the sociology of safety - american industrial hygiene ... a. hartle & dianna h. bryant 2006...
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The Sociology of Safety
Jeffery A. Hartle Dianna H. BryantCFPS, MIFireE CIH, CSPVice President Associate Professor of Industrial Hygiene Skillful Means, Inc. Central Missouri State University
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 2
Which Social Science?Psychology?
Focus and study is on the individualBasis for Behavioral Based Safety
Often blames the workerManagers become comfortable knowing that they are not responsible for causing accidents or preventing them (Kletz, 1991)
Sociology?Focus and study is on social groups and organizationsOffers different perspectives on accidents
Often blames system or organizational factors
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 3
Sociology
Patterns of human systemsObserve and develop theoriesUse theories to review past events and predict future outcomesExamine failures of systems, resulting in:
Accidents (localized failures)Disasters (catastrophic failures)
Accident and disaster causation research provides fertile ground for new theories about human systems
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 4
Can We Study Organizations?
Groups/organizations are more than the sum of their members
May have a individual legal identity (corporations)Organizations are entities separate from the individuals in themOrganizations generate collective phenomena Organizations are “real” and can be studied as “distinctly social processes and factors”(Warriner, 1956)
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Who’s In Control?
Safe Person
Human Factors
Motivation/Attitude
Behavior
Safe Place
Design
Engineering
Physical Controls
OrganizationsPurchase facilities
Maintain equipment
Implement procedures
Hire
Train
Supervise
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Characteristics of Organizations
Structure/HierarchyExternalitiesPowerDecision makingCulture
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Structure/HierarchyBureaucracies are the ideal organizations (Weber, 1978)
EfficientHierarchy of authorityDivision of laborStandardizationPrescribed rules
Limited authority and specialization may not be the best arrangement for safety
“Trained incapacity”Specialties function as inadequacies or blind spots (Merton, 1957)
Efficiency for whom?“People at the bottom are…sacrificed for the sake of organizational objectives” (Sjoberg, et al., 1984)
“Unanticipated consequences of a purposeful action”(Merton, 1936)
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 8
Externalities
Everything outside of the organizationShifting costs to others to maximize profit
Social costsEnvironmental damage
For whom does safety pay? (Hopkins, 1999)Employers only bear “30% of the total cost [of accidents], the rest being borne by the worker and the community”Preventing infrequent catastrophes costs too muchUnion Carbide plant, Bhopal, India
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 9
PowerOrganizations have taken over society (Perrow, 1991)
Wage dependencyExternalization of social costsFactory bureaucracy
Power concentrated in the hands of the elite
“Those with the most power have the greatest discretion in interpreting the rules” (Sjoberg, et al., 1984)
Managerial decision makers isolated from consequencesOrganizations attempt to maintain control
Corporate reaction to labor activism in 1920s (Rosner & Markowitz, 1987)
Blame the workersHold workers responsible for their own safety
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 10
Decision MakingManagement decisions support organization’s goals“Bounded rationality” (Simon, 1957)
Incomplete knowledge constrains decisionsBut most accidents are predictable!Managers intentionally remain ignorant of facts
“Knowledge is a necessary ingredient for ethical decision making” (Schneider, 2000)
Challenger accidentConflict in goals between managers and engineers“Take off your engineer’s hat and put on your manager’s hat” (Boisjoly, Curtis, & Mellican, 1989)
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CultureOfficial vs. unofficial culture
Official culture is for the public viewUnofficial culture may be at odds
Gauley, WV 1930-1933Official message-project good for communityUnofficial message-doctors misled workers about “tunnelitis”
Western cultureOrganizational culture exists within the larger society
Organizational goals assumed to reflect societal goals
Unit culture reflects organizational culture
What is the dominant culture for EHS professionals?
New technology is always better than old
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 12
Barry Turner’sDisaster Incubation Theory
Organizations suffer from “a failure of foresight”Most disaster research starts at the event
Focus is on response and recoveryTurner focused on precursors of the event
Incubation periodUnnoticed events occur which are at odds with organizational norms about safe operation
Turner, B. A. (1976). The organizational and interorganizational development of disasters. Administrative Science Quarterly, 21 (3), 378-397.
