Safety  Culture:    Where  Do  We  Stand?  and  where  are  we  going…  

John  S.  Carroll  MIT  Sloan  School  of  Management  

Safety  Culture  Symposium  Halifax,  NS  

October,  2014  

Three  Problems  

1)  We  know  liNle  of  what  safety  culture  is,  how  to  measure  it,  or  how  to  change  it  (ambiguity)  

2)  AQer  decades  of  avoiding  culture,  “bad  safety  culture”  is  now  thought  of  as  the  source  of  safety  issues  (root  cause  seducUon)  

3)  Safety  culture  is  seen  as  a  “thing”  to  be  managed  and  improved  as  a  separate  project  (soluUon-­‐mindedness)  

History  of  “Safety  Culture”  •  A  label  invented  by  IAEA  25+  years  ago  following  Chernobyl  

•  Chernobyl  was  due  to  “something”  more  than  equipment/design  or  human  error  –  pervasive  yet  hidden  –  neither  understood  nor  managed  

•  The  pragmaUc  result  of  the  label  was  decades  of  aNenUon,  also  by  regulators  and  consultants:  –  Piper  Alpha,  Herald  of  Free  Enterprise,  Baker  Panel  – NASA  shuNle  losses,  Gulf  Oil  Spill,  hospitals,  etc.  – US  NTSB  blames  pipeline  leaks,  train  collisions,  etc.  on  “ineffecUve  safety  culture”;  Canada  TSB  Lac-­‐MeganUc  

–  INPO  10  “traits  of  a  healthy  nuclear  safety  culture”  – NAS  Marine  Safety  Board  safety  culture  study  group  

“Safety  Culture”,  like  any  culture,  is  

•  Values:  a  high  priority  placed  on  safety  •  Norms:  what  we  do;  what  is  expected  and  “right”  •  Beliefs:  what  is  perceived  to  be  true  •  Assump0ons:  unstated  definiUons  and  raUonales  (fish  don’t  see  the  water)  

•  Symbols:  heroes,  stories,  jargon,  arUfacts  •  Strength:  few  or  many  impacts;  shared  widely  or  divergent  across  groups,  locaUon,  or  subcultures  (Schein:  managers  vs.  engineers  vs.  operators)  

Schein’s  Model  of  OrganizaUonal  Culture  

Ar0facts:  what  you  see,  objects,  structures  

Values:  strategies,  goals,  philosophies,  jusUficaUons  

Assump0ons:  taken  for  granted  beliefs,  mental  models,  habits  

Culture  is  Meaning  

•  Leaders  and  individuals  “emphasize  safety  over  all  other  compeUng  goals”  (e.g.,  BSEE,  2011)  

•  “AppreciaUon  for  the  importance  of  safety…  for  its  integraUon  and  balance  with  compeUng  performance  objecUves”  [how  different  is  that?]  

•  What  does  this  mean?    We  learn  what  to  do  thru  watching  and  improvising  to  see  what  works  

•  How  to  get  commitment  to  desired  values  and  behaviors  vs.  cynicism  and  check-­‐the-­‐box  compliance  (and  defensive  misrepresentaUon)?  

Cultural  AssumpUons    Each  culture  will  be  a  unique  combina2on  of  behaviors,  values,  &  assump2ons  arising  from  history  &  leaders,  based  on  what  has  worked  in  the  past,  then  taught  to  newcomers:  

 •  “Human  error  is  the  cause  of  accidents”  •  “People  must  be  held  accountable  for  their  acts”  •  “Good  managers  don’t  have  any  problems”  •  “Safety  is  the  responsibility  of  safety  experts”  •  “Safety  is  assured  by  wriUng  and  following  rules”  •  “Risks  can  be  calculated”  •  “There  is  one  best  way,  one  best  safety  culture”  •  “Our  organizaUon  is  unique  –  we  must  do  it  our  way”  •  “We  need  humans  to  deal  with  unpredictable  events”  

Artifacts? Values? Assumptions? Anything “wrong” here? Is this one person innovating, or part of a “culture”? Will improvement require culture change? Did you see the other worker and supervisor?

Safety  Culture?  

