Building a World-Class Safety Culture: The National Ignition Facility and the Control of Human and Organizational Error

Accidents in complex systems send us signals. They may be harbingers of a catastrophe. Some even argue that a ''normal'' consequence of operations in a complex organization may not only be the goods it produces, but also accidents and--inevitably--catastrophes. We would like to tell you the story of a large, complex organization, whose history questions the argument ''that accidents just happen.'' Starting from a less than enviable safety record, the National Ignition Facility (NIF) has accumulated over 2.5 million safe hours. The story of NIF is still unfolding. The facility is still being constructed and commissioned. But the steps NIF has taken in achieving its safety record provide a principled blueprint that may be of value to others. Describing that principled blueprint is the purpose of this paper. The first part of this paper is a case study of NIF and its effort to achieve a world-class safety record. This case study will include a description of (1) NIF's complex systems, (2) NIF's early safety history, (3) factors that may have initiated its safety culture change, and (4) the evolution of its safety blueprint. In the last part of the paper, we will compare NIF's safety culture to what safety industry experts, psychologists, and sociologists say about how to shape a culture and control organizational error