Turner, B. A. & Pidgeon, N. (1997). Man-made disasters. Oxford: Butterworth-Heinemann.
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 13
Common Features of Incubating Disasters
Rigid perceptions and beliefs about the organizationDecoys
Focus upon the wrong signal, allowing other problems to develop
Organizational exclusivityDisregard of nonmembers
Information difficultiesNoiseAmbiguities about warningsWrong or misleading information
Involvement of strangersOutside the organizationThe public
Failure to comply with regulations
Do they apply to us?Perceived as out-modedWhat can we get away with?
Minimizing emergent dangerUnderestimated Even when seen, undervalued
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 14
Case Study: Aberfan, Wales1966 accident
Killed 144, including 109 children in school
1939-Report predicts tip slides under certain conditions
National Coal Board limits circulation of report
Numerous tip slides occur throughout UK
Community concerned as tip grows in size
Citizens complainBorough gov’tcomplains
National Coal Board dismisses complaints as nuisances
Focus is on mine safety, not tip safetyNo one understands coal issues except us!
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 15
Charles Perrow’s Normal Accident Theory
High-risk technologies are too complex to be controlled by humans
Accidents are “normal” because the conditions for failure are built into the system
Complex systems characterized by:Complexity (non-linear interactions)Tight coupling (little slack in the system)
Perrow, Charles. (1984/1999). Normal Accidents: Living With High Risk Technologies.
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Interaction/Coupling
Figure 3.1 Interaction/ Coupling Chart (p. 97)
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Key Concepts
Linear InteractionsExpected in familiar production or maintenance sequencesVisible, even if unplanned
Complex InteractionsUnfamiliar, unplanned, or unexpected sequencesNot visible, or not readily comprehensible
Loose CouplingDelays possibleChange order of sequenceAlternative methods
Tight CouplingLittle slack in resourcesBuffers and redundancies built inLimited substitutions
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 18
Case Study: Three Mile IslandNuclear reactor is complex system
Actual process is unseen by operatorsGauges indicate working condition
Accident on March 28, 1979Leak in cooling system flooded pneumatic instrument linesInstruments indicated false signals
Open valve released radioactive waterCore almost melted down
True signals were hidden in multiple “false signals”
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 19
High Reliability Organizations (HRO) TheoryAn organization is an HRO if it could have failed > 10,000 times or more, but did notBased on 3 organization studies:
FAA air traffic controlDiablo Canyon nuclear plantTwo U.S. Navy carriers in peacetime
Univ. of California-Berkeley
Geoffrey Gosling, Todd R. LaPorte, Karlene H. Roberts, Gene I. Rochlin, Paul Shulman, and Karl Weick
Other proponentsJoseph Marone & Edward J. WoodhouseAaron Wildavsky
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 20
Characteristics of HROs
Leadership places a high priority on safety and reliability
Short-term efficiency is second to high reliabilityLeaders communicate very clear operational goals
Significant redundancy existsDuplication (2 different units with same job)Overlap (2 different units with some functions in common)
Error rates reduced through:Decentralization of authorityStrong organizational cultureContinuous operations and training
“Richer is safer”(Wildavsky, p. 58)
Organizational learningFirst, trial and errorSupplemented by anticipation and simulation
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 21
Case Study: U.S. Navy Carriers
LeadershipCO briefs new crewNever break ship’s rules unless safety is at stakeCommon commitment to goal of reliability
RedundancyTechnical resourcesPersonnel resourcesConstant flow of info on multiple radio channels
Errors ReducedDecentralized-lowest ranks can stop flight opsClosed system with common ‘culture of reliability’Flight ops & training
Learning Organization
Innovations a result of earlier accidentsExtensive use of simulation
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 22
James Reason’s Organizational Accidents Theory
Individual accidentsSpecific person/group is the cause and victim
System failures or organizational accidentsMultiple personsMultiple causes Multiple levels of responsibility
Reason, James. (1997). Managing the Risks of Organizational Accidents.
