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Becoming Ultra SafeBy getting the culture right

Dr. Mark FlemingSaint Mary’s Universitymark fleming@smu camark.fleming@smu.ca

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Workshop programWorkshop programIntroduction and overviewFeatures of a positive safety cultureSafety Culture Maturity (SCM)Safety Culture Maturity (SCM)Safety Culture AuditImprovementImprovement

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Aims and objectivesAims and objectives

By the end of the workshop you shouldBy the end of the workshop you should understand:the relationship between culture and safetythe relationship between culture and safetythe Safety Culture Maturity Modelhow to measure safety culture perceptions andhow to measure safety culture perceptions and systems supporting a positive culture

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High Reliability OrganisationsHigh Reliability Organisations

Piper AlphaPiper Alpha

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Organisational Factors in DisastersOrganisational Factors in DisastersDespite the adoption of a full range of safety systems, complex systems broke down disastrously because the people running them failed to do what they were supposed tosupposed toThese were not simple individual errors but malpractices that corrupted the social system that

d h i i f imade the organisation functionBlaming “human error” and hoping that a cure can be found for these random frailties is unlikely to workfound for these random frailties is unlikely to work

Some 'holes'DANGER

Some holesdue to active

failures

Defences

failures

in depth

Other 'holes'due to latent

conditionsFrom Reason 1997

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Safety improvement hierarchySafety improvement hierarchys

dent

rate

s

Engineering

nt /

Inci

d

Systems

Acc

iden

Behaviour/ culture

Time

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Reasons for InterestSafety management system not effective unless

Reasons for InterestSafety management system not effective unless accompanied by a “good” safety culture Wish to stay alert to potential risk factors that increase the risk of a major disasterPro-active approach involving self-assessment and feedback of less visible elements of safetyfeedback of less visible elements of safety management systemDesire to win “hearts and minds” to improve safetyAlternative, leading safety performance indicator

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CultureCulture has been defined as:

CultureCulture has been defined as:

A pattern of basic assumptionsInvented discovered or developed by a given groupInvented, discovered or developed by a given groupLearnt from coping with problems of external adaptation and internal integrationThat has worked well enough to be considered valid Is taught to new members (as the)Correct way to perceive, think and feel in relation to problems

Schein 1990 p110

Iceberg modelIceberg model

Trade - offs & the “Unrocked boat”

BankruptcyBankruptcyBetter defences

converted to

Protection

increased production

Increased

Catastropheinvestment in protection

ProductionFrom Reason 1997

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Safety cultureSafety culture

Safety culture “refers to the shared perceptions among members of anperceptions among members of an organization with regard to aspects of the organizational environment that inform grole behavior” (Zohar & Luria, 2005, p616).

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C lt d S f tCulture and Safety

Norms andBehaviour SafetySafety

Culture

Safety I t ti

Enabler/Barrier InterventionsBarrier

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Origins of safety cultureOrigins of safety culture

A “poor safety culture” was identified as aA poor safety culture was identified as a factor contributing to the Chernobyl disaster by the International Atomic yEnergy Agency (1987)“It is essential to create a corporate patmosphere or culture in which safety is understood to be and accepted as, the

b i it ” 300 L d C llnumber one priority” p 300 Lord Cullen

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High Reliability OrganisationsHigh Reliability Organisations

Preoccupation with failure (investigate allPreoccupation with failure (investigate all lapses)Encourage employees to report errorEncourage employees to report errorSeek to develop deep understanding of issuesissues Decentralised decision making to those with most expertise pAttentive to frontline employee concerns

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High Performance Work SystemsHigh Performance Work Systems

Self-managed teams; decentralized decisionSelf-managed teams; decentralized decision makingReduced status distinctionsExtensive sharing of information Extensive training S fSelective hiring of new personnelCompensation contingent on performanceEmployment securityEmployment securityHigh quality work

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Low accident companiesLow accident companies High level of communicationgGood organisational learningStrong focus on safetySenior management commitmentParticipative style of leadershipS fSkills training emphasis safety aspectsGood working conditionsHigh job satisfactionHigh job satisfactionPromotion / selection based on safety

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Positive safety culture elementsPositive safety culture elements

Good organisational learningGood organisational learningWorkforce involvement TrainingTraining Safety performance evaluation C i tiCommunication Job conditions and satisfaction C it t t f tCommitment to safety

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Elements of a negative cultureElements of a negative culture

