process safety management & safety culture 22 nov 2007

Date: Nov. 22-23, 2007Technical Seminar on Industrial Process Safety Management

FICCI, New Delhi

Process Safety Management

& Safety Culture- An Overview -

John ThomasJoint Director

FICCI

history Process Safety was born on the banks of

the Brandywine River in the early days of the 19th century at the E. I. du Pont black powder works.

Recognizing that even a small incident could precipitate considerable damage and loss of life, du Pont directed the works to be built and operated under very specific safety conditions.

history Process Safety evolved as industry progressed

through the 19th and 20th centuries, but really emerged as a industry-wide discipline following the major industrial accident at Union Carbide, Bhopal, India, in which a catastrophic release of methyl isocyanate killed more than 3,000 people.

In the twenty years since Bhopal: process safety has gained corporate importance, process safety expertise has extended into the general

skill set of chemical and petroleum engineers and operators, and

many industry-wide guidelines for process safety have been developed.

http://www.bhopal.com/

http://www.bhopal.com/

What is Process Safety Management ?

The proactive and systematic identification, evaluation, and mitigation or prevention of chemical releases

that could occur as a result of failures in process, procedures, or equipment.

Process Safety Management (PSM) Integral part of OSHA Occupational Safety

and Health Standards since 1992

Known formally as: Process Safety Management of Highly Hazardous Chemicals (29 CFR 1910.119)

PSM applies to most industrial processes containing 10,000+ pounds of hazardous material

OSHA’s PSM vs. EPA’s RMP Process Safety

Mgmt’s concern: - potential hazard and

protection of employees inside a regulated area

Employer Highly Hazardous ChemicalsFacility Standard Workplace Impact

Risk Mgmt Program’s concern:

- potential incidents that may cause environmental and health hazards outside facility boundaries

Owner or OperatorRegulated Substances Stationary SourceRule Off-Site Consequences

The 14 Components of PSM?

1. Process Safety Information

2. Employee Involvement3. Process Hazard Analysis4. Operating Procedures5. Training6. Contractors7. Pre-Startup Safety

Review

8. Mechanical Integrity9. Hot Work10. Management of Change11. Incident Investigation12. Emergency Planning and

Response13. Compliance Audits14. Trade Secrets

DuPont’s PSM wheel

PSM: The 4 Critical Success Factors

The Safety culture Management commitment & leadership The right programs & systems Operational Discipline


FICCI, New Delhi

Safety Culture

Safety Culture

1. What Is it & How do we have one…? The Way It Is Around in your organization

and you already have one ………. Still evolving !!!!

Historical Perspective The term ‘Safety Culture’ appears to

have arisen out of the report on the 1986 Chernobyl disaster

Adopted increasingly by industries characterized by:High capital investment High operating risksHigh public visibilityFragile public imageCutting-edge technologies

Examples:

Nuclear, space, offshore operationsAviationShipping

In HIGH reliability industries, there has been an increasing

recognition of the importance of the cultural and behavioural aspects

of safety management.

Safety Culture Investigations into major disasters such as

Piper Alpha, Zeebrugge, Flixborough, Clapham Junction, and Chernobyl have revealed that complex systems broke down disastrously, despite the adoption of the full range of engineering and

technical safeguards,

because people failed to do what they were supposed to do.

These were not simple, individual errors, but malpractices

that corrupted large parts of the social system that makes organisations function.

Safety Culture The focus over the past 150 years was:

Improving Technical aspects of engg systems to improve safety

These efforts have been very successful – resulting in low accident rates in the majority of safety critical industries

However, it does appear that a plateau has now been reached.

As the frequency of technological failures in industry has diminished,

the role of human behaviour has become more apparent,

Safety experts estimate: 80–90% of all industrial accidents are

attributable to ‘human factors’.

“The product of individual and group’s values, attitudes, perceptions, competencies, and

patterns of behaviour that determine

commitment to, and the style and proficiency of, an organisation’s health and safety management”.

The Advisory Committee for Safety in Nuclear Installations

Corporate Safety Culture

However, Commerciality must be balanced against safety for both to have a positive effect

on the bottom line.

Corporate Safety Culture• The ultimate goal of the safety culture is to

eliminate accidents. • The Board must be actively involved, or work to

improve safety performance will die on the vine.• Top management’s drive and commitment must

be unwavering and demonstrable. • The Company’s safety performance is the

product of the Safety Culture of the organisation plus it’s Luck Factor

Safety Culture and Performance

The Company’s safety culture is perhaps the most significant influencing factor on safety performance.

