Ivan PupulidyDynamic Inquiry LLC

Santa Fe, New Mexico

Safety Culture or A Culture of Safety

Achieving excellence in High-Risk Environments

What we learned about culture and change

•Everyone hated changes and we had a bunch of them.

•What made this different?

•What difference did the change make

A Predictive Maturation Model

1. Compliance-

based Phase

3. Learning

Organization

2. Best Practice

Phase…

Evolution of a Safety Culture

1. Safety Performance is Based on Rules,

Regulations and Compliance Driven

2. Safety Performance is Considered an

Organizational Goal

3. Safety Performance Can ALWAYS be

Improved and learning is essential

Safe Operation, in reality, is a complicated and messy business.

Culture is shaped by what we measure reward and punish.

How an organization responds to error, failure and success shapes culture.

We began to learn how to:

Challenge Existing Models.

Including: Where and how we believe safety is created?

Safety is Perceived

Workers make operational trade-offs based on the feeling of being

safe.

Traditional Response• Drive out error and Punish the Culprit

Application& adaptation

Procedures

Complex adaptive problem solving

ExperienceImprovisation

Prescriptive PolicyControls

Empowerment

Explicit Training

Expert

ComplianceNoviceRules

Tacit Skills

Planning

Intuition

NoviceRigid adherence to rules or plansLittle situational perceptionNo (or limited) discretionary judgment

Advanced Beginner

Guidelines for action based on attributes and aspects, which are all equal and separateLimited situational perception

CompetentConscious deliberate planningStandardized and routine procedures

Proficient

Sees situations holistically rather than as aspects Perceives deviations from normal patternsUses maxims for guidance, whose meanings are contextual

ExpertNo longer relies on rules, guidelines or maximsIntuitive grasp of situationsAnalytic approach used only in novel situations

Dreyfus and Dreyfus

The currency of safety is information

Our first steps toward understanding the

Human Contribution!

Routine vs. Adaptive Responses

• Programmatic Responses - Programs are a sequence of predetermined actions

• Based on by predicted circumstances

• Great economy - don’t have to think

• Adaptive Responses - Deal with unexpected circumstances and require the capacity to make sense of information, learn in the moment and innovate solutions.

Realistically -Things go right because people:

• Learn to overcome design flaws.

• Adapt performance to meet demands.

• Interpret (adapt) guidance to meet conditions.

• Detect and correct problems before things go

wrong.

Heroes and Villains

• “Why do they allow them to

fly where the birds fly” NBC News

“THE INSIDE STORY

OF A TEXTBOOK

LANDING”USA Today

Our systems can

be:

Simple,

Complicated and

Complex

All at the same

time!

• Interactive

• Interconnected

Simple

Complicated• Interactive

• Interconnected

• Diverse

Complex• Interactive

• Interconnected

• Diverse

• Adaptive

Complex systems require

•Sensemaking

•Learning

•And Improvisation

•Routine can make the the system more vulnerable.

Cultural Change

Our Story

Initial PremisesEspoused

values

Deep Assumptions

Actions/Decisions

Leadership Journey

•Challenge the concept of Knowing

• Humble Inquiry

• Role of leadership

• To create an environment where workers can be successful

• Dialogue and Relationship - Trust

Safety Journey

•Visited other organizations to learn

• USCG, ConEd, UPS, LANL

• What was the investment in safety

• How was safety defined

• How could we develop our definition

• Self-Design

Organizational Response

•How did we change our approach to learning from events

• Who had do learn

• How we redefined learning from events

• Learning Review

• Re-define learning - Trust

The Search for Justness

The organization’s willingness to explain

how the incident could have happened and

Why the actions made sense to the

individuals at the time.

Martin Luther King

“Not so much who ...”

Questions

Ivan Pupulidy, Ph.D.Dynamic Inquiry, LLC

DynamicInquiry@me.com

Safe Systems Drift

• The longer a system functions without incidents (i.e. ones that work “safely”), The greater the expected departure from prescribed rules, regulations, policies and procedures.

What impedes objective risk quantification

• System complexity

• System variability

• Individual adaptation

• Risk compensation

• Experience

• Everyone else is seeking to manage risk

• They are all guessing - or it wouldn't be risk

• Their guesses are strongly biased by beliefs

• The behavior of nature and others = your risk environment

• Safety interventions must alter peoples propensity to take risk (contentment)

• Nature will retain most of her secrets and science will continue to invent new risks

• Potential safety benefits tend to get consumed as performance benefits.

Pupulidy

Pupulidy

Expectation and Judgment