Major accidents/crisesMajor accidents/crises– role ambiguity

management complacency– management complacency– poor communication– production and safety conflictsproduction and safety conflicts

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Safety culture modelSafety culture modelSafety External y

complianceFactors

Safety motivation

Worker perceptions

Organisationalenvironment

Proactivesafety

beha io r

•Management practices•Safety systems•Communication

•Management attitude toward safety•Production pressure behaviour•Supervision practices

p•Status of safety•Supervisor attitude

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Safety culture and outcomesSafety culture and outcomesSafety culture questionnaire responses have y q pbeen linked with accident rates in the following industries:– Nuclear power (Lee, 1998)– Offshore oil (Mearns, Flin, Fleming & Gordon 1997)

R d t ti (Ni k 1994)– Road construction (Niskanen, 1994)– Chemical industry, (Donald & Canter, 1994)– Manufacturing (Brown & Holmes 1986) (Zohar 2000)– Manufacturing, (Brown & Holmes 1986), (Zohar, 2000)

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Safety culture assessmentSafety culture assessmentMethod frequently used:q y– Self completion questionnaire

PurposePurpose– Obtain a baseline– BenchmarkingBenchmarking – Identify areas of strength and weakness

Utility of resultsUtility of results– Mixed at best

“Safety culture surveys are a bit like describing the water to a drowningdescribing the water to a drowning man, they tell you how bad things

are but do not help you to solve theare but do not help you to solve the problem”.

Phil Ley (safety manager)

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Need for a new approachNeed for a new approachMany companies have conducted safety y p yculture surveys and have difficulty in using the results to take action to improve safetyThere is a need for a simple framework to represent the current culture and what a better

lt ld l k likculture would look likeGood safety interventions (e.g. behavioural safety) appeared to fail because because thesafety) appeared to fail because because the company was not ready (mature enough)

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What is SCMWhat is SCMSafety culture development is broken down y pinto five stages or levels of maturity, from poor to goodA b f i il d l tl iA number of similar models currently in use (e.g. hearts and minds, shell)Five safety culture dimension/ elementsFive safety culture dimension/ elementsOnce the level has been established sites identify the actions required to move to the de t y t e act o s equ ed to o e to t enext level

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Safety culture maturity elementsSafety culture maturity elements

LeadershipLeadershipSupervisor visible commitmentP d tiProduction pressuresWorkforce involvementCommunication

Pathological Level 1

Reactive Level 2

Generative Le el 5

Bureaucratic Level 3

Proactive Le el 4Level 1 Level 2 Level 5Level 3 Level 4

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PathologicalPathological

Why waste our time on safety?Why waste our time on safety?Information supports power and gloryLoyalty and conformity is maintainedLoyalty and conformity is maintained through intimidationReaction to problemsReaction to problems– Suppression

Encapsulation– Encapsulation

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ReactiveReactiveWe do something when we have an incidentWe do something when we have an incidentInformation is controlled – Information is manipulated to ensure weInformation is manipulated to ensure we

conform to organisational standards (e.g. target incident rate)

We focus on finding who is at fault and using appropriate disciplineSafety would improve if employees wereSafety would improve if employees were more careful

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BureaucraticBureaucratic

We have systems in place to manage all likelyWe have systems in place to manage all likely risksInformation supports departmental interestsInformation supports departmental interests, – to make the department look good, to support

departmental objectivesdepartmental objectivesInformation flow is managedReaction to incidentsReaction to incidents– Local fix: treats symptoms not root cause

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ProactiveProactive

We are always on the alert for risks thatWe are always on the alert for risks that might emerge Information is important and we work hardInformation is important and we work hard to capture it and understand what is going on.Our outcomes are better that our industry averageStill surprised by some events

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GenerativeGenerative

We know why we do not have incidentsWe know why we do not have incidentsInformation supports the missionInformation flows freely honesty is valuedInformation flows freely, honesty is valuedResponse to incidents:

Gl b l fi t t fi l f– Global fix: try to fix every example of a problem, share information with other stakeholdersstakeholders

– Inquiry: Get to the root cause of problem

V1.2What type of culture do you have?have?