It is primarily evidenced by its effect on human behaviours and attitudes in the workplace.

The performance of the staff together with the influences of their supervisors and managers determines the level of human error suffered by the Company.

Styles of Safety CultureManagement are able to determine the style of safety culture of the organisation, their actions not words have a significant effect on that culture.

Blame Just and Learning No Blame

Styles of Safety Culture

• Safety Culture is not only about the management’s commitment to safety,

• It’s also about the subsequent approach the staff take to safety in the workplace.

Styles of CultureQuestion the Board should ask about its culture?

• What is the safety culture in the company?

• Is it Robust enough to support the safety performance we require?

• Does it need to change and if so what do we need to do?

Ideally Management should seek to develop be a Just and Leaning Culture, that is capable of supporting the Company’s business principles and safety objectives

Styles of CultureA Just and Learning Culture should:• be supportive of the staff and management.• engender honest participation.• seek to learn from its mistakes and errors.• accept that mistakes will happen.• encourage open reporting.• treat those involved in the errors justly.• consider the implications of management and

their systems in all incidents.

A Road Map to Safety Culture?Uninformed CultureSymptoms• Gaps in knowledge, & skills needed for safe operations• Poor emergency preparedness• Lack of training• Absence of exercises

Evasion CultureSymptoms• Perfunctory approach• Focus on paperwork• Appearances are most important• Inadequate training• Poor emergency response

Safety CultureSymptoms• Safety awareness visible throughout• Collective approach• Proactive risk identification• High degrees of preparedness• Cohesive team

Compliance CultureSymptoms• Focus on compliance• Conversant with rules• Flawless records• Safe practices a routine• Extensive checklists• Inability to deal with unforeseen emergencies Culturally driven

beliefs• Fatalism• Safety measures increase accident risk• No matter what you do, accidents will still occur

Culturally driven beliefs

•‘Excessive’ safety is “bookish”•‘Smart’ operations involve cutting corners •The chief objective is not to get into trouble with authorities

Behaviour pattern

• Discipline• Obedience to rules• Clear role definition• Pride in doing things right• Group commitment• Clean record matters most

Behaviour pattern

• Clarity of objectives• Positive group dynamics• Professionalism• Sure of support• Confident in emergencies

Emerging Level 1

Managing Level 2

ContinuallyImproving

Level 5

Cultural maturity model

Involving Level 3

Cooperating Level 4

Develop management commitment

Involve frontline staff and develop personal responsibility

Develop cooperation between management and frontline workers

Ensure consistency

Improving

Safety Cultu

re

Reinforce

ment of d

esired

behaviours

Source: Kiel Centre, UK


FICCI, New Delhi

Safety Culture Assessment Diagnostic tools

Safety climate surveys Structured workshops Combination of the above

Results assist in selection of appropriate behaviour modification program and planning in how to implement

Tools to Improve Safety Diagnostic

Used to identify issues, which require improvement

Intervention Improve safety by addressing specific safety behaviours

Establishing where an organization’s safety culture maturity lies is key to selecting appropriate behaviour modification programs and implementing them effectively

Safety Culture Improvement Process

Assess current level Develop plan to improve Implement plan Monitor implementation Re-assess to evaluate success and identify

further actions

Management and Safety Culture Lessons Learned Oversimplification of technical information could mislead decision-making Proving operations are safe instead of unsafe Management must guard against being conditioned by success Willingness to accept criticism and diversity of views is essential

Recommendations Re-evaluate decision-maker qualifications and technical development for

key decision-makers and encourage continued technical growth of key NNSA decision-makers.

Communicate the cultural and organizational lessons learned for NNSA from the NASA CAIB report.

Change the safety behavior of NNSA to be more open to alternate views and minority opinions.

Develop and publish a safety culture policy statement that clearly defines NNSA’s commitment and expectations regarding the role of safety within NNSA.

Hold periodic safety forums to discuss, as a minimum, trends, issues, lessons learned and best practices from both internal and external sources.

NNSAColumbia Accident Investigation Board (CAIB)

Lessons Learned Review

Brig Gen Ron HaeckelFacility Representative Workshop18 May 04

Beyond ‘Safety Culture’ It is structural dimensions of business

organisation, the interlinkages and discontinuities of accountability, rather than deficiencies in normative ‘safety cultures’ which need to be addressed in examining safety failures.

“Risk transfer mechanisms” accompanying precarious forms of employment in the offshore industry are characteristic of modern business organisation as a whole.

