SAFETY CULTURE - t C

Charles Packer 2006 [email protected]

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SAFETY CULTURE

CANADIAN AVIATION SAFETY SEMINAR 2006

Charles Packer

26 April 2006

CherrystoneManagement Inc.


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OVERVIEW OF TOPICS

Organizational Culture

Safety Culture & Events

Culture & Management Systems

Assessing & Improving Safety Culture

Making Change


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ORGANIZATIONAL CULTURE

“The way we do things around here…..”


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ORGANIZATIONAL CULTURE

Edgar Schien’s simple model of culture is widely accepted.

He suggests that organizational cultures can be considered in THREE LAYERS

Everything Observable

Not directly observable

Stated by management

Visible

InvisibleAssumptions

Espoused Values

Observable Artefacts


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SCHEIN’S LAYERS: THE CONCEPT

1. What we experience shapes what we believe: ARTEFACTS CREATE ASSUMPTIONS

2. What we believe shapes what we do and say: ASSUMPTIONS CREATE ARTEFACTS

3. What we do and say gets imitated and eventually become the “NORMAL PATTERNS “ of thinking and behaving that we call “THE CULTURE”

4. Ultimately the most important influences are the INVISIBLE ASSUMPTIONS that we hold.

We do not guard against what we do not believe can happen


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CULTURE AS CYCLE

which create our BELIEFS and PATTERNS about what to do in situations, that drive….

BEHAVIOURS (words and actions)…

create VISIBLE OUTCOMES….

Our…

Other People’s …

that we OBSERVE AND EXPERIENCE


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ORGANIZATIONAL SUB-CULTURES

1. The Executive Culture: Focused on money, performance, measurement, production, processes, information, abstractions…..

2. The Technology Culture: Focused on science, equipment, automation, IT…. Tends to want to eliminate the human being as a uncontrolled variable, is rational, logical, resists “culture” ……

3. The Operating Culture: Focused on making things work, accepting the frustrations of “the way things are”, a camaraderie of people living in “the real world”…….

4. All influenced by… The Regulatory Culture…….


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SOME RULES OF ORGANIZATIONAL CULTURE

1. Cultures are not good or bad, but they ARE good or bad at achieving certain outcomes

2. There is always a security culture in an organization. But is itwhat is needed?

3. Cultures are learned by their members, so changing the culture requires a lot of discussion, communication and learning

4. Changing behaviours is difficult, because people have very strong “patterns” that they follow from habit

5. People are generally unconscious of their own assumptions

6. Leaders change culture by holding different assumptions and by making them visible through words and action.


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WHY DO ASSUMPTIONS (BELIEFS) MATTER?

Suppose we work in a nuclear power plant, and we get very comfortable with the technology and there has never been a majorevent….We can come to believe (usually unconsciously) that

“THE PLANT IS ROBUST… IT HAS SOME SAFETY MARGIN”

20 YEARS AGO TODAY…… (26 April 1986)…….

The control room operators at Chernobyl held this belief, or they would not have bypassed all of the interlocks and ignored alarms as the reactor was moving towards disaster.

The reactor tried to speak to them, but their belief in the technology and their pattern of obedience to instructions from above were stronger than its desperate signals…..


10EVENT

“LAST-CHANCE” Barrier

LEARNING Barrier

PEOPLE Barrier

PHYSICAL Barrier

HAZARD

INVISIBLE ASSUMPTION

“The plant is robust, it has some margin”

Make non-conservative decisions in situations of uncertainty

Don’t report minor problems or unusual observations

Don’t follow all the procedures

Lack of a sense of urgency about fixing defective equipment


11EVENT

RESPONSE Barrier

LEARNING Barrier

BEHAVIOUR Barrier

PHYSICAL Barrier

THREAT

INVISIBLE ASSUMPTION

“There is no major threat”

Don’t take immediate action to an unusual situation

Don’t report unusual observations

Don’t repair security equipment

Let people through barriers without proper checks

A SECURITY EXAMPLE……..


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A SINGLE INCORRECT ASSUMPTION LEADS TO A

BREACH IN EVERY SAFETY OR SECURITY BARRIER

At this point we say we have “CULTURAL

PROBLEMS”!


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SAFETY CULTURE AND EVENTS


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EVENTS

1. Challenger and Columbia Space Shuttle disasters

2. Rail crashes in the UK

3. Oil platform fires (Brazil and others)

4. Nuclear safety events

a) All of these events have their roots “deep in the organizational culture”

b) Most events have happened in developed countries.

c) The root causes appear to have been established many years before the event, yet went undetected

d) The root causes are hard to fix: (e.g. in the case of the space shuttle there appears to be overlaps of causes with the Challenger disaster of 1986)


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CULTURE AND MANAGEMENT

SYSTEMS


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SAFETY CULTURE & SAFETY MANAGEMENT

Systems are understood and followed?

YES

NO

Strong Management Systems Exist?

YES NO

Good Safety Culture Informal Systems Appear

Poor Safety Culture Blind Spots


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BARRIERS

THE MAJOR BARRIERS TO EVENTS ARE:

1. BELIEFS AND ASSUMPTIONS about what can go wrong, and how to deal with it

2. Effective MANAGEMENT SYSTEMS

3. Appropriate BEHAVIOURS by leaders and everyone

4. PHYSICAL SYSTEMS AND EQUIPMENT

The SAFETY (or quality or security) CULTURE is “The way we handle these things”.


