Does safety culture undermine safety?

Like all safety initiatives “safety culture” has within it the capacity to be both an enabler and “underminer” of safety management and good safety performance. It seems to me that more and more of the initiatives undertaken in the name of safety culture far from enabling our safety objectives are actively undermining them.

It is perhaps worth starting the discussion with some definition of safety culture. Interestingly, it is a term bandied around in safety circles quite freely but without much evidence that everybody is talking about the same thing. For this discussion I will use the term safety culture in the context described by Hopkins (2005, p. 11), that is a “culture of safety” or an organisation that is focused on safety.

In this context, not all organisations have a safety culture; it is a conscious decision and something that you strive for.

This can be distinguished from “safety climate“. All organisations have a safety climate, and the safety climate may be weak or strong, good or bad and so on.

If we go back to the source, the term safety culture was first used in the International Nuclear Safety Advisory Group’s (1986) Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident. There, safety culture was described as:

“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.”

This is at the heart of what Lord Cullen (1990, p. 300) described in his inquiry into the Piper Alpha disaster:

“it is essential to create a corporate atmosphere or culture in which safety is understood to be and is accepted as, the number one priority”

Most recently, this notion of safety culture is implicit in the Royal Commission into the Pike River Coal Mine Disaster in New Zealand (Pankhurst et.al, 2012, Volume 2, p. 176):

Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands. Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that health and safety management was not taken seriously enough at Pike.

It does seem however, that when many organisations talk about safety culture, in fact they are talking about safety climate, and whether the “environment” of the organisation is conducive to good safety performance.

What I have observed over the past 20 or so years is that initiatives bundled under the heading safety culture do not contribute to safety receiving the attention it warrants by its significance. Rather, they often divert attention away from giving sufficient attention to safety and in many cases are excuses for not paying proper attention to serious health and safety risks.

Over and above this, the “window dressing” that often masquerades as safety culture contributes significantly to the “illusion of safety” (see for example Borys, 2009), creating an impression that health and safety risks are being controlled, when in fact there is no evidence to support that. Executive management see significant time and resources committed to initiatives branded as “safety culture”, and they see shifts in perception surveys which are somehow interpreted as indicators of safety culture, and more dishonestly as indicators of good safety performance.

This, unsurprisingly, creates the impression that safety is being effectively managed. The reality is seldom the case, with no effective assurance that the health and safety risks in the business are actually being controlled.

Unfortunately, like many safety concept, safety culture has:

1. Become commercialised, as something that organisations have to purchase;
2. Become commoditised, as a product that organisations can buy off the shelf;
3. Been perceived as a silver bullet for all of our safety concerns. This is particularly apparent in the safety profession where the use of the term safety culture to describe underlying problems in safety management has become ubiquitous to the point of being embarrassing.

In the result, I have increasingly seen organisations, led by their safety managers, blindly pursuing the holy grail of safety culture (with no clear picture of what it even looks like) while significant health and safety risk remain unchecked.

Some key themes that I have seen emerge in the pursuit of safety culture are:

Safety culture as a product of perception surveys: The relentless pursuit of perception surveys in no way represents safety culture, nor does it represent an organisation giving safety the serious attention that it deserves.

The difficulty that I have with perception surveys as a measure of safety culture is that they provide no insight into whether or not risks are being controlled – they are after all no more than perceptions. Yet, somehow they are sold as an indication of a good safety culture and then, by some extraordinary leap of logic, proof of an effective safety management system.

They are neither. At best, they may give an insight into an organisation’s safety climate.

Perceptions can change (and can be changed) but this does not mean that the organisation is doing anything differently; it does not mean that the organisation has a culture focussed on safety, and it in no way means that an organisation’s health and safety risks are being controlled.

I am reminded of a lesson that I was taught by a very wise academic about 6 years ago. At the time, I was teaching a University program on accident prevention and had got my first report from my students on the amount of “feedback” I had provided to them during the semester. To my surprise, I had been marked very low in this area.

My friend asked me what I wrote to students when I sent back their papers, and I showed her. It was generally something like:

Please find attached a copy of your paper marked up with my comments ……

Her suggestion? Change it to:

Please find attached a copy of your paper marked up with my comments and feedback……

I did. Nothing else changed but my “rating” for providing feedback moved to over 90% approval.

