Seminar: Accident Investigation and Safety Culture

  Event description   Programme    


Accident Investigation and Safety Culture

Wednesday 27 April, 2022 - Online via Zoom

The online seminar Accident Investigation and Safety Culture was held 27th April 13:00-17:00 via Zoom. 

This webinar (free to SCWG members) looked at the influence of safety culture on historical accidents. There were speakers from a range of sectors looking at the issues from different perspectives.

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Presentations included:

Catherine Baker, CIRAS - Overcoming a culture of safety silence to prevent accidents

Tom Hughes, EDF - Nuclear Safety Culture: From the biggest accident that never was (Davis-Besse) to the realities of building the first new nuclear plant in a generation

Steve Gamble, Royal Navy Flight Safety Centre - Organisational influences on safety: RFA Argus – Wildcat Case Study

Michael Wright - Just culture, psychological safety & facilitating learning from error

Followed by a facilitated discussion: Learning from recent major accidents (Facilitated by Michael Wright and Eric Griffiths)

The slides from this seminar and video recording of the presentations will be available on the website shortly after the event, see the Programme tab above. The edited meeting chat is available here.

Bio Information

Catherine Baker 

Catherine heads up the Confidential Incident Reporting and Analysis Service, a not-for-profit organisation that has provided a confidential health, wellbeing and safety reporting line for workers in the transport and infrastructure sectors for the last 25 years. Starting from a science and analytical background, Catherine has held a range of senior roles in the transport sector spanning policy, risk management and research, all connected by the thread of working to deliver better outcomes for businesses, their customers, and their people – particularly for health, wellbeing and safety. Having spent much of her career working with those taking decisions that impact safety outcomes, it is now a privilege to be enabling people on the front line who often have the best first-hand knowledge of the hazards to have their voices heard when they might otherwise stay silent. Hence helping the companies they work for to take better informed decisions.

Steve Gamble

Steve Gamble joined the Royal Navy and Fleet Air Arm in 1996 and has spent the majority of his time in the Service firmly attached to the cockpit. A rotary wing aviator, Steve has deployed worldwide, flying the Lynx helicopter from numerous RN vessels and spent the majority of his time back in the UK as an instructor and latterly as an examiner flying all types of rotary wing aircraft in FAA service. Prised out of the cockpit, he has served at both RN Air Stations, Navy Command in Portsmouth and in Mali as the UK Senior National Representative supporting French operations in the region. Currently the senior Flight Safety expert within the FAA, Steve is hopefully using his experience to influence the current generation of Fleet Air Arm flyers.

Tom Hughes

Tom is a Chartered Mechanical Engineer and specialist in Light Water Reactor technology, nuclear safety assessment and technical training. Tom has the role of Nuclear Safety Culture Lead for EDF at the Hinkley Point C nuclear new-build project, tasked with developing the site's construction safety culture into an operational nuclear safety culture through a programme of communications, training and strategic development. Tom has 12 varied years of experience in nuclear on numerous operational and new-build sites, from independent site inspection and technical assessment to training and operations development.

Michael Wright


Michael is Director, Wright Human Factors Ltd. He is a Human Factors & Safety Culture specialist with more than 30 years experience, covering management of organisational change, fatigue risk, competence, safety critical task analysis, Human Factors integration & root cause analysis. He has performed numerous assessments of safety culture in defence, manufacturing, rail, nuclear and other sectors as well as supported safety culture improvements strategies, and explored the safety culture aspects of major accidents. He is also an Independent Member of company safety committees with a special interest in Human Factors, where he supports safety assurance.

Eric Griffiths

Eric has spent 40 years in the MoD as a Naval Architect, Procurement and Project Manager and Safety Engineer. He has many years experience in Safety & Environmental Engineering, initially on SONAR systems and Underwater Weapons. He has also worked as a MoD Safety Manager on Merlin Mk1 & 3 helicopters. He left the MoD in 2008 working for companies such as MBDA, Lockheed Martin, SDE, SAFRAN, RINA, BAES and many smaller organisations.

Talk Abstracts

Catherine Baker Overcoming a culture of safety silence to prevent accidents

In a world of complexity, even with well-designed systems, well-trained staff and carefully thought-through procedures there are unknown and unpredictable events which can affect safety. Even more so where systems have open interfaces to the outside world and can be affected by the public, weather, cyber attacks or outside-of-work influences on staff actions (intentional or unintentional).

This is a world in which information, and the ability to use it effectively, is critical to delivering outcomes safely, sometimes in real-time. Gaps in that information, the safety silences, can have serious or even fatal consequences. However the culture of an organisation can sometimes produce an outcome of safety silence, and avoiding this is a challenge.

This talk will explore ‘safety silences’ that have been noted in accident investigations, and ways they can be overcome including the role that confidentiality can play.

Tom Hughes - Nuclear Safety Culture: From the biggest accident that never was (Davis-Besse) to the realities of building the first new nuclear plant in a generation

In this fascinating insight to safety culture in the nuclear industry, Tom Hughes (Nuclear Safety Culture Lead at HPC) will talk us through the ‘biggest accident that never was’ – at a plant called Davis-Besse in the USA in 2002, severe corrosion was discovered on the reactor pressure vessel that put the plant in grave danger. This condition had been developing over years and the warning signs were there – so how could such a thing have been allowed to happen? Reflecting on the lessons learned from this near-miss, the talk will then consider the challenges surrounding developing and embedding a robust safety culture on the largest construction site in Europe, Hinkley Point C.

Steve Gamble - Organisational influences on safety: RFA Argus – Wildcat Case Study 

Significant changes programmes in an environment of continued output can create challenges which have the potential to erode safety barriers, none more so than the change of an aircraft type in the dynamic and inherently demanding sphere of maritime aviation. By using a case study from a Wildcat helicopter incident in 2017, this ‘near-miss’ will hopefully be thought provoking and highlight some of the long term organisational and human behaviours which may adversely influence safe operations.

Michael Wright - Just culture, psychological safety & facilitating learning from error

Michael will present the findings from a review completed for the Energy Institute and Shell. The review explored research into the effect of Just Culture interventions and then went on to explore the concept of psychological safety and how it may support learning from error and thence the improvement of safety performance.

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