Safety Behavioural Systems

Transcription

1 Safety Behavioural Systems Steve Mason The attitudes and behaviour of a company's workforce are closely linked to its safety performance. This link is discussed and guidance given on those features of the workplace and the work organisation that tend to shape the behaviour of the workforce. With an understanding of these factors, management is better able to identify the areas where improvement should be targeted and the most appropriate management initiatives. Latest Updates 22/ 07/ 2002 When looking into aspects of human error that affects health and safety, a common issue is that of people deliberately not following safety rules. However, research now published in the journal Neuron (2002; 35: ), indicates that it is more likely for people to co-operate with each other, even when it is not necessarily to their advantage to do so, which may give an indication of a method to combat the problem of the Error Type: Violations. 01/ 07/ 2002 The HSE has published research that aims to promote more widespread application of behavioural safety principles to improve health and safety, as detailed in the Introduction. Table of Contents Quick View Accidents, Behaviour and Human Error Types Introduction Types of Human Error Error Type: Violations Why do Violations Lead to Increased Accidents? Types of Violation Routine Violations Situational Violations Addressing Routine and Situational Violations Recognising the Causes of Inappropriate Behaviour Why do People Choose to Violate Rules and Procedures? Direct Motivators Making Life Easier Getting the Job Done Quicker or Saving Time Financial Gain Practicality of Rules Unrealistic Operating Rules or Maintenance Schedules Demonstrating Skill and Enhancing Self-esteem Deliberate Sabotage/Vandalism Behavioural Modifiers Pressure from Above to Cut Corners Pressure from Colleagues Perceptions of the Risks Perceived Benefits from Risk Taking Management and Supervisory Attitudes Likelihood of Detection Copyright GEE Publishing Ltd Contents

2 2.3.7 Effectiveness of Disciplinary Procedures Accountability for Safety Complacency in an Accident-free Environment Addressing Attitudes and Behaviour Tools for Change Strategy One: Behaviour-Shaping Programmes Strategy Two: Identifying and Correcting Organisational Failings Comparison of Two Strategies The Use of Questionnaires and Incident Reports Use of Incident Reports The Use of Questionnaires General Purpose Attitude Surveys Targeted Attitude Surveys Further Information Key Questions Troubleshooter Previous Successes not Repeated Elsewhere Using Results from Attitude Surveys Copyright GEE Publishing Ltd Contents

3 Quick View 1. The main causes of accident have changed in recent years with human error and behavioural issues usually being the dominant factors. Inadvertent types of human errors ('slips/lapses' and 'mistakes') are best dealt with by training or improved design. See Introduction. 2. Safety behavioural systems focus on reducing another form of human error - 'violations'. This is a type of error where an individual, or individuals, deliberately contravenes established and known safety rules drawn up for the safe or efficient operation and maintenance of plant or equipment. See Types of Human Error. 3. There are a number of factors that form the basic reasons why people want to violate safety rules and procedures. These are the 'direct motivators'. See Direct Motivators. 4. There are a number of other factors that increase or reduce the likelihood of violations. These are the 'behaviour modifiers'. See Behavioural Modifiers. 5. Compliance with procedures can be achieved by providing additional supervision, monitoring and audits and involving the workforce in setting behavioural. See Strategy One: Behaviour-Shaping Programmes. 6. A more effective way can be to use questionnaires or incident analyses to identify and correct those underlying organisational factors that increase the likelihood of violations. See Strategy Two: Identifying and Correcting Organisational Failings. Copyright GEE Publishing Ltd Quick View