Approaches  to  Safety  Culture  •  An  ideal:  Safety  as  an  overriding  value,  aNenUon  to  safety  

commensurate  with  risks  •  A  set  of  organizaUonal  a;ributes  or  processes,  e.g.:    

–  Informed,  reporUng,  just,  learning,  flexible  (Reason);  –  PreoccupaUon  with  failure,  reluctance  to  simplify,  sensiUvity  to  operaUons,  resilience,  experUse  (HRO;  Weick  &  Sutcliffe);  

–  INPO  10  traits  of  a  healthy  safety  culture      •  A  scorecard:  Self-­‐percepUons  of  climate  on  a  survey,  

including  management/front-­‐line  difference  •  A  conversa0on  starter:  An  acceptable  way  to  get  lots  of  

people  talking  and  working  on  “soQ  stuff”:    e.g.,  can  people  discuss  that  “the  mentality  now  is  to  move  trains”?  

   

Culture  and  Climate  •  Culture  is  difficult  to  measure  and  manage  •  Climate  is  percep0ons  of  culture:  easy  to  measure  (survey)  

and  holds  the  promise  of  a  leading  indicator,  but…  •  Percep0ons  can  be  misleading,  e.g.,  “respect”  scores  low  

because  health  insurance  changed  •  Variability  within  organizaUon  by  unit,  hierarchical  level  •  Aspects  of  safety  climate  may  act  in  combina0on  (safety  

priority,  procedures,  communicaUons,  learning  climate)  •  Safety  climate  antecedents  and  consequences  may  be  

industry  specific  (recent  meta-­‐analysis)  •  Most  safety  climate  evidence  refers  to  personal  safety,  not  

process  safety  –  personal  safety  is  more  tangible,  percepUble;  process  safety  involves  interfaces/linkages  

Looking  for  the  Keys  Under  the  Light  

•  “As  applied  by  safety  researchers,  the  culture  concept  is  deprived  of  much  of  its  depth  and  subtlety,  and  is  morphed  into  a  grab  bag  of  behavioral  and  other  visible  characteris8cs,  without  reference  to  the  meaning  these  characteris8cs  might  actually  have,  and  o:en  infused  with  norma8ve  overtones.”  (Guldenmund,  2010)  

•  Can  percepUon  surveys  pick  up  the  typical  “culture”  problems  seen  aQer  invesUgaUons  of  major  events?  –  Senior  leadership  decision  making,  teamwork,  prioriUes  –  AllocaUon  of  resources,  status,  power  –  OrganizaUonal  silos  with  unrecognized  interdependencies  –  RouUne  violaUons  (“we’ve  always  done  it  this  way”)  

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The Meaning of “Safety”: BP days away from work 1987-2008

North Sea Disaster; Grangemouth Incident

BP Amoco Merger

TXC explosion

Measures Days Away From Work Case Frequency (DAFWCF) per 200,000 hrs

BP’s  obsessive  aNenUon  to  personal  safety  remains  embedded  in  the  culture.    The  

assumpUon  that  “safety”  =  “personal  safety”  had  to  be  changed  (cf.  TXC),  but  this  has  taken  years!  

Very  similar  story  with  D.C.  Metro  train:    “safety”  =  no  parking  lot  injuries!  

*Plan  is  to  delegate  HCA  authority  to  CBC.

SRS RL ORP CBFO PPPO ID

EM-­‐1EM-­‐4

Chief  Business  Officer

EM-­‐5  Communications  &  External  Affairs

Chief  of  Staff

OR CBC*Small Sites**

The  EM  Leadership  Pyramid

EM-­‐2EM-­‐3

Chief  Technical  Officer

DASProject  Management

EM  Recovery  Act  Program

DASSafety  &  Security  Program

Technology  Innovation&  Development

DASTechnical  &  Regulatory  Support

DASProgram  &  Site  Support

DASProgram  Planning  &  Budget

Management  Systems  &  Analysis

**Small  Sites:  EM:  WV,  SPRU,  GJO/MOAB,  Oakland,  ETEC,  SEFOR,  Miamisburg,  GE  Vallicitos;  Science:  BNL,  ANL,  SLAC;  NNSA:  NTS,  LANL;  LM:  Tuba  City

DASHuman  Capital  &  Corporate  Services

DASAcquisition  &  Contract  Management

DOE  Env.  Mgmt.  Redesign:  Empower  the  Field  

“The  ‘EM  Leadership  Pyramid’  and  supporUng  organizaUon  structure…    recognizes  that  the  EM  mission  is  performed  and  achieved  in  the  field.”  