Westrum (1998) identified three types of cultures for dealing with information:Pathological Bureaucratic Generative

Do not want to know

May not find out Actively seek information

Messengers are shot

Listened to if they arrive

Messengers are trained

New ideas are actively crushed

New ideas present problems

New ideas are welcomed

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Safety culture assessmentSafety culture assessment

Safety culture workshopsSafety culture workshops– 2-3 hour sessions with sample of workforce

Card sorting exercise discussion– Card sorting exercise, discussion– Analysis and action planning

S f t lt ditSafety culture audit– Self assessment – external assessment

C i i– Calibration – Action planning

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SCM ProcessSCM ProcessSenior management briefing and SCM card sorting

iexerciseOrganise workshops with a cross section of the workforce– Give presentation about SCM and purpose of the session– Split into pairs and give each pair a set of SCM Q-Sort

cardscards– Get them to select the card that most closely reflects their

perception – Get them to record their selections

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SCM Process (cont)SCM Process (cont)Workshops (cont)p ( )– Record group results– Describe current situation– Discussion of level of SCM – Identify actions to improve level of maturity

CCollate data Analyse resultsDevelop action planDevelop action planFeedback to workforce

Summary of responses for each element by level

10% 9%17%

22%90%

100%

51%

30%

37%

41%

70%

80%

48%

31%40%

50%

60% GenerativeProactiveBureaucraticReactivePathological

38%

48%

37%

14%20%

30%

40% Pathological

0%6%

1% 1% 0%1%

7%9%

15%

1%

26%

0%

10%

Leadership Supervisor visible Production pressures Workforce involvement CommunicationLeadership Supervisor visiblecommitment

Production pressures Workforce involvement Communication

4

334 ( People)Overall summary of responses for each element

3

2

Leve

l

1

90%88% 71% 73%98%

0

Leadership Supervisor visiblecommitment

Production pressures Workforce involvement Communication

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LeadershipLeadership Current situation Actions

Good on the big issuesSome managers actively i l d

Measure managers on the extent to which they demonstrateinvolved

Variation between managersHealth and safety not

demonstrate commitment to safetyProvide leadership Health and safety not

evident enough in day to day activities

skills training for managersSenior managers to setSome managers lack

required leadership skillsSenior managers to set the example/ coach subordinates

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SCM Improvement ProcessSCM Improvement ProcessSCM Improvement Process (SCMIP) developed to p ( ) passess culture without the need to survey workersRational for SCMIP

Employee perceptions are based in reality– Employee perceptions are based in realityi.e. perceptions of management commitment reflect their interactions

with managersOrganisations with different cultures have different– Organisations with different cultures have different practices

– Safety culture improvement involves system changee.g. perceptions of management commitment is improved through

training and evaluating leadership practices

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SCMIP elementsSCMIP elements

Organisational learningOrganisational learning– Incident Investigation Team

Workforce involvementWorkforce involvement– Workforce Involvement

T i iTraining – Frontline Worker Safety Training

S i S f i i– Supervisor Safety Training– Manager Safety Training

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SCMIP elementsSCMIP elementsSafety performance evaluationSafety performance evaluation– Manager Safety Performance Evaluation– Supervisor Safety Performance Evaluation

Communication– Safety Communication

Commitment to safetyCommitment to safety– Planned Maintenance– Rules and Procedures– Managers Visiting the Worksite– Supervisors Visiting the Worksite

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How to use SCMIPHow to use SCMIP

Self assessment of systems supportingSelf assessment of systems supporting the safety culture– Completed by safety department to assist inCompleted by safety department to assist in

annual planning– Completed by senior management team toCompleted by senior management team to

form basis for improvement workshop– Integrate into existing audit processg g p

External assessment of safety culture

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Benefits of SCMIPBenefits of SCMIPAvoids need to survey employeesAvoids need to survey employeesCan be used by management team to assess current safety culture without yraising employee expectations of change.Identifies specific interventions as the

dit th d lit faudit assess the presence and quality of safety culture indicatorsCan be used to identify improvementCan be used to identify improvement areas for contracting organisations

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Improvement strategiesImprovement strategiesChange management systems to supportChange management systems to support the desired cultureFor example perceived management p p gcommitment can be improved by:– Providing managers with the skills to be

ff ti f t l deffective safety leaders – Motivating managers to change by monitoring

performance (leading indicators)performance (leading indicators)– Rewarding effective performance

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Safety Culture ChangeSafety Culture Change

“Peoples attitudes and opinions have been formed over decades of life and cannot beformed over decades of life and cannot be

changed by having a few meetings or giving a few lectures”

(Mao Tse Tung)