4 1. Accidents, Behaviour and Human Error Types 1.1 Introduction While many organisations do not have serious reservations about their safety procedures, organisation, or management, serious flaws are regularly revealed following major accident investigations. The nature of accident causation in many industries has changed in recent years. Engineering failures are no longer a major part of most accidents. Human error now causes most accidents. In turn, human error is influenced by a combination of organisational, employee, job and workplace factors. For example, the safety culture of an organisation will have a strong influence on the behaviour of employees at all levels. The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation's health and safety management. Key aspects of a positive safety culture are: 1. Safety commitment of all managers 2. Commitment to involve the workforce in key decision making 3. Effective means of informing and consulting all staff 4. Effective two-way communications between management and the workforce 5. Acceptance of the importance of each person's role in the organisation 6. Co-operation between employees 7. An organisation seeking continual improvement and excellence. The 'safety climate' is a term used to describe the tangible outputs or indicators of an organisation's safety culture as seen by individual or work groups at any point in time. An employee is more likely to take a risk if they underestimate the risks (an employee factor). Mistakes are more likely to be made if the job requires excessive concentration (job factor). Operators are also more likely to make errors if their equipment is poorly designed. The result of these errors is a behaviour which is contrary to that specified in the safety rules and procedures. The HSE has published research that aims to promote more widespread application of behavioural safety principles to improve health and safety. Many behavioural safety programmes currently used throughout the UK focus on promoting safe behaviour among frontline staff, thereby excluding other behaviours that can influence health and safety performance. The report, CRR430/2002 Strategies to promote safe behaviour as part of a health and safety management system (ISBN ), is available from HSE Books, price 15.00, or online at It aims to provide the reader with an understanding of: 1. The theory underpinning strategies to promote safe behaviour 2. The key elements of programmes in use to promote safe behaviour 3. How to use behavioural strategies to promote critical health and safety behaviours 4. How to integrate behavioural strategies into a health and safety management system Copyright GEE Publishing Ltd Accidents, Behaviour and Human Error Types

5 1.2 Types of Human Error Human errors can usefully be classified into one of three types. The first two are essentially accidental or inadvertent errors. These are called 'slips/lapse' and 'mistakes'. The following section explains these error types, and the most appropriate management actions for dealing with them. Error Type: Slips/Lapses Slips and lapses of attention are forms of unintentional error where the actions differ from those intended. Most people have experienced a time when they go to make a pot of tea but for some unknown reason forget to put a tea bag in the pot. Similar errors happen in industry. A workman may forget a simple step in a procedure. These errors tend to occur during activities that are regularly performed. They may be thought of as absentmindedness. They are often caused by distractions. Improved training is not an effective solution to deal with these errors as those making them are fully aware of what they should do. Where these errors can be critical to safety, it is best to try to design them out by incorporating safety interlocks and other devices to eliminate or reduce the consequence of slip/lapse type errors. Error type: Mistakes These errors occur when an individual decides on a plan of action which with hindsight proves to be inadequate. The plan would have been made to the best of their ability and with the knowledge and information available at the time. Subsequent unknown factors made this plan fail. Improved training is generally the best strategy to address this type of error. Training must, however, be directed to addressing unusual circumstances such as dealing with unusual faults, limited information or dealing with limited resources. The third error type is concerned with deliberate or knowing deviations from approved rules and procedures. These are called 'violations' and must be addressed when considering the link between the human factor and behaviour Error Type: Violations Most accidents are associated with an error type where an individual, or individuals, deliberately contravenes established and known safety rules drawn up for the safe or efficient operation and maintenance of plant or equipment. These errors are termed 'violations'. A distinction needs to be made between a violation of a law and violations used in this sense. A driver may pass a red traffic light. This is clearly a traffic violation. It could, however, have been the result of a distraction or a deliberate act. If the cause was a distraction then the traffic violation would have been the result of an inadvertent error. This type of error would be classed as a 'slip or lapse of attention'. Only the deliberate act is a violation as the term is used here. People committing violations are aware of what they should do but, for some reason, decide not to follow the rules. Before managers can effectively address this form of behaviour they must have an understanding of why people violate rules. Violations can affect production, maintenance efficiency and quality as well as safety. Retraining people in the correct methods cannot be the answer as they already know what they should do. Before managers can effectively address this form of behaviour they must have an understanding of why people violate rules. When looking into aspects of human error that affects health and safety, a common issue is that of people deliberately not following safety rules. However, research published in the journal Neuron (2002; 35: ), indicates that it is more likely for people to co-operate with each other, even when it is not necessarily to their advantage to do so, which may give an indication of a method to combat the problem of violations, as reported by Reuters Health (17 July, 2002). A group of researchers based at Emory University in Atlanta, Georgia, found that when a woman is involved in a situation where she is co-operating with someone else, she experiences activation in brain areas that are also activated by 'rewards' such as food, money and drugs. This indicates that our bodies may have been somehow programmed to 'tag Copyright GEE Publishing Ltd Accidents, Behaviour and Human Error Types