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MANAGING THE BARRIERS

UNDESIRED EVENTS ARE CONTROLLED BY:

1. Barrier elements that are established AHEAD OF TIME (e.g. Regulations, Design Basis, Physical Systems, Procedures, Training, Information Gathering…)

2. Barrier elements that OCCUR IN REAL TIME (e.g. Monitoring, Decision-making, Responding, Following procedures, Diagnosing problems….)

3. Barrier elements that MINIMIZE OR MITIGATE THE UNKNOWN (e.g. Observant people, Questioning attitude, Reporting unusual occurrences, performing culture assessments….)

The “TYPES OF CONTROL” and the “MAJOR BARRIERS” can be put onto a map


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SAFETY CULTURE AS BARRIERS AND CONTROLS

Outcomes

Physical Equipment &

Conditions

Behaviours

Management Systems

Assumptions (INVISIBLE)

What we believe

CONTROL AHEAD OF

TIME

CONTROL IN REAL TIME

MINIMIZE OR MITIGATE

UNKNOWNS

UNEXPECTED EVENTS

Emerge suddenly from what isINVISIBLE or UNKNOWN


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TYPICAL SAFETY CULTURE FRAMEWORK

Objectives and results indicate a strong regard for safety

Physical working conditions are safe and equipment is in good condition

Safety principles are applied

Safety-critical assumptions are widely shared

Behaviours foster a healthy safety culture

(Leaders & Individuals)

Management Systems are effective

Organizational learning is embraced


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IMPROVING SAFETY CULTURE


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STEPS FOR CULTURE IMPROVEMENT

1. Obtain Top Management Commitment

2. DESCRIBE THE DESIRED CULTURE in a structured “framework”

3. Build a Common Understanding of Culture

4. ASSESS THE EXISTING CULTURE

5. Communicate the Assessment Results

6. Identify Gaps, Root Causes and Key Initiatives to Improve

7. Communicate the Direction and Engage Supervisors & Staff

8. IMPLEMENT CHANGE


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DESCRIBE THE DESIRABLE “OBSERVABLE CHARACTERISTICS”

EXAMPLE (Organizational Learning)

“People report they are comfortable raising safety concerns without fear of retribution. This includes concerns which are less tangible such as feeling excessive pressure to get the job done.”

A typical comprehensive safety culture framework will contain 60-80 characteristics


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ASSESS THE CULTURE

1. Produce a set of tools matched to the framework

2. Examples: staff survey, event review checklist for quality culture elements, interview guides, meeting observation guide etc.

3. Perform assessment using an internal team with some external help. Use professional expertise for statistics etc. but own the methodology internally as far as possible


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EXAMPLE

“Staff report they are comfortable raising safety concerns without fear of retribution. This includes concerns which are less tangible such as feeling excessive pressure to get the job done.”

This could be assessed by:

1. SURVEY

2. INTERVIEWS

3. CHECKING THE RECORDS TO SEE THAT MINOR CONCERNS ARE IN FACT BEING REPORTED


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REPORTING AND INTERPRETING SAFETY CULTURE

1. Low scores are not always bad – the problem may have only just been recognized, awareness may be high and dissatisfaction may reign.. This is NOT bad, provided progress is made over time

2. High scores are not always good – If 95% of people say they work safely, but the accidents and events do not agree with thisperspective, then there is something wrong

3. Culture is DYNAMIC to some degree. New programs will typically score low until they start to be accepted.

To get round some of these problems, we plot safety culture results on a “MAP”


27DYNAMIC: The issue is receiving attention and appears to be dynamic

EMBEDDED: The issue is long-standing and appears to be relatively stable

EMERGING: The issue is not widely recognized but may impact the SC

Strong characteristic >90%

Good characteristic 75% - 90%

Attention Characteristic 40% - 74%

Weak characteristic < 40%

Not Rated: emerging issues only

SAFETY CULTURE MAP

IDEAL TREND from awareness

to strength

MAJOR PROBLEMS


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SUMMARY

1. There is always a Safety Culture in the organization

2. It is founded on invisible beliefs or assumptions, and these assumptions can be highly dangerous

3. The culture manifests its self as patterns of behaviour and other observable characteristics

4. The desired safety culture should be described in a structured framework

5. A set of assessment tools can be developed to find out how the real culture matches up to the desired culture

6. The results need careful interpretation

7. Improvements can then be made


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MAKING CHANGE


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MAKE CHANGE

THE ORGANIZATIONAL AQUARIUM

Think of the existing patterns of thinking and acting as fish in an aquarium..


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GOLDFISH AND PIRANHAS

MANAGEMENT INTRODUCES GOLDFISH PROGRAMS…

The existing patterns in the culture (existing fish) are interested in their own survival.

A new goldfish may be interesting and nice to look at, but the existing fish keep swimming!

There is lots of food for them and their habitat is not being changed

MANAGEMENT INTRODUCES PIRANHA PROGRAMS…

The new ideas and methods are introduced in ways that eat up or eliminate the old patterns…..


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LAUNCHING PIRANHAS NEEDS LEADERS WHO….

1. Tell stories and explain things well

2. Challenge existing practices

3. Are willing to be criticized and to learn

4. Are very specific about behaviours

5. Compel when necessary

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SAFETY CULTURE - t C