HQ    

“Field”  

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Cultural Organizations are institutions

An organization is a symbolic system of meanings, artifacts, values, and routines.

Informal norms and traditions exert a strong influence on behavior.

Action comes through habit.

Poli0cal Organizations are contests An organization is a social system

encompassing diverse, and sometimes contradictory, interests and goals.

Competition for resources is expected. Action comes through power.

Strategic  Design Organizations are machines

An organization is a mechanical system crafted to achieve a defined goal. Parts

must fit well together and match the demands of the environment. Action comes through

planning.

Perspec2ves  or  “lenses”  are  organized  ideas  (e.g.,  metaphors)  that  fundamentally  shape  our  understanding  of  things  and  events.  

“Culture”  is  One  PerspecUve  

Building  Safety  Culture  •  Difficult  to  mandate;  culture  is  not  an  end  in  itself    •  Shape  culture  while  solving  problems  (together)  •  Build  shared  purpose  and  capability:  commitment  allows  

for  shorter  feedback  loops  (more  reliable)  •  Leaders  are  watched  closely  for  signals  •  Leverage  exisUng  posi0ve  examples/models  •  NRC  was  NOT  the  main  source  of  safety  culture  in  nuclear  

power:  INPO  peer  learning  in  compeUUon-­‐free  context  •  Be  clear  where/why  you  need  strict  compliance  •  It  takes  0me  to  culUvate  and  try  out  new  behaviors  •  Safety  culture/climate  self-­‐analyses  may  generate  useful  

conversa0ons,  aNenUon  to  culture,  openness  and  trust,  but  there  is  also  a  risk  of  increased  cynicism  and  resistance  

Measuring  (Safety)  Culture  •  Ethnography  –  anthropological  field  worker  observes  for  months,  interviews  key  informants;  emphasis  on  novelty  and  richness  over  reproducibility  

•  Surveys  –  universal  dimensions  to  compare  cultures,  e.g.,  Hofstede,  Quinn  compeUng  values,  OCI,  climates  (safety,  innovaUon,  learning,  performance,  service…)  

•  Facilitated  Group  Self-­‐Analysis  (Schein,  2004):  describe  arUfacts  and  espoused  values  and  examine  contradicUons    

•  Cultural  strength  or  uniformity,  e.g.,    –  Top  vs.  middle  vs.  boNom  climate  score  differences  –  Subcultures  and  “hotspots”  (departments,  locaUons,  professions,  cohorts,  etc.)  

Measuring  Safety  Culture  

Prac0cality  (cost,  0me,  exper0se)

Valid

ity  (accuracy)

Ethnography

Guided  self-­‐analysis

Interviews, Focus  groups

Surveys

Surveys  +  Focus  groups

Surveys  +  Guided  self-­‐analysis

Measurement  à  Management  

•  Measurement  is  necessary  but  not  sufficient  •  Measurement  is  an  interven0on  –  everyone  is  curious  and/or  anxious  -­‐-­‐  what  will  happen?  

•  Another  top-­‐down  ini0a0ve  that  changes  nothing  and  increases  cynicism  and  resistance?  

•  Or,  an  opportunity  to  engage  a  wide  range  of  stakeholders  in  self-­‐analysis  and  innovaUon?  

•  Sustained  change  requires  engagement,  commitment,  and  embedding  mechanisms  

Climate  Surveys  as  Tool  for  Change  •  Get  people  involved  in  planning  and  design  •  Work  hard  to  get  a  high  response  rate,  e.g.,  Nuclear  Fuel  Services  had  well  over  90%  

•  Include  some  free  text  responses  •  Feedback  to  workforce  and  engage  focus  groups  in  generaUng  meaning  from  responses  

•  Create  task  forces  to  work  on  themes  •  Put  resources  into  change  implementa0on  •  Communicate,  communicate,  communicate  •  Tilt  the  culture  by  how  you  engage  people  to  solve  real  problems  they  care  about  

SUBSAFE  •  Created  aQer  loss  of  Thresher  in  1963  by  Adm.  Rickover  (16  subs  in  50  yrs.  before  vs.  0  in  50  yrs.  aQer)  

