement system, entailing civil or professional liability; 

  d) Human Behavior, the common  factor: A source of failure in the
protection system is often a result of the influence of the so called human
factor. This influence can be minimized by proper training, implementation
of good principles and proper planning and design of equipment and facilities.

Thanks for all the previous statement

Rozental

J.J.Rozental <josrozen@netvision.net.il>
Consultant, Radiation Safety and Regulation
for developing countries