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“Swiss Cheese” ModelHazards → Defenses →LossesDefenses can be breached
Active failuresErrors at ‘sharp end’ of systemHas immediate effectNow seen as consequence, not cause
Latent conditionsErrors beyond individual psychologyErrors at top levels of organizationsPresent in all systemsFigure 1.5 Accident Trajectory (Page 12)
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 24
Latent Conditions
Exist for yearsMay combine with active failures or local circumstances
Created by strategic decisions
Often top-level choicesGovernment, regulators, designers, corporate managers
Impact pervades the organization
Changes cultureLies dormant until interactions occur, then overwhelm defenses
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 25
Case Study: Nakina, Ontario DerailmentRailroad bed laid in 1916
Rail bed built on portion of beaver dam
Train observes missing railroad bed in 1992
Rails suspended in air, train can’t stop, overturns, kills 2 crewmen
Latent FailuresRailroad kills beavers to reduce road bed damageDam is not maintained and weakensHeavy rain raises water level, soaks roadbed, washes out sludgeNo active failures!
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Thoughts on RedundancyReason
Defenses in depth “create a variety of problems in complex sociotechnical systems” (p. 54)
Conceal errors and their long-term consequencesMay not respond to individual failures
PerrowRedundancy increases complexityRedundancy make the system opaque to operators“Fixes, including safety devices, … often merely allow those in charge to run the system faster, or in worse weather, or with bigger explosives” (p. 11)
HROsRedundancy is essential to achieve reliability
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 27
Fantasy Documents
Lee ClarkeEverything will work right the first timeEvery contingency is known and prepared forIntended to support organization’s view of reality
Goal is NOT to deceive the public, but to deceive themselves
Political organizations are able to ensure the public that government is in control of systems over which the government has no controlManagers may substitute own judgment of risk for the professional judgment of experts
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 28
Failure of Hindsight
Brian ToftOrganizations must learn from their own experience and experiences of othersNegative feedback must be provided internally or it will be provided externally (regulations)Organizational learning
Passive (perception)Active (implementation)
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Conclusions
Sociology provides insights about organizational behavior that impacts on safety and healthOrganizations resist change
Environmental, health, and safety are perceived as reducing profit
What values will EHS professionals adopt?What is the dominant culture of your organization?EHS professionals “have often adopted the values and assumptions of their employers regarding responsibility for risk” (Rosner & Markowitz, 1987)Ethical codes must guide EHS decisions, not profits!
Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 30
Additional SourcesClarke, L. (1999). Mission improbable: Using fantasy documents to tame
disaster. Chicago: University of Chicago.Hopkins, A. (1999). For whom does safety pay? The case of major
accidents. Safety Science, 32, 143-153.LaPorte, T. R. and Consolini, P. M. (1991). Working in practice but not
in theory: Theoretical challenges of “High-Reliability Organizations”. Journal of Public Administration Research and Theory, 1 (1), 19-48.
Roberts, K. H. (1990). Managing high reliability organizations. California Management Review, 32 (4), 101-113.
Rosner, D., & Markowitz, G. E. (Eds.). (1987). Dying for work: Workers’safety and health in Twentieth-Century America. Bloomington: Indiana University Press.
Toft, B. and Reynolds, S. (1997). Learning from disasters: A management approach (2nd ed.). Leicester, UK: Perpetuity Press.
Turner, B. A. (1992). The sociology of safety. In David I. Blockley (Ed.), Engineering safety (pp. 186-201). London: McGraw-Hill International.
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For More Information
Jeffery A. Hartle CFPS, MIFireE
Vice PresidentSkillful Means, Inc.850 NE 771Knob Noster, MO [email protected] (toll free) 660-441-1976 (mobile)
Dianna H. Bryant CIH, CSP
Associate Professor of Industrial Hygiene
Central Missouri State University
Warrensburg, MO [email protected] (work)816-914-6571 (mobile)