It has to come from within

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It's a question that we all face now and then, in our private lives as well as professionally: how can we achieve safety?

And it's tempting, but rather futile, to come up with replies that essentially translate as ‘by coercion’.

Of course, a few strict rules are a necessity; there must be enforcement in terms of licensing, inspection, and at times penalties for non-compliance. Exasperated young parents, trying to prevent accidents to their small children, may feel that there is no alternative to explicit bans coupled with threats of dire punishment (and, if need be, execution of such punishments).

Unfortunately, this approach is not very efficient, and as the children grow older, all sensible parents will want to instil a sense of personal responsibility in their children's minds, such that safety is the result of the children's own wishes and considerations, not the result of rules set by parents or of fear of punishment. As adults, we avoid illegal and hazardous behaviour, not because there might be a policeman round the corner catching us, but because it actually makes sense to behave safely.

Applying this parable to radiation safety, we can never achieve true safety by having ‘sufficient numbers of inspectors’ or ‘sufficiently severe penalties’ to keep unreliable operators on a short leash. Safety must come from within, from a genuine desire by operators to run a safe operation.

In such a scenario, a primary task of the regulator's is to help licensees by providing as much information as possible about the prevention of accidents. This is one of the important messages in the present publication: an incident reporting system with feedback to operators is vital in order to prevent the recurrence of accidents.

For such a system to work, mutual trust is required. Obviously, regulators need to be able to trust operators. In a sense, that's what licensing is about: operators must prove that they have the knowledge, the organisation, and the resources (including an internal audit mechanism) required to run a safe operation, and the license once issued is an indication of trust from the regulator. But it also has to work the other way around: operators must be able to trust regulators.

One aspect is that all operators need to be sure that the regulator will only award licenses to trustworthy operators - otherwise, serious operators would be unfairly disadvantaged. Another aspect, perhaps less obvious at first sight, is that operators must be confident that the regulator really is there primarily to achieve safety, not to find and punish culprits. This is particularly evident in the case of incident reporting. If the inevitable result of incident reporting is that the operator is punished, then few operators will be willing to come forward with their problems, and in the end safety will suffer for lack of information transfer.

Probably the best proof of this comes from aviation, where there is a long history of incident reporting. In aviation, operators and their staff are trained to volunteer information, not only about accidents, but also about unsafe situations that could have developed into an accident but did not go that far. They provide this incident information, convinced that the authorities will not want to press charges or punish them other than in cases of blatant and deliberate disregard for rules and procedures. The important point here is that the system of mutual trust has generated an unsurpassed level of safety that makes aviation the safest mode of transport by far.

Safety experts sometimes speak of four stages of safety awareness. Operators at the lowest stage simply try to evade authorities and rules. The next stage is when the operator complies with regulations, but tries to minimise the short-term efforts and costs. The third stage is when the operator is willing to spend any amount of effort and money to achieve safety, but requests the regulator to tell them exactly what to do. The highest level of safety awareness is when the operator is not only willing to invest whatever it takes, but also actively participates in furthering the safety objective, and is capable of conducting discussions with peers and regulators on an equal footing in order to further improve safety.

At least some of the accidents described in the present report would probably not have happened, or at least could have had less devastating consequences, if all operators had reached the highest stage of safety awareness. If this report can contribute to increasing safety awareness, then it will have achieved its objective.

Jack Valentin