This provides an explanation of underlying causation which goes beneath the surface of purely ‘culturalist’ approaches to safety systems or indeed ‘human factors’ approaches.

Poor Safety Culture “Accidents that result in severe injuries may not

be random events, rather their causal factors may derive from an accumulation, over time, of deficiencies in an organization’s safety culture”

We are convinced that the management practices overseeing the Shuttle program were as much a cause of the accident as the foam that struck the left wing CAIB Report

A Good Example of Safety Culture

E. I. Dupont starting manufacturing explosives in the early 1800s

Developed concept of separation distances for the powder mills and designed buildings so that explosions would go upwards or away from occupied buildings

Built his house inside the plant and insisted managers also live inside the plant

Developed plant rules and procedures

Definitions Safety Culture

The collective values and attitudes of people in the organization Step Change Behavioural Issues Task Group

The knowledge, values, norms, ideas and attitudes which characterize a group of people

Seldom a unified or homogenous quantity, usually diversified, fragmented and split into sub-cultures

Definitions Safety Climate

Surface snapshot of the state of safety providing an indicator of the underlying safety culture Step Change Behavioural Issues Task Group

Behavioural Aspects of Safety The way organizations act out their safety

management systems and how systems operate in reality. Includes safety culture, safety leadership and behaviour modification

Safety Culture – What is it? The product of individual and group

values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to and style and proficiency of an organization’s health and safety management ACSNI 1993

The way we do things around here” CBI 1990

Safety Culture – What is it? As the Board investigated the Columbia accident, it

expected to find a vigorous safety organiztion, process and culture at NASA, bearing little resemblance to the ineffective “silent safety” system identified during Challenger Disaster (’86)

NASA’s initial briefings to the Board on its safety programs espoused a risk averse philosophy that empowered any employee to stop an operation at the mere glimmer of a problem

Unfortunately, NASA’s views of its safety culture, did not reflect reality CAIB Report

Imagine the difference if a Shuttle Program Manager had simply asked “Prove to me that Columbia has not been harmed by the foam strike”

Frequently Asked Questions What does a good safety culture look like? How do you know if the safety culture is

improving? What are the key issues to focus upon first? When to stop working on a specific safety

culture issue and move onto the next Is it always necessary to survey staff to

measure safety culture? How does behaviour modification link to

safety culture improvement?

Improvements in Safety Performance

Road to QHSE Culture

- Warning signs- Training- Inspections / Maintenance plans- Regulatory compliance- Incident reporting / investigations

- Performance Analysis- Refresher training- Auditing and Management Review- Change Management process

- Human Behavioural Implications- Procedural compliance- Obligation to intervene- Empowerment to stop the job

Reduction through TRADITIONAL QHSE PROGRAMS

Reduction through further addition of MODERN APPROACHES

Reduction through addition of ADVANCED APPROACHES WITH SUPPORTING SYSTEMS

Time - Maturity of QHSE Approach

Inci

dent

Fre

quen

cy

Safety Culture Change “Peoples attitudes and opinions have been

formed over decades of life and cannot be changed by having a few meetings or giving a few lectures”

(Mao Tse Tung)

Sound Safety Culture A sound safety culture is INFORMED

Good reporting systems Just and fair Learning from experiences Flexible and adaptable

James Reason 2001

What Influences Safety Culture? Interaction between:

The person The job Organizational factors

Unsafe behaviour may have been the final act in an accident sequence, but worker behaviour will have been influenced by the job, work environment and the organization

What Influences Safety Culture?

Person

JobOrganization

Safety CultureSafetyClimate

What Influences Safety Culture? Safety performance is improved when all

factors job, environment and organization are considered

Requires behavioural changes at all levels in the organization, not just at workplace

People behave the way they do because of the consequences that result for themselves after doing it.

Who Influences Safety Culture? If there are safety problems, it is because

the behaviours producing the problems are being reinforced

Managers and supervisors change worker behaviours by their own action or inaction

Focusing only on the front line worker will not result in positive changes

Who Influences Safety Culture? Management has the most influence How do they “walk the talk” and

demonstrate safety leadership? Field visits to talk knowledgeably about safety

e.g. accident stats and near misses Safety manager is a full member of the senior

management team


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Safety Culture Continuum

Safety Culture: Evolution Stages

• Encourage– Educate Them and Do It WITH Them

• Engage– EVERYONE Does Safety Activities And Is Held Accountable

• Evolve– Change With Your Needs Over Time

• Evidence- Based– Leading Indicators vs Trailing Indicators…Do What WORKS!

