Preoccupation with Failure: The Foundation of a safe culture

This report summarises the findings of a recent organisational review conducted by safety consultant Edmund Wilson, with a specific focus on Near Miss Incidents categorised under Process Integrity. The review, involving a major oil and gas organisation, identifies the need for a cultural shift toward proactive safety management and highlights critical insights into incident causation, reporting methodology, and future improvements.

Introduction

“If we are to become a safe culture, we should be preoccupied with the possibility of failure and work continuously to become more resistant to operational hazards. We should strive to be a safe and informed culture knowing where the edge is without having to fall over it.”

— Edmund Wilson

This statement underpins the review’s guiding philosophy: safety should not rely solely on reacting to incidents after they occur. Instead, it should centre on anticipating and preventing failures before they manifest.

Scope of Review

The organisational review analysed 1,032 recorded incidents over the designated period, with a focus on those classified under Process Integrity. These particular incidents accounted for 220 cases, representing 30% of the overall Incident Severity Risk.

(Incident Severity Risk Pie Chart Not Included in the report, this is detailed in Monthly Review reporting)

Key Findings

1. Timely Response, But Limited Prevention

The review found that while most incidents were managed appropriately, this response was largely reactive. The interventions addressed the outcomes but did not guarantee the prevention of similar future events. A shift toward proactive safety strategies is necessary.

“The organisation was sliding over the edge. It now has the opportunity to pull itself back and take all necessary measures to become more proactive,”

2. Reliability of Methodology

The Incident Severity Rating Methodology used by the organisation is consistent with industry standards and has been validated across major corporations:

• It is based on a recognised formula for determining risk potential.

• A multi-disciplinary committee, including an independent external consultant, reviews and rates incidents.

• The process, while subjective, is deemed comparatively fair and reliable.

“We must trust the integrity of the committee to render a fair Incident Severity Rating.”

Lessons from High Reliability Organisations (HROs)

High Reliability Organisations (HROs) offer a powerful framework for improving safety culture. These organisations—such as air traffic control or nuclear power plants—operate in high-risk environments but maintain exceptionally low incident rates.

Key HRO Principles (Weick & Sutcliffe, 2007):

• Preoccupation with failure

• Reluctance to simplify interpretations

• Sensitivity to operations

• Commitment to resilience

• Deference to expertise

“Even the absence of errors is viewed suspiciously, because it may mean we are not detecting errors that are actually occurring.”

— Weick & Sutcliffe, 2007

Organisations that do not foster this vigilance risk normalising deviance, where deviations from safety norms become routine—often cited in high-profile failures like the Challenger disaster (Vaughan, 1996).

Recommendations

To enhance safety culture and prevent future incidents, the following proactive strategies are recommended:

1. Enhance Near Miss Reporting Systems

•  Foster open, no-blame reporting environments.

2. Establish Cross-Functional Analysis Teams

• Ensure diverse perspectives in incident investigations.

3. Leverage Predictive Analytics

• Use data to identify early indicators of risk.

4. Foster a Learning Culture

• Conduct post-incident reviews and knowledge-sharing sessions.

5. Promote Psychological Safety

• Encourage team members to voice concerns without fear.

“A safe culture is an informed culture. One that is preoccupied with failure, resists oversimplification, remains sensitive to operations, is committed to resilience, and defers to expertise.”

— Reason, 1997

Conclusion

The findings of this review signal a critical opportunity for the organisation to reinforce a safety-first culture grounded in proactivity, vigilance, and continuous learning. Moving forward, prioritising preoccupation with failure is not merely best practice—it is essential.

References

• Reason, J. (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing.

• Vaughan, D. (1996). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University of Chicago Press.

• Weick, K. E., & Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. John Wiley & Sons