•  Unified  approach  to  safety  embedded  in  culture  •  Limited  goals  (hull  integrity),  clearly  stated,  shared,  “hearts  and  minds”;  separa0on  of  powers  (program/tech  authority/safety)  

•  Tough  but  fair:  objecUve  quality  evidence,  documented;  audits  a  partnership  mixing  insiders  and  outside  peers,  a  learning  opportunity,  ALL  are  audited  (HQ  too)  

•  A;en0on  to  culture:  annual  renewal,  alert  to  complacency  and  arrogance,  “trust  but  check  up,”  audit  up,  quesUoning  aytude,  vigilance,  shared  responsibility,  training,  learning  

Going  Forward…  1)  We  know  liNle  of  what  safety  culture  is,  how  to  

measure  it,  or  how  to  change  it  (ambiguity)  §  We  are  learning  as  we  work  together  mindfully  on  

shared  important  problems  (including  researchers!)  2)  AQer  decades  of  avoiding  culture,  “bad  safety  culture”  

is  now  thought  of  as  the  source  of  safety  issues  (root  cause  seducUon)  §  Yes,  and…  use  mul8ple  lenses;    mostly,  what  we  call  bad  

safety  culture  is  just  bad  management!  3)  Safety  culture  is  seen  as  a  “thing”  to  be  managed  and  

improved  as  a  separate  project  (soluUon-­‐mindedness)  §  Focus  on  the  work;  improve  the  culture  by  the  way  

people  work  and  learn  together  to  solve  problems  and  develop  capabili8es  

I look forward to discussion

“Not  everything  that  counts  can  be  counted,  and  not  everything  that  can  be  counted  counts”

   W.  B.  Cameron  (widely  aNributed  to  Albert  Einstein)  

Extra  Slides  

“Safety  Culture”  

The  product  of  individual  and  group  values,  aHtudes,  percep2ons,  competencies,  and  paIerns  of  behavior  that  determine  the  commitment  to,  and  the  style  and  proficiency  of,  an  organiza2on’s  health  and  safety  management.  (INSAG,  1991)  

Safety  Culture  Themes  Like  personaliUes,  each  culture  is  unique,  yet  there  are  recurrent  themes  and  similariUes,  e.g.,    

•  Accountabili0es:    individual,  group,  organizaUonal,  including  blame  and  jusUce?  

•  Approach:  PrevenUon  or  Resilience?  •  Hazard  Focus:  Personal  or  Process  Safety?      •  Compliance:  How  many  rules?  Rules  =  Guidelines?    Rules  as  a  way  to  shiQ  blame  to  the  front  line?  

•  Power  and  Status:    Scarce  or  shared?  •  Trust:    Faith  in  people?  Faith  in  insUtuUons?  •  Knowledge:  Exploit/perform  or  explore/learn?  

INPO   Flin  et  al   Chris0an   Cox   Health  F   Reason   Weick  

Leader  Values  

X   Mgmt  aN  &  beh  

Mgmt  commit  

Mgmt  commit  

Leader  

Decisions  PrioriUes  

X   Work  pressure  

Work  pressure  

Safety  priority  

Work  environ  

Respect   X   HRM  prx   Support   Just  

Report   X   Speak  up   X  

Improve   X  

Learn   X   X   Resilient  

Work  Processes  

X   Safety  systems  

Safety  systems  

Safety  rules/en  

Safety  systems  

SensiUve  to  ops  

Account-­‐ability  

X   Teamwork  

Involvement  

Teamwork  

Defer  to  experUse  

QuesUon   X   Risk  aN?   Job  risk   Risk  aN   Risk  perc   Preocc  

Commun   X   Superv   Commun   Commun  

Competence  

X   Personal  resource  

Reluct  to  simplify?  

How  does  Culture  Change?  

•     Natural  evoluUon  (society,  technology,  market)  •     Managed  evoluUon  (learning  &  development)  •     Challenges  to  Cultural  AssumpUons:  

•  “CharismaUc  Leadership”  •  Scandals  •  Infusion  of  “Outsiders”  • Mergers  &  AcquisiUons  • Coercive  Persuasion  (turnarounds)  •  Self-­‐DestrucUon  &  ReconstrucUon  

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