Safety Culture: How organizations cause their own safety failures (Part 1 of 3)

[tweetmeme] The following is the first of a three part paper written to help explain the critical role safety culture plays is the overall success or failure of organizations related to implementing and sustaining a record of safety that goes beyond compliance.  Safety culture plays a vital role in determining the overall success (financially) of an organization and the amount of risk that organizations assume, more often than not, unwittingly…

Over the years, a lot of attention has focused on the causes of occupational incidents.  Although safety on the surface seems easy, and a simple matter of applying common sense, creating a safe working environment or safety culture in which no one ever get injured is, as it has been described, “like a state of grace, something that is striven for but rarely attained.”  (Reason, 1997).

When incidents do occur in the workplace it is important to understand what factors may have contributed to the outcome in order to avoid similar incidents in the future.   Such factors commonly considered as possible casual agents are human, technical, and organizational.  It is also widely accepted that through developing an understanding of why and how incidents occur, future incidents can be prevented. 

Designing safer systems preoccupied the safety professional’s world for a long period of time, despite the early studies by Heinrich and others that indicated a direct influence of human behavior in work place incidents (Herbert William Heinrich, 2010).  However, a number of major incidents stirred attention to the impact of organizational factors (i.e. policies and procedures) on the outcome of safety performance, with numerous books and papers identifying safety culture as having a definitive impact on the outcome of these incidents.

The Space Shuttle Challenger disaster occurred on January 28, 1986, when Space Shuttle Challenger broke apart 73 seconds into its flight

One of the highest early profile examples of this came in 1986 when in a report into the Challenger space shuttle disaster, the Rogers Commission found that NASA’s organizational culture and decision-making processes had been a key contributing factor to the accident.  According to the report, NASA managers had known that contractor Morton Thiokol’s design of the SRBs contained a potentially catastrophic flaw in the O-rings since 1977, but they failed to address it properly.  Furthermore, the report stated that they disregarded warnings from engineers about the dangers of launching posed by the low temperatures of that morning and had failed to adequately report these technical concerns to their superiors. (Space Shuttle Challenger disaster , 2010)

With every major disaster we try to establish exactly what factors contributed to the outcome of the event.  These investigations pay particular attention to detail and prove to be an invaluable source of information in identifying factors that make organizations vulnerable to failures.  More often than not, organizational accidents are not a result of operator error, chance environmental or technical failures alone.  Rather, these failures tend to be a result of a break down in the organization’s policies and procedures that were established to deal with safety. 

Although safety culture was a concept originally used to describe the inadequacies of safety management that resulted in major incidents, the concept is now being applied to explain incidents at the individual level.  Since the late 1990’s there has been a movement to apply the concept of safety culture at the individual level as well as the organizational level.  It is important to note that this concept is far different than the long established concept of behavior-based safety.  Behavior-based safety (BBS) got its wings in the late 1970’s and focuses on the predictive aspect of individual behaviors or observed “percent safe acts.” (Energy, 2003)  Its reliance on highly structured observations, its hefty price tag to implement, and the perception that BBS isolates safety from other aspects of the organization, rather than integrating it has rendered BBS programs a tough sell.  The crucial feature that distinguishes those BBS programs that work from those that don’t is whether or not there is trust between workers and management. (Hopkins, 2005)

However, trust between workers and management isn’t gained by making observations and handing out movie-theater gift cards, as a means of positive reinforcement.  Trust comes from an appreciation of whether leaders are perceived to be committed to safety, whether managers consult actively and respectfully with workers and whether there is a mature safety management system that is functioning well in practice. (Hopkins, 2005)  In other words, is there a culture of safety present throughout the organization?



  1. […] in the Gulf,  has released a preliminary report and in it, he clearly implicates a lack of safety culture at BP as the most probable root cause of the accident.   While comparing the current situation to […]

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