6 co-operation as rewarding', study author Dr. Gregory S. Berns told Reuters Health. The authors opted to use all women to avoid any sexual undertones that might influence how women and men behave with each other, Berns noted. He said he expected experiments using only men would produce similar results to the current study, but that further studies are needed to demonstrate if that is, in fact, the case. The researchers uncovered the brain's reaction to co-operation by scanning the brains of 36 women while they played a game known as the Prisoner's Dilemma. Based on the logic of the game, the most rational decision a player could make is to defect, which ensures she will not get the least amount of money, and provides her with the opportunity to earn the most. They scanned the brain of one player, and instructed the other player to either play as she wished or follow certain rules when choosing either to defect or co-operate. Despite the fact that defecting is the most rational option, when both players were given the freedom to choose as they wished, both decided to co-operate more often than any other decision. Out of a total of 20 rounds, players chose to co-operate an average of 11 times, compared to two to three times for each of the other decision patterns. Using MRI scans, the investigators found that when both players co-operated, the player whose brain was being scanned showed significant activation in brain regions associated with reward. Berns admitted that he and his colleagues were surprised to discover this finding. People can become visibly upset when their opponent defects against them, and it was in this situation the researchers had expected to see the strongest brain activity Why do Violations Lead to Increased Accidents? Once a person has deviated from the approved working practices, they are much more likely to encounter situations they have not been trained to deal with. This will therefore increase the likelihood of subsequent unintentional errors. Risk-taking behaviour is often associated with acts of violation. By definition, risk-taking leads to actions that are more likely to be associated with an accident. 1.3 Types of Violation The two most important forms are routine violations and situational violations Routine Violations These occur when breaking a rule or procedure becomes the normal way of working. When asked, people will acknowledge that their method is not approved. A major factor in routine violations is that managers or supervisors are seen to condone the breach of the rule by their unwillingness or inability to enforce it. Over time, this can lead to a phenomenon called 'rule erosion' whereby more and more of the workforce increasingly break more and more of the safety rules. Such violations can be easily transferred to new entrants who see and copy this behaviour without realising they are breaking safety rules Situational Violations These violations occur primarily as a consequence of specific events or conditions. The motives for situational violations include: unusual pressure to get the job done; insufficient staff, time or resources; or factors such as extreme weather conditions. In such situations, staff may judge that it is not possible to keep to the rules or that in such situations the rules or procedures do not represent the best way of working Addressing Routine and Situational Violations 1. Review the practicality of rules and procedures, especially in relation to possible shortfalls in resources and unusual environmental conditions. Copyright GEE Publishing Ltd Accidents, Behaviour and Human Error Types

7 It is often useful to consider how rules and procedures have evolved. In many companies, certain rules and procedures are amended following a major incident with the intention of preventing a repeat incident. Similar amendments are made following further incidents until the remaining rules and procedures are heavily restrictive compared with those originally drafted. Obviously some of these changes would have been necessary; however, others may be overly restrictive for competent and skilled staff to perform their duties efficiently and safely. Over-restrictive rules may not produce the safest course of action. Situations have arisen where the organisation acknowledges that keeping strictly to the rules would not have been the best course of action for that particular situation. Although it is always difficult for managers to 'relax' safety rules and procedures, this issue must not be overlooked. The only justification for such a tactic would be to 'protect the management's back'. 2. Review the effectiveness of the supervision. There can be a range of reasons why supervision is ineffective. A common reason is that certain jobs are difficult to reliably supervise as a result of lone-working or the physical distances over which a supervisor must supervise. In such circumstances it is often desirable to 'engineer' a culture whereby there is a mutual expectation among the workforce to adhere to the highest standards of safety. This is supervision by the peer group. Supervisors may be unclear about their roles and responsibilities. This can occur through gradual changes in working practices without the supervisor's needs being reviewed. For example, an increased use of contractors can introduce ambiguities in the extent to which supervisors are responsible for their safety and the extent of their authority. Supervisors may not intervene if they are unsure of their responsibilities. In such situations the roles, responsibilities, authorities and accountabilities of the supervