The characteristics of a Safety Culture

[tweetmeme]What does an organizational culture that gives safety a priority look like?  There are several identified characteristics that go to make up a safety culture. Included in these are:

  • An informed culture*: one in which those who manage and operate the system have current knowledge about the human, technical, organisational and environmental factors that determine the safety of the system as a whole,
  • A reporting culture*: a culture in which people are willing to report errors and near misses,
  • A just culture*: a culture of ‘no blame’ where an atmosphere of trust is present and people are encouraged or even rewarded for providing essential safety-related information- but where there is also a clear line between acceptable and unacceptable behavior,
  • A flexible culture*: which can take different forms but is characterized as shifting from the conventional hierarchical mode to a flatter professional structure.
  • A learning culture*: the willingness and the competence to draw the right conclusions from its safety information system, and the will to implement major reforms when the need is indicated.

*Reason, J.T. (1997) Managing the Risks of Organisational Accidents

Taken together these five characteristics help form a culture of trust and of informed collective.  Of course trust is needed, especially in the face of assaults upon the beliefs that people are trying their best,  such as accidents and near-miss incidents which all too easily look like failures of individuals.  Informed people know what is really happening, lessening the chance of mistakes.  These and other critical elements help us to identify what beliefs are associated with a safety culture and will ultimately help reduce the frequency of accidents/incidents.

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Preliminary Deepwater Horizon Accident Findings Cite Lack of Safety Culture at BP

[tweetmeme]I want to make is perfectly clear that I am not an expert in the Oil & Gas Industry, and I don’t envy those safety professionals that work hard every day to try to help make sure that every worker who reports to work, also goes home safely at the end of the shift.  However, I feel strongly (as do many others) that the accident on the Deepwater Horizon should never have happened. 

I hope that we all can learn valuable lessons from the accident.  Knowing and admitting that the decisions made that led up to the accident, are the same types of decsions being made everyday throughout ALL industry types.  We must realize that incremental mistakes may seem insignificant at the time, but they are as Bob Bea says; a slippery slope!

Bob Bea, a UC Berkeley engineering professor, and a former consultant for BP who was asked by the White House to help analyze the Deepwater Horizon accident 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 that of the levee failures following hurricane Katrina, Bea says “We had this long slide down this slippery slope of incremental bad decisions [regarding the levees].   This is following the same trail.”

Although there are some critical direct causes of the accidents cited in the report, including not following industry standard practices due to apparent cost cutting and time-saving demands.  the root cause of the accident has yet to be determined.  Although according to Bea the fault primarily lays with BP—e.g., after overruling Transocean workers and managers—BP made the call to remove heavy drilling mud and displace it with seawater.  It was a move that Transocean managers equated to “taking shortcuts,” according to witness statements reported by The Associated Press.

All of this points to a probable root cause of lack of appreciation for safety and serious lack of any type of safety climate in place on the Deepwater Horizon.  According to Bea, during an interview with NBC,  “I think we’ve got the outline of the picture puzzle,” Bea says. “The details are still missing.  But I think we got the outline right.”

Safety Culture: How Organizations Create Their Own Safety Failures (Part 3 of 3)

[tweetmeme]There is ample research and real life examples of the financial benefits of creating and sustaining and culture of safety.  So why doesn’t everyone do it?

Patrick Hudson of the Centre for Safety Science in the Netherlands opined the following conclusion in his paper, “Safety Culture – Theory and Practice”:

“The answer seems to be contained in the type of culture the organization is at the time. Pathological organizations just don’t care.  Reactive organizations think that there is nothing better and anyone who claims better performance is probably lying.  They do what they feel is as good as can be done.  Calculative/Bureaucratic organizations are hard to move because they are comfortable, even if they know that improvement is possible.

The more advanced cultures, either Proactive or Generative, are probably easier to attain with small organizations.  Large ones will inevitably be heavily bureaucratic unless active steps are taken to counter that tendency.”

It would seem that if you are to evolve into a state of generative safety culture, you’d better do it early on in your organization’s growth and it should be sustainable; as an organization’s safety culture is the most significant influencing factor on safety performance.  An organization’s ability to build a culture of safety and therefore develop trust with its workers will more often than not is the key component in the level of an organization’s safety performance, and the associated benefits or negatives.  Safety cultures can only be created and sustained when a high level commitment is present.  An organization’s safety performance is either the product of the safety culture, or the product of the organization’s luck.

Because few safety systems have a culture focus they tend to fail to answer the question “why” deficiencies exist and therefore fail to show how well the system is actually functioning.  If you consider a typical audit score of 85% for emergency response in an audit finding, the tendency for management may be to consider that a passing score.  However the question of the remaining 15% failure remains unanswered. 

If you apply this score to an employee population of 500 of which 15% is unable to respond to a specific emergency, this leaves 75 employees at risk.  Or does it?  If the audit sample size is 10%, can we really say how effective the system is where 90% of the population have not been evaluated?  Statistics can be misleading, even with the most rigorous controls in place.  That is why organizations with calculative cultures that rely solely on safety management systems either evolve into a better proactive or generative state, or regress into a reactive or worse still a pathological state.  The time and expense of this type of command and control system doesn’t lend itself to a sustainable enterprise, due to the lack of perceived progress.  Even worse, a poorly designed or ill managed system can actually act as a cancer to an organization, destroying it from within.

The key element in overcoming these types of limitations is the presence of a generative safety culture throughout the organization.  It is however important to acknowledge that safety culture does have implications for the behavior of individuals, but that the concept should truly be used to describe the organizational phenomena of culture, and not simply the aggregated behaviors of individuals.  The aggregated behaviors of individuals can be better defined as the safety climate, and it is in this realm that BBS is focused.  This should be considered a lagging indicator, but all too often it is considered a leading indicator of safety.  After all, the mere absence of incidents or failures does not imply the presence of safety.

Generative organizations continuously strive to achieve a perfect alignment between management and employees in terms of their shared beliefs, values, norms, attitudes, trust, credibility, commitment, leadership, rewards, etc.  All of these factors shape employee perceptions of management, supervisors and peers, and have a significant influence their behavior, not only with respect to safety, but also with respect to productivity and quality.  It is the organization’s culture that dictates how employees will conduct their work.

Do you think your organization has a culture of safety?  How do you know?  Remember you are a part of the very culture you want to define.

Works Cited

Edwards, C. (2005, October). Developing Safety Management Systems – Shell Aircraft International’s Experience . Retrieved May 19, 2010, from Transport Canada: http://www.tc.gc.ca/eng/civilaviation/standards/sms-info-oct2005-1367810-2482.htm#27

Energy, U. D. (2003). Good Practices for the Behavior-Based Safety Process. Washington, D.C., USA.

Herbert William Heinrich. (2010, March 28). Retrieved May 12, 2010, from Wikipedia: http://en.wikipedia.org/wiki/Herbert_William_Heinrich

Hopkins, A. (2005, May 19). What are we to make of safe behaviour programs? Retrieved May 12, 2010, from http://w.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_what_are_we_to_make_of_safe_behavior_programs.pdf

Reason, J. 1997 op cit, p 220. The definition was formulated for nuclear power plants but it is obviously generalisable.

Safety culture. (2010, May 9). Retrieved May 12, 2010, from Wikipedia: http://en.wikipedia.org/wiki/Safety_culture

Space Shuttle Challenger disaster . (2010). Retrieved May 12, 2010, from Wikipedia: http://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster

Westrum, R. & Adamski, A.J. (1999) Organizational Factors Associated with Safety and Mission Success in Aviation Environments. In D.J..Garland, J.A. Wise & V.D. Hopkin (Eds.) Handbook of Aviation Human Factors. Lawrence Erlbaum, Mahwah, NJ.

Zohar, D. (1980). Safety Climate in industrial organizations: theoretical and applied Implications. Journal of Applied Psychology , 65, 96-102.

Safety Culture: How Organizations Create Their Own Safety Failures (Part 2 of 3)

[tweetmeme]The culture of an organization definitely has an impact on the behavior of employees, but there are other localized factors (i.e. supervisors, interpretation of safety policies, and production demands) that can have an impact on behaviors.  This is known as the “local safety climate,” and is more susceptible to risk due to constant management transition and employee turnover.

If safety culture can be described as safety attitudes, values, and practices that exist at a deeper level than safety climate, or to put it plainly – “the way we do things around here,” then safety climate is best described as “the manifestation of safety culture in the behavior and expressed attitude of the employees.” (Safety culture, 2010)  An organization’s safety climate therefore refers specifically to the workers’ perceptions and their reactions to how safety is managed in the workplace, and the likelihood those perceptions and reactions will contribute to a workplace incident.

The application of the concept, local safety climate is relatively new and, to some, may sound like an evolution of; or a new skin on BBS; but key differences do exist.  Safety climate measurements will include, for example, management commitment, supervisor competence and leadership skills, and supervisor’s understanding of the “why” not just the “how” of safety policies and procedures, priority of safety within production, and other time pressures (overtime, turnover, etc).

The concept of safety climate emphasizes the importance of how organizations manage health and safety in the workplace.  It is important that organizations consider that any changes made to the operations of a business, will have an impact on workers perceptions of the organization.

As the workers’ environment changes around them, they adapt their perceptions and ultimately their behaviors. (Zohar, 1980)  Consequently safety-related behaviors of workers (i.e.

Source: Edwards, Developing Safety Management Systems, October 2005

wearing PPE, following safety procedures) are influenced by their perceptions and attitudes towards an organization’s view of safety. (Safety culture, 2010)  The impact that safety culture has on processes such as communication, decision-making, problem solving, conflict resolution, attitudes, motivation, must be a critical element of any organizational decision to avoid creating future safety failures.

Organizations that use predictions for the future that are viewed through the tinting of the rosiness of the past when it comes to workplace safety are operating under the ‘illusion of safety.”  An illusion of safety can best be described by following beliefs: (Edwards, 2005)

  • Organizations with a good safety record will continue to be safe
  • Instructions and procedures for safe operations are in place, well read, understood, remembered and systematically used.
  • Responsibility for safety can be devolved to the line managers
  • Trained, experienced employees are immune to errors
  • It is sufficient that from time to time leaders talk about safety and its importance.

A culture of safety cannot coexist with the illusion of safety.  Safety cultures can be distinguished along an evolutionary line from pathological, caring less about safety than about not being caught; through calculative, blindly following all the logically necessary steps; to generative, in which safe behavior is fully integrated into everything the organization does. (Westrum & Adamski, 1999).

The most recent illusion of safety can be found within the oil giant BP.   Goldman Sachs has since 2004, rated publically traded oil companies on their environmental, social and governance (ESG) performance, and has found that firms scoring highly on issues like employee safety tend to also produce higher returns on investment (Wallstreet Journal, May 26, 2010).  This should come as no surprise, afterall a smoother running organization with fewer accidents, fewer workers’ compensations claims, and lower turnover will have a smoother operation and thus increased profits.  BP’s long-term valuation is threatened because it’s illusion of safety is now being recognized by long-term buy and hold type investors. (BP Is in Danger of Being Tarred With a Safety Discount, Wallstreet Journal, May 26, 2010).

The Deepwater Horizon accident in the Gulf of Mexico in April 2010, wasn’t an anomaly, as BP would like for the public to think.  Just as NASA’s organizational failures throughout the 1970’s weren’t highlighted until 1986,  BP’s organizational failures regarding environmental management, social responsibility, and occupational safety should be looked upon as window into the past and present culture within BP.  (Part 2 of 3).

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?

Admitting you need help is the first step in creating a culture of safety

[tweetmeme]I have been engaged in several projects lately involving helping companies with their safety culture and thought I’d share some musings…

Achieving a safe working environment isn’t a neatly defined thing that can be approach with a cookie cutter mentality.  Because safety is primarily a human focused endeavor, it is important to remember that people will react differently to the same stimuli.  Some people for example will view peer to peer observations, as done in Behavior-Based Safety programs, as an intrusion or a violation of their perceived privacy.  Whereas others may welcome it as a means to achieve a greater good.  They aren’t threatened by it at all.  Trust is a key factor here, and it isn’t something to be taken lightly.

I have found that safetybehavior is a primarily a product of three considerations: 1) job or environmental factors, 2) organizational factors, and 3) human factors.  All three must be considered and evaluated if sustainable improvements can be made for attaining a safety culture. 

If safety culture is simply “an assembly of characteristics and attitudes in organizations and individuals which establishes that as an over-riding priority; safety issues receive the attention warranted by their significance”, as made popular by this quotation from the International Atomic Energy Agency.  Then it would seem pretty simple to attain a safety culture at most any organization.  Yet it remains elusive for many orgainzations.  With competing forces fighting for limited resources, safety has for many, slipped into the background.  But it need not be that way!

Beliefs, perceptions, recognition, and social pressures are just some of the human factors that can be, and should be addressed relatively on the cheap.  It doesn’t take a huge capital investment to be a champion for a safety culture and to be able to demonstrate a favorable return on investment.  Likewise, some organizational factors can be improved without drastic financial comittments.  Things like reviewing hiring practices, updating policies and procedures, implementing management systems that are top down, and implementing a return to work policy to reduce worker compensation costs can yield tremendous human factor benefits that will descrease your costs and improve safety.  Perceptions and social pressures aren’t to be ignored.

The first step is admitting that your orgainzation needs help.  Sometimes, that is the hardest thing to do to achieve meaningful change, and bring a culture of safety to any organization.