V1.2

Safety culture安全文化

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

V1.2

Outline 大纲 Introduction and overview 介绍和概述 Safety culture 安全文化 Characteristics of positive safety culture

积极的安全文化的特点 Safety culture development 安全文化培育 Conclusions 结论

V1.2High Reliability Organisations高可靠性组织

Why Do Injuries Happen ?

职业伤害为什么会发生？

HUMAN UNRELIABILITYconcentration, memoryDESIGN BOOBY TRAPS: hardware, proceduresOPERATING ENVIRONMENTtraining, supervision, resources, cultureCOMMUNICATIONassumptions, misunderstandings

人不可靠注意力，记忆力设计陷阱：硬件，程序经营环境培训，监督，资源，文化沟通假设，误解

V1.2

Piper Alpha

Piper Alpha 钻井平台

公众对 Piper Alpha 钻井平台灾难的质询

V1.2

It won’t happen to me....

When anyone asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worth speaking about....I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort.“

当有人问我怎样才能最好地描述我在海上近 40 年的经历，我只是说平安无事。在我身上从未发生过任何事故。。。我从未见过一个沉船事件，自己的船也从未沉过，我也从未陷入任何让我生命受到任何形式灾难的威胁的困境。Edward J. Smith

(Captain of the Titanic 泰坦尼克号船长 )

V1.2

Piper Alpha

It is essential to create a corporate

atmosphere or culture in which safety is understood to be and accepted as, the number one priority”

对企业来说，营造一种氛围或文化是至关重要的。在这种氛围或文化中，安全被理解为，并且被接受为头等重要的大事。 (Cullen, 1990)

V1.2

Safety 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 disaster

Pro-active approach involving self-assessment and feedback of less visible elements of safety management system

Desire to win “hearts and minds” to improve safety Alternative, leading safety performance indicator 安全管理系统不会有效，除非 有“良好的”安全文化相伴随 对会提高重大灾害的风险的潜在危险因素能一直保持警惕 前瞻式方法涉及到自我评估和对安全管理制度较少的不可见的元素的反馈 赢得“人心和智慧”的愿望推动安全改进 可选择的，引向安全绩效的指标

Why focus on culture?为什么要关注文化

V1.2

Culture has been defined as: 文化被定义为： A pattern of basic assumptions 一个基本假设的模型 Invented, discovered or developed by a given group 由指定的一个团队发明、发现或开发 Learnt from coping with problems of external adaptation and internal integration

从处理外部适应性问题和内部整合问题中学习 That has worked well enough to be considered valid 运行良好，足以被认为是有效

的。 Is taught to new members (as the) 传授给新成员 Correct way to perceive, think and feel in relation to problems

用正确的方法去感知、思考和感觉相关问题

Schein 1990 p110

Culture 文化

V1.2

Elements of the culture 文化的要素 Basic assumptions: 基本假设

– Represent a system of shared meaning that is difficult to verbalize. Shared values that guide decision making.

– 代表一个难以用语言表达的共享意义的系统。共享价值观指导决策 Espoused values 信奉的价值观

– What people say is important expressed through stories and myths

– 人们通过故事和神话表达的内容是很重要的 Artefacts include: 人工制品包括

– Physical symbols e.g. status symbols, buildings, expected clothing, equipment and safety policies

– 物理符号，如地位的象征，建筑物，预期着装，设备和安全政策– Behavioural norms e.g. greetings, gestures, ceremonies

– 行为规范，例如打招呼，手势，仪式

Iceberg model 冰山模型

基本假设

信奉的价值观

人工制品

V1.2

“The way we do things around here” CBI 我们做事情的方式“Safety culture is that assembly of characteristics and attitudes in organizations

and individuals which establishes that as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance” p1 INSAG-4. 1991

安全文化是组织中特征和态度的集合，并且人们把它视为绝对优先的事情。核电厂的安全问题由于其重要性得到重视。

“Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety and by the efficacy of preventive measures.” ACSNI

拥有积极的安全文化的组织拥有如下特征：建立在相互信任基础之上的沟通，对安全的重要性有共同的看法，以及预防措施的有效性。

Safety Culture: What Is It ?安全文化，它是什么？

V1.2Safety culture and outcomes安全文化和结果

Safety culture questionnaire responses have been linked with accident rates in the following industries:

在下列行业中，安全文化问卷的回答与事故率相联系– Nuclear power (Lee, 1998) 核电站– Offshore oil (Mearns, Flin, Fleming & Gordon 1997) 海上石油– Chemical industry, (Donald & Canter, 1994) 化学工业– Manufacturing, (Brown & Holmes 1986), (Zohar, 2000) 制造业

Safety culture has been identified as a causal factor in: 在下列事件中，安全文化已被确定为一个原因因素：

