MaryAnn Rae

After the Piper Alpha accident in 1988, survivor Steve Rae wanted to understand what had caused the tragedy and others like it. His research into accident investigations led him to conclude that the same six causal factors were typically present.  

A separate Health and Safety Executive1 study reached similar conclusions, suggesting these factors were important in many industries including nuclear, rail, air and coal mining. Steve and wife MaryAnn, a health and safety engineer, believed that pursuing good practice in these areas can improvsafety culture and performance.

What are the six ‘C’s? 

If you look at accident investigations in many safety critical industries, you’re likely to find evidence of failure or poor performance in at least one of these factors: 

  • Competencyknowledge, skill and/or ability to complete tasks  
  • Communication: sharing of critical information at worksite 
  • Complacencytask focus and/or conscious engagement 
  • Commitmentintellectual and/or emotional buy-in
  • Control of workprocess discipline, task assurance
  • Change management: supporting people when the way things are done alters 

However, you can turn this on its head, and focusing on good practice in these areas can both improve safety culture and prevent them becoming factors in future incidents. 

What does it look like in practice? 

In the offshore oil and gas industry, annual production shutdowns for maintenance and engineering work are common. They often involve higher risks due to the non-routine nature of the work, and because there are often ‘new’ people on the platform who are unfamiliar with company procedures and practices. Here’s some examples of how we used four of the six ‘C’ factors to help us work safely during a shutdown period. 

  • Control of WorkTo ensure that suitable controls and processes were in place and clearly communicated, we created a shutdown handbook. This included a new platform diagram and job numbers system to make sure that staff knew who was working around them - above, below and either side - and what risks were present.
  • CompetencyThe shutdown handbook also described the Permit to Work (PTW) system which ensured all staff had the relevant level of competence. Visiting workers had to take part in and pass the PTW training appropriate for their position.
  • Commitment: The company Managing Director issued his phone number to all staff to demonstrate how important he felt it was that they should feel able to report concerns. A ‘Stop Work Authority’ was also issued, committing all workers involved in the shutdown to ‘do it safely or not at all’.
  • CommunicationMeasures were taken during the shutdown period to make it very clear who was who. We introduced a policy of green hats for all new starts so they could be easily identified, and extra care and attention given. Red hats were provided for safety representatives, so workers knew where to go if they had any concerns.

What are the challenges to implementation? 

As with many approaches which look to change culture, applying the six ‘C’s only works if people buy into it – at all levels. Rules and regulations are important but won’t keep people safe on their own. For that, you need to engage with people and get them involved. Use the six factors to identify examples within people’s own work area, helping them make the link between the risks and what they personally can do about them. This encourages ownership - ‘how does this affect me’. The key is to build trust by being honest about what the approach offers, following through on commitments, and providing feedback to staff.

Would it work outside oil and gas? 

The six causal factors are equally applicable in other safety critical industries, such as transport - you see the same factors feature in investigations undertaken there. It stands to reason therefore that building a safety culture which embraces these issues can help ensure we all go home safely – regardless of where we work. For example, we recently did some work with new CIRAS member Stagecoach Bus. So our message is - if you're looking at whether this approach could apply in your business - focus on the similarities and not the differences. 

MaryAnn Rae is an independent health and safety consultant and Steve Rae is Executive Director of Step Change in Safety, the oil and gas industrys safety body. To find out more contact MaryAnn at, or Steve at

1 Ref1 – Bell.J , N. Healy - The Causes of Major Hazard Incidents and How to Improve Risk Control and Health and Safety Management: A Review of the Existing Literature HSL/2006/117