Active Caring Measure your willingness to “actively care” about

co-workers: 1. You are willing to observe others to help guard

them against doing things that are hazardous 2. You are willing to coach and inspire other people

in safe behaviour 3. You are willing to intervene, and caution or

challenge others who are working unsafely 4. You are willing to receive the same kind of ‘Active

Caring’ and respond in a positive way

Leading Indicators Of Safety

- • Safe Behaviours Observed • Time To Resolve Safety Issues • Processes Reviewed • Management Of Change Completed • Safety Meetings & Discussions • Recommendations Implemented • Workplace Observations Completed • Cultural Analysis • Employee Perception

Behaviour Basics

Antecedents or Activators – What happens to motivate the Behaviour

Behaviour – The action(s) taken by the person

Consequences – What results from the Behaviour

Safety Culture Maturity Model

Source: Dr Mark Fleming, Chartered Psychologist, The Keil Centre, UK

Topics in the Paper• What is the Corporate Safety Culture.

• How does that effect the Business.

• Human Factors, where it fits with Culture.

• Professional Sub-Cultures.

• Defining the current Engineering Culture.

• Making changes to the Safety Culture.

Human Error• Controlling human error within the maintenance

environment is the most significant challenge we face today in the aviation industry.

• The provision of adequate resources, human factors considerations, technical and development training, and the maintenance function’s perceived importance to safety have been minimised .

• The impact of the safety culture in a Maintenance Organisation is significant in today’s environment.

Human ErrorIn March 2000 a board member of the NTSB announced that of the 14 FAR-121 carrier hull losses that had occurred in the last 5 years to US registered aircraft, 7 were caused by maintenance shortfalls.

This is a far worse figure than previously considered. Accident studies have shown that attitudes to safety by the Engineers and their Maintenance Managers can result in a weak safety culture within the many companies.

Human ErrorThe vast majority (80%+) of our incidents and accidents are caused by human error. To Err is Human! We are all error prone, even the most experienced engineers and managers! Error is a natural condition of being human! It is a primary function of development.

Management should not be surprised when Human Error occurs!

But they should be surprised if their systems of work are not robust enough to contain that error!

Common Incident Features• Inadequate pre-planning, equipment or spares • Time pressures• Work being done at night. • A Handover of work• Supervisors were doing hands on tasks• Staff shortages • Frequent interruptions during the task• Confusion in the text of the manuals• A failure to use approved data or procedures• An element of can-do attitude

An AAIB assessment of key features of three major Maintenance Incidents concluded that there was :

Common Incident FeaturesAlmost all of those common features that appeared in the incidents reviewed are “organisational system” related. They are of the company not the person .

Those that were not are:• Failure to work to the procedures - which flaunts

the stated organisational systems.

• Can-do attitude - which undermines organisational systems.

Regrettably, these two shortfalls are often “condoned by management” in normal operations.

Professional Sub-CulturesStudies into company cultures in many industries have identified that beneath the corporate culture, there may also be Professional Sub-cultures.

This means that the approach taken to work by a specific grouping may differ to that which the company desire and envisage.

There is no malice or ill intent in such sub-cultures, it just relates to the beliefs, attitudes and understanding of that group, and it affects the way they work.

One such professional sub-culture lies within the Maintenance Arena.

Maintenance Sub-CultureThis could be generalised as being:• Engineers are trained problem solvers and trouble

shooters. • They are committed to their own safety standards,

they often doubt the need for all the procedures, rules and especially auditing.

• They see adversity as a challenge.• They work in teams, but as Individuals not as

Team Players, nor do they use the teams strength.• As with most people, engineers also enjoy a little

risk taking, although rewarding, it is error prone.

Maintenance Sub-CultureEngineers have a macho attitude, evidenced by:• They have great faith in the ability to get the job

done! • They don’t like to be seen as not knowing something

about the aircraft!• They are highly reliant on their ability to memorise

tasks, even down to such things as part numbers!• Related to work, they are poor communicators!• They tend to resist being monitored, or supervised!• They are prone to believing they know better than

the company, or manufacturer’s procedures?

Management's Approach to the Maintenance Sub-CultureMaintenance Managers are often happy to condone issues, such as working from memory, whilst everything is going right, but may be quick to criticise if it goes wrong!

Commercial pressure frequently allows safety controls to be eroded!

Although, it is known that engineers face adversity in the workplace every day, little is done to identify what, or indeed fix the problems.

Management's Approach to the Maintenance Sub-CultureCompliance Monitoring would aid managers in identifying what was happening in the workplace.