The power of perception over action.

Glorified behavioural based safety programs as safety culture: The majority of programs that I have seen in the past that purport to be safety culture programs are nothing more than trumped up behavioural based safety programs. Whatever your view on the efficacy of these programs or their place in a good safety management program (and in my view they do have one), they do not represent safety culture.

One of the clearest indicators that these programs have nothing to do with safety culture is that they are directed almost exclusively at the workforce. Very seldom are middle management involved, much less senior management or executive management – and not a board member to be seen. To borrow from Carolyn Merritt[1]:

Thus when we talk about safety culture, we are talking first and foremost about how managerial decisions are made…

When these programs are described as something that they are not (safety culture) rather than what they are (targeted modification of workers’ behaviour), it is my view that they actively disengage the workforce from the organisation’s safety effort, and undermine any perception that might have existed that management was committed to safety.

An excuse or distraction from the real work of safety management – understanding that risks are being controlled: This is perhaps the most disconcerting aspect of the way that safety culture is being touted in organisations. It is held out as a safety catchall while the difficult work of understanding whether risks are actually being controlled is lost amid the management speak and motherhood statements that now define safety culture in practice.

Two examples spring to mind.

In the first, a worker discovered some fibrous materials at a worksite and was concerned that they were asbestos. In breach of all documented policies and procedures, the worker put the fibres into an empty plastic Coke bottle, put the Coke bottle into a yellow inter-office envelope and dropped it into the internal mail. To describe the investigation into the incident as superficial would be generous, but the ultimate conclusion was that despite all of these policy and procedure breaches the outcome was a good one because the worker, by raising his concerns, had acted in accordance with the expectations of the [insert name of commercial program] which demonstrated a good safety culture.

In an organisation with anything even remotely approaching a safety culture, I cannot imagine this incident being viewed as anything but an unmitigated failure of the safety management system and a failure of management to properly supervise and oversee that system in every important regard: incident investigation, hazard identification, training and competence, supervision and communication.

The mere fact that safety culture can be used to paper over such a fragile safety management system shows how far we have managed to move away from its original intention.

In the second case, a review of a contractor’s safety performance identified that the principal did not have a traffic management plan for vehicle movement in an open pit mine. This was described by the principal’s safety manager as a problem of safety culture. How absurd.

Rather than dress this failure up in some amorphous notion of culture (for which he offered no solution) the safety manager should have faced the reality that it was a complete failure by him to identify a significant risk, and then asked the obvious question: What other risks have I missed?

For such a fundamental control to be missing in a high hazard environment can only be regarded as a complete breakdown of the safety management system. It should also call into question the competence of the safety manager, but once again, safety culture was used as an excuse to avoid doing the hard work of understanding how the safety management system came to be in such a state of disrepair.

I have no doubt that safety culture properly understood by the highest levels of executive management and pursued at that level will help drive excellence in safety performance. The nonsense that we dress up as safety culture will not. It undermines our aspirational statements about health and safety, it disengages the workforce from the safety message of the organisation, it contributes to the illusion of safety and distracts us from the genuine hard work that needs to be done to understand whether the risks in our businesses are being controlled.

References:

Borys, D. 2009. Exploring risk-awareness as a cultural approach to safety: Exposing the gap between work as imagined and work as actually performed. Safety Science Monitor, Issue 2, Volume 13.

Cullen, Lord. 1990. The public inquiry into the Piper Alpha disaster. Department of Energy. London: HMSO.

Hopkins, A. 2005. Safety, culture and risk: The organisational causes of disasters. Australia: CCH.

International Nuclear Safety Advisory Group. 1986. Summary report on the post-accident review meeting on the Chernobyl accident. Vienna: International Atomic Energy Agency. (see Also http://www-pub.iaea.org/books/IAEABooks/3598/Summary-Report-on-the-Post-accident-Review-Meeting-on-the-Chernobyl-Accident)

Pankhurst, G., Bell, S., Henry, D. 2012. Royal Commission on the Pike River Coal Mine Tragedy. Wellington, New Zealand