– Chernobyl 切尔诺贝利– Bhopal 博帕尔– Space shuttle Challenger and Columbia

挑战者号和哥伦比亚号航天飞机

V1.2Comparison of Chinese with US Nationals 中国人与美国人的比较

Nationality

Chinese

Expatriat

Rules less important

Importance of heirar

Language Difficulty

Job clarity

Work Pressure

Reluctance to speak

Productivity vs safe

Supervision

Rules & Regulations

Safety on rig

Risk behaviour

.6.4.20.0-.2-.4-.6

中国人

外国人

规则没有那么重要

层级的重要性语言困难

冒险行为

装备安全

规章制度监督

效率与安全

工作明确

工作压力不愿意说话

V1.2

Main findings 主要发现 No difference in self reported risk taking behaviour 在自我报告冒

险行为方面没有区别 Chinese staff valued hierarchy to a greater extent than expatriate

staff 与外籍员工相比，中国员工更加重视层级 Chinese staff indicated that rules were of less importance than

getting the job done 中国员工指出，相对于把工作完成，规则没有那么重要 Findings indicated that safety could be improved by using

hierarchical structures to reinforce the importance of following rules

结果表明，通过层级结构来强调遵守规则的重要性可以让安全得到改进

Characteristics of a strong safety culture强有力安全文化的特征

Safety is learning driven 安全受学习驱动

Safety is a clearly recognized value 安全是

被清楚认识到的价值观

Accountability for safety is clear安全责任明确

Safety is integrated into all activities

安全被纳入所有活动Leadership for safety is clear

安全领导力明确

IAEA five characteristics of a strong safety culture 强有力安全文化的五个特店

V1.2

Safety is a clearly recognised value 安全是一个被清楚地认识到的价值观

It is clear to everyone that safety is the top priority.

每个人都清楚，安全是首要任务 The importance of safety is demonstrated by 安

全的重要性从如下两个方面得以展现– the decisions managers make and

管理者所做的决策– how managers allocate resources.

管理者如何分配资源

V1.2Leadership for safety is clear安全领导力是清晰的 Managers take every opportunity to demonstrate their

commitment to safety. Leaders across the organization are actively involved in

safety and act as role models for others. Leadership skills are actively developed

管理人员利用一切机会展示他们对安全的承诺。

整个组织的领导们都积极参与安全活动，并成为其他人的榜样。

领导技能得到积极开发

V1.2Accountability for safety is clear对安全的责任是清晰地 There are clear lines of authority for safety Everyone is aware of their specific tasks and

responsibilities. Everyone feels ownership for safety within their span of

control. The independent and distinct role of the regulator is

understood and respected. 安全的权限很清晰 大家都知道他们的具体任务和责任。 每个人都感到自己能要对其所控制范围的安全负责 监管者的独立和独特作用得到理解和尊重

V1.2Safety is integrated into everything 安全要纳入到所有活动中 Safety is an approach to doing things rather than an activity;

therefore it is part of all activities. An operation or task is only a success if completed safely. Factors that influence performance such as motivation are

acknowledged to influence safety outcomes 与其说安全是一项活动，不如说安全是一种做事的方法，因此它是所有活动的一部分。

一个操作或任务只有在安全完成的情况下才是成功的

影响绩效的要素，例如动机，被公认是影响安全结果的。

V1.2Safety is learning driven安全是学习驱动 Striving for continuous improvement. Learning drives improvement. Actively seeking out lessons from operational experience and

conducting self assessments. Seeking to understand both failure and success in order to

improve. Encouraging reporting all failures 追求持续改进。

学习驱动改进。积极从运行的经历中找出教训，并进行自我评估。为了改进，争取对失败和成功都进行了解鼓励报告所有失败

V1.2

Safety culture maturity 安全文化发展阶段 Safety culture development is broken down into five stages or

levels of maturity, from poor to good A number of similar models currently in use (e.g. hearts and

minds, shell) Once the level has been established sites identify the actions

required to move to the next level

安全文化的发展分为五个阶段或成熟水平，从差到好 目前有几个类似的模型在使用 一旦水平被确定下来，组织就需要确定要达到下一个水平所需要采取的措施

Pathological 病态的Level 1

Reactive 反应式的 Level 2

Generative内在的

Level 5

Bureaucratic 官僚式的 Level 3

Proactive前瞻式的 Level 4

改善安全文化

计划

落实

评估监督

V1.2

Pathological 病态 Why waste our time on safety? 为什么要在安全上浪费我们的时间？

Effort is focused on avoiding getting caught 努力的重点是避免被抓到 Loyalty and conformity is maintained through

intimidation 通过恐吓保持忠诚和一致性 Reaction to problems 对问题的反应

– Suppression 抑制– Encapsulation 封装

V1.2

Reactive 反应式的 We do something when we have an incident Information is controlled

– Information 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 discipline Incidents appear to be random 当有事故发生时，我们才做一些事情 信息被控制 信息被操纵，以确保我们符合组织标准（例如事故发生率目标） 我们关心的是发现是谁的错，并且使用相应的惩罚措施 事故的出现是随机的