Compliance Monitoring is a requirement in JAR 145.65b, this states:

“the JAR-145 approved maintenance organisation must establish a quality system to monitor product standards and compliance with and adequacy of the procedures to ensure good maintenance practices and airworthy aircraft”.

However, this is largely under achieved or ignored?

Management's Approach to the Maintenance Sub-Culture

The Senior and Middle Managers of our Maintenance Organisations have an awareness of what is happening in the workplace,

However, perhaps through pressures on them, they rarely use such controls as compliance monitoring or line supervision to identify workplace shortfalls.

It certainly is going to be problematical resolving some of the issues maintenance departments face today.

Management's Approach to the Maintenance Sub-CultureHowever, if top management are serious about reducing human error and having a more robust safety culture in their companies.

They must first recognise the perceptions and real problems faced in the workplace and then begin address them.

They don’t stand alone in this as the regulators also need to support such initiatives.

Making the ChangesThe culture of an organisation is extremely slow to change, and it is more easily eroded than improved.• First we must recognise the need to change,

• Then we must define the changes required,

• Then communicate those changes to everybody involved,

• Get buy-in from the regulators and staff, and

• Then make it happen.

Making the ChangesIt will take time and a lot of commitment from managers, the staff and contractors within the maintenance organisation.

However, these are steps that must to be taken if we are to make a difference in our industry.

Indeed we must reverse the trend of increasing numbers of maintenance induced incidents.

Developing the Right Safety Culture• Establish your Corporate Principles• Define your Safety Objectives• Establish your Safety Plan• Lead by example, Live Your Word (do what you

say, say what you do).• Use the Substitution Test when things go wrong.• Motivate• Communicate.• Manage Change, confusion is the enemy.

MotivationMotivation is a management issue:• Motivated staff perform better than those that

are de-motivated.• Empowerment of the staff at appropriate levels

gets commitment and involvement from the staff.• Some Self Determination is a great motivator.• A feeling of having a view that is sought after,

considered and sometimes used motivates people.• Money and fear are poor motivators, they don’t

have a lasting effect and are not the answer.

CommunicationCommunication involves staff & builds on the culture:• Be open in your communications where possible and as

practicable in the business.• Remember that unsaid communications (actions and

attitudes) say more that verbal communications.• Communication requires a transmitter & a receiver.• Rumours are destructive, but are addictive, they are

the natural by-product of not enough information.• Communication should be open, frequent and

two-way (up and down or peer to peer).• Develop the Team Briefing approach (leadership/followship)

Managing Change• What are the implications of the Change?• How will the change be effected in practice? It is not enough to issue a note or amendment and expect the changes to take place in practice.Safety Significant change has to be managed into place and is a line management responsibilityIf the change is important, so is the effort that needs to be put in to make it work.Most people are resistant to change, they believe that they do things safely, and it is not them that the accident will happen to!

Changing CulturesSafety Is No Accident!

The Safety Culture of your Maintenance Organisation is of your making and can be used to reduce the

risks to your business

The Choice is Yours

Why is Culture Important?

Culture affects the way we feel, act, think and make decisions!

Characteristics of Organizations Who “Get It”Organizational Value for SafetyAccountabilityTeamwork

Characteristics of Organizations Who “Get It”

TrustSupport

What Can YOU Do as a Leader to influence a

Safety Culture?

Components For A Successful Safety Culture

Regulatory ComplianceMoneyEthics

Ethical ApproachControlCooperationCommunicationCompetenceChange

Factors leading to an Accident: The“Swiss Cheese” Model

Accident & InjuryAccident & Injury

Latent Unsafe Conditions


Active Failures

Active FailuresandLatent Unsafe Conditions

TopManagement

Pre-Conditions

OperationalActivities

SafetyFeatures

LineManagement


[Based on: Reason, J. (1997)]

ACCIDENTACCIDENT

Risk, Safety and Culture Risk = Probability of occurrence of an undesired

event x Consequences Safety:

Measures and practices undertaken to prevent and minimise the risk of loss of life, injury and damage to property and environment

Culture: Way of life; the customs, beliefs and attitudes that people in a

particular group or organisation share Safety Culture:

Is a subset of the organisational culture organisational culture is ‘the product of multiple interactions

between people (Psychological), jobs (Behavioural) and the organisation (Situational)

A Model for Understanding Safety Culture

[Source: Bandura (1986), Cooper (2000)]

Key Issues What is safety culture and how does it manifest? What are the factors that influence safety culture? How to measure or benchmark safety culture? How can we achieve “global minimum standards of

safety culture”? What has been the impact of the ISM Code?

Shipboard Safety Culture

Shipboard safety manifests in terms of: Ability to appreciate the risks associated with routine actions Preparedness to deal with emergency situations Clearly communicated safe practices and procedures Reporting and reviewing mechanism Perceptions about top management’s commitment to safety Confidence in self and others to respond to emergencies

A Road Map to Safety Culture?Uninformed

CultureSymptoms• Gaps in knowledge, & skills needed for safe operations• Poor emergency preparedness• Lack of training• Absence of exercises

Evasion Culture

Symptoms• Perfunctory approach• Focus on paperwork• Appearances are most important• Inadequate training• Poor emergency response

Safety CultureSymptoms• Safety awareness visible throughout• Collective approach• Proactive risk identification• High degrees of preparedness• Cohesive team

Compliance Culture

Symptoms• Focus on compliance• Conversant with rules• Flawless records• Safe practices a routine• Extensive checklists• Inability to deal with unforeseen emergencies


• Fatalism• Safety measures increase accident risk

• No matter what you

do, accidents will still

occur


•‘Excessive’ safety is “bookish”•‘Smart’ operations involve cutting corners •The chief objective is not to get into trouble with authorities

Behaviour pattern• Discipline• Obedience to rules• Clear role definition• Pride in doing things right• Group commitment• Clean record matters most

Behaviour pattern• Clarity of objectives• Positive group dynamics• Professionalism• Sure of support• Confident in emergencies

Two Approaches1. Top-down approach

Safety culture as a sub-set of organisational cultureObservation: Safety culture is market driven

2. Bottom-up approachSafety culture as learned behaviourObservation - MET institutions in developing countries (main suppliers of seafarers) are hampered by:

financial constraintspoor infrastructurenon-availability of qualified faculty and research capabilities

Proposed Strategy Combine top-down and bottom-up approaches Shipowners and MET institutions to interact closely in matters

of pre-sea and in-service training HRD policies and practices to come under the scrutiny of ISM

audits Benchmark safety culture in terms of risk (probability x

consequences) using exercises and simulations Link HRD practices and onboard safety with risk

management

Summary & Conclusion Bandura’s triangular model (Person, Organisation and Job)

offers a dynamic perspective of safety culture.

Top-down strategic HRD measures interfacing with a bottom-up approach in close association with MET institutions will help in fostering of safety culture.

Since top-down approach is the primary intervention strategy, the HRD practices come under scrutiny.

Integration of HRD practices and risk management tools can lead to effective promotion of safety culture in shipping.

Sound Culture Reporting Culture

Organizations with little trust often find it difficult to get people to admit to their own mistakes

Just and Fair Reaction to the reporting of events should be

proportionate to the intentions behind and the consequences of an action

Organizations which apply sanctions in a fair and just manner will build trust and creativity

Sound Culture Flexible and adaptable

Organizations which want creative contributions from its employees must have a degree of tolerance. E.g. value a verbal exchange of experience and creativity if it means work will be safer.

Sound Safety Culture Learning

The ability to share knowledge across organizational boundaries is a key aspect of a sound safety culture e.g. are employees fully involved in decisions affecting their safety and health?

Conflicting objectives are a way of life i.e. do the job quickly and efficiently, but do it safely without getting hurt

Management and Culture The significance of the way managers

speak and behave is often underestimated Managers who only get involved after the

event e.g. an accident will not enjoy the same credibility as those who were involved all the time

Behavioural Issues Behavioural issues are extremely

important Behaviour turns systems and procedures

into reality Good safety performance is determined by

the way an organization “lives” its systems and processes

Example of airlines - Fly similar aeroplanes Similar standards of pilot training Risk to passengers varies by a factor of 42

Demonstrate Management Commitment Senior managers meet to discuss safety

performance against objectives and targets

Time off provided for safety training. Managers safety leadership appraisal and

self assessment questionnaire Managers lead Safety Orientation training Adequate # of safety professionals are

available to assist operational and field staff. (Not to take over!!)

Behaviour Modification Pre-conditions

Is a significant proportion of accidents primarily caused by the behaviour of front line workers?

Do a majority of managers and supervisors want to reduce the current accident rate?

Will management be comfortable with empowering and delegating some authority for safety to workers?

Is management willing to trust the results produced by the workers?

Are the workers willing to trust management?

Behaviour Modification Pre-conditions

Is there a high level of management involvement in safety?

Is management willing to provide the necessary time and resources for workers to be trained and to carry out observations?

Has a program “champion or champions” been identified?

Are the existing communication processes adequate for the increased communication and feedback between management and workers?

Behavioural Change Conclusions Any behavioural modification program

needs a strongly implemented and robust HSE MS as a foundation

Research and practical evidence shows significant improvements can be achieved by implementing appropriate behaviour interventions

Behavioural modification initiatives unlikely to be successful unless job environment and organization factors also considered

Behavioural Change Conclusions Intervention tools which work at one

location, may not work at another Suitability of behavioural tools is

influenced by the existing safety culture

A Safety Culture model provides a framework to identify current level and identify appropriate action to improve and move to next level

The Journey

ForwardsBackwards

Stab

ility

HSE MATURITY CHART

• Administrator driven• Loose systems, elements of

NOSA• Re-active risk assessment• Minimum legal compliance• Apply PPE as a way of

eliminating exposure• Incident investigation and root

cause analysis (AOR)•Remedial action•Incident inquiry•Video conference

• Waste recognised but no plans• Ad hoc occupational hygiene and

environmental surveys• Reactive medical monitoring• Ad hoc HSE inspections

• Co-ordinator driven• NOSA 5 star system and ISO

9002 or equivalent• Risk assessment through existing

systems• Total legal compliance• Strictly enforce the use of PPE

where required (knowing risk)• Incident knowledge sharing

across departments• Waste sorting at source• Planned Occupational hygiene /

environmental monitoring• Periodical medical examinations• Planned HSE audits• Safety talks• Planned task observations

• Line driven• ISO 14001 and OHSAS 18000 or

equivalent• Pro-active formal risk assessment• Beyond legal compliance• Seek to actively engineer out

process/equipment inadequacies• Incident knowledge sharing at all

levels between individuals• Active waste reduction initiatives• Focus on control rather than

monitoring• Integrated audits• Peer evaluation and discussion

• Individually internalized• Integrated management

systems• Risk assessment integrated

into all systems• Self regulating• Eliminate problems before

they occur• Waste elimination as far as

possible• International recognition

through externalevaluation

• Un-coordinated• No system• No risk assessment• Legal non compliance• Accept equipment /

process decay• Superficial incident

investigation• Waste a necessary evil• Poor equipment condition• Permit non-compliance• Potential illegal practices

• Compliance culture• Participation• Near miss discussions

• Acceptable training/awareness• Established and good

communication channels• Safety half hour for people

involvement and focus

• Ownership culture• Involvement at floor level• Near miss involvement

• High level of training/awareness• Communication at a high level

hiding nothing

Improve the workingenvironment

Proactive

Regressive

Accept that incidentshappen

Prevent incidentsbefore they occur

PlannedReactive

Prevent a similarincident

Stable

HSE culture

Varia

bilit

y

• No care culture• Apathy/resistance• Near misses not

recognized• Negligence• Dishonesty• Hiding incidents

• No or little training• Poor or no communication

• Blame culture• Acceptance• Near miss reporting• Potential for window

dressing e.g. pre-inspectioncleanups and light duty

• Disciplinary action• Minimum training• Some communication on a need

to know basis

• Way of life• Comes natural• Personal involvement

by all to preventincidents

• Complete understanding• All informed at all times

about everything

Questionnaires Pros and Cons Wide coverage Can ask for yes/no or

sliding scale responses

Flexible timing for respondents

Standard format easy to summarize

Limited explanation, understanding of responses

No discussion of remedies, improvements

No commitment to change

Regular Meetings Pros and Cons Regular, frequent

opportunities Real players are in the

room Decisions can be

made Commitment to act

Regular agenda items intrude

No fresh perspectives Unequal status of

participants Internal problems go

unchallenged

Self Assessment Carefully considered evaluation resulting

in a judgment of the effectiveness and efficiency of the organization and the maturity of its HSE Management System

Self Assessment provides fact based guidance on where to invest resources for optimum improvement

Self Assessment and Audit Self Assessment

those who have the knowledge and expertise perform the evaluation

Audit auditee provides information to auditor who

performs the evaluation

ModuSpec Self Assessment Process

Combination of Survey Questionnaire and Facilitated workshop

Complements the audit process by focusing resources on prioritized areas

Where to use? Need to measure status of HSE MS

performance and the safety culture

Self Assessment Deliverables Comprehensive review of HSE MS to provide

status of: Compliance, performance and effectiveness

Reliable identification of HSE Culture and all major concerns and strengths

Full understanding of underlying factors Prioritized action plan for continual improvement Commitment and support from all levels

Facilitated Workshop Pros and Cons Brainstorming plus

standard questions Key players in room Focus and equality Deep discussion New benchmarks Electronic voting =

speed, anonymity

Time consuming for participants

Limited coverage Participants all come

to location Is there adequate time

to develop action plans?

Workshop principles Open, frank communication Trust Everyone's input is important The person who performs the task

understands it better than anyone else Group comments may be shared

externally but individual anonymity is preserved

Combination HSE Self Assessment Process

Decisions

Analyze

EmployeeQuestionnaire

PreliminaryAnalysis

Mixed TeamWorkshops

ManagementWorkshop(s)

No Action

Audit Key Risks

PrioritizedAction Plan

Combination Advantages Wide coverage to gather data Deep discussion to understand Managers/staff collaborative effort Accurate final analysis Graphic + Qualitative reporting Save audit for key risk areas Management workshop takes decisions

and feeds into business (action) plan

This Company Walks the Talk on Safety

1

4

7

Stronglydisagree

Stronglyagree

Just What We’re Looking For

2

4

6

1 2 3 4 5 6 7Disagree Agree

01234567Votes

This company walks the talk on safety.

A Specific Problem – Known Only to a Few

2

1 1

3

5


01234567Votes


Abandon Ship!!

6

4

2


01234567Votes


HSE Corporate Profile

0

1

2

3

4

5

BU Comparisons

0

1

2

3

4

5

North South Central

Workshop Output

Conclusions The need to understand Safety Culture or

Human Factors is the way of the future if we are to improve safety performance

Everyone’s doing it! UK - Culture Maturity Model and Climate

Questionnaires Canada – Safety Stand Down Week Perception

Survey, Imperial, CPC, Shell Hearts and Minds US – Dan Petersen Perception Surveys started

in the early 90s on railroads

Conclusions In the 80s, there was UPITFOS, which initiated the

Basic Safety Program (BSP) and Certificate of Recognition (COR)

Is Safety Culture the step change needed for the beginning of the 21st century?

Should we draw closer parallels to Quality Management and use Six Sigma Safety Culture approach?

Statistical information from the UK offshore and North America would suggest that significant improvements are resulting from Safety Culture initiatives

Expansion of safety culture framework: Two approaches to managing uncertainties* (Grote, 2004)Minimizing uncertainties complex, central planning systems reducing operative degrees of freedom through procedures and automation disturbances as to be avoided symptoms of inefficient system design

Coping with uncertainties planning as resource for situated act ion maximizing operative degrees of freedom through complete tasks and lateral cooperation disturbances as opportunity for use and development of competencies and for system change

Dependence /

feedforward control

Autonomy /

feedback control

Balance through loose coupling Motivation through task orientation

Higher order autonomy Flexible changes between organizational modes

Culture as basis for coordination/integration * Uncertainties may stem from the system environment and/or from the transformation processes within the system.

Sociotechnical model of safety culture (Grote & Künzler, 2000)

}

}

Proactiveness

Sociotechnical integration

Value- consciousness

Joint optimization of technology and work organization aiming at the control of disturbances at their source

Integration of safety in organizational structures and processes

Values and beliefs that further integration of safety in all work processes

Norms related to socio-technical design principles like automation philosophy and beliefs concerning trust/control

visible, but difficult to decipher

Material characteristics of the organization

hidden, taken for granted

Immaterial characteristics of the organization

Aim: Linking safety culture to overall organizational culture as well as to characteristics of the material organization beyond directly safety-related activities

Assessing safety culture by comparing judgements of employees in different departments/hierarchical positions

(as complement to observations and interviews) Assessing safety measures (=Proactiveness re: safety)

Formal Safety: e.g. There are sufficient written procedures, checklists etc. to ensure process safety.Enacted Safety: e.g. Proposals developed during safety meetings are swiftly implemented.

Assessing system design strategies (=Socio-technical integration)Example:Plant personnel can intervene in automated processes to ensure quality and safety of production.vs.Plant personnel may not intervene in automated processes in order not to jeopardize safety.

How to include organizational change in safety management?

Organizations may need evolutionary, but also radical change in order to respond to internal and external demands

Limitations of organizational development. Radical organizational change can harm process and work safety.

Structural level: Reduced resources for safety; unsafe work processes etc.

Individual level: "objective" indicators like absenteeism; "subjective" indicators like anxiety

Which effects are caused by organizational change depends also on the way the change process is carried out.

In risk audits, safety management as well as change management need to be assessed.

process safety management & safety culture 22 nov 2007

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