V1.2

Bureaucratic 官僚式的 We have systems in place to manage all likely risks Information supports departmental interests,

– to make the department look good, to support departmental objectives Information flow is managed Reaction to incidents

– Local fix: treats symptoms not root cause

我们已建立各种制度来管理所有可能的风险信息支持部门利益，

使该部看上去不错，支持部门目标信息流被管理对事故进行反应局部整改：治标不治本

V1.2

Proactive 前瞻式的 We are always on the alert for risks that might emerge Information is important and we work hard to capture it and

understand what is going on. Our outcomes are better that our industry average Still surprised by some events

我们对可能出现的风险总是很警惕 信息是重要的，我们总是很努力掌握信息，并了解正在发生的事情。 我们的结果比行业平均水平要好 对一些事件仍感到吃惊

V1.2

Generative 内在的 We know why we do not have incidents Information supports the mission Information flows freely, honesty is valued Response to incidents:

– Global fix: try to fix every example of a problem, share information with other stakeholders

– Inquiry: Get to the root cause of problem 我们知道我们为什么没有事故 信息支持使命

信息自由流通，诚实得到欣赏 对事故的反应：

全方位整改：尝试整改一个问题的每一个例子，与其他利益相关者共享信息调查：寻找问题的根源

V1.2

Norms andBehaviour规范和行为

Safety安全

Safety Interventions

安全举措

Safety Culture

安全文化

Enabler/Barrier

促成要素 /障碍要素

Culture and Safety 文化和安全

V1.2

Safetymountain

Where are you? 你在哪里

Pathological病态的

Reactive 反应的Bureaucratic 官僚的

Proactive 先行一步的

Generative内在的

Improvement Orientated

以改进为导向的

Status Quo 现状

V1.2Review systems that drive culture审视驱动文化的制度

SCM Improvement Process (SCMIP) developed to assess culture without the need to survey workers

SCM 改进过程 Rational for SCMIP

– Employee perceptions are based in reality i.e. perceptions of management commitment reflect their interactions with managers

– Organisations with different cultures have different practices– Safety culture improvement involves system change

e.g. perceptions of management commitment is improved through training and evaluating leadership practices

所开发的 SCM 改进程序可以评估文化，不需要对工人进行调查 SCMIP 的合理性 - 员工的认知是基于现实

例如对管理层承诺的认知 反映了他们与管理者之间的互动关系- 组织文化不同，做法就不同- 安全文化的改善涉及制度变革 例如管理层承诺的理念通过培训和评价领导力的实践得到提升

V1.2Sample: Commitment to safety范例：对安全的承诺

Managers Visiting the Worksite

Select

level打分

Managers do not visit worksite to specifically discuss safety 0

Managers visit worksite regularly to discuss safety as specified by a formal policy/ program (e.g. STOP ）

1

There is a formal manager worksite visit program that specifies the number of visits to be conducted by each manager and tracks completion.

2

There is a comprehensive program that specifies how to perform a worksite visit, trains managers how to conduct a visit, evaluates managers to ensure they are competent and tracks frequency of visits and close out of actions.

3

There is a comprehensive program described above plus the quality of the managers’ visits is evaluated by workers and anonymous feedback is provided.

4

V1.2Sample: Commitment to safety范例：对安全的承诺

管理人员访问工作场所Selec

t level打分

管理人员不访问工作场所来专门讨论安全问题 0

管理人员定期访问工作场所来讨论由正规政策 / 计划规定的安全问题 1

有一个正式的管理者工作场所访问计划，计划规定了每个管理者的访问次数，并记录完成情况

2

有一个全面的计划，计划规定如何进行工作场所访问、培训管理人员如何进行访问、评估管理管理人员以确保他们有能力并记录访问频率和完成的活动

3

除了有上面描述的全面计划外，工人对管理者的访问质量进行评估，并且匿名反馈被提供。

4

V1.2

SCMIP exercise SCMIP 练习 Review the SCM assessment form For each element select the most level that most closely describes

the situation within your part of the organisation For each element review the practices at the next highest level of

maturity Select practical improvement strategies for each element 审视 SCM 评估表 对与每一个要素，选择与你所在组织情况最为接近的等级水平 对与每一个要素，审视在下一个成熟度最高等级水平上的做法 对每一个要素选择务实的改善策略

V1.2

Conclusion 结论 Safety culture is complex and is difficult to

change 安全文化是复杂的，并且很难改变 It will only changes in response to actions

talking does not help! 只有在付诸实际行动的情况下才会变化，光说没有用 Improvement plan: 改进计划

– Assess culture 评估文化– Change management systems to support the desired culture 支

持理想文化的变革管理体系– Re assess to see if change worked 再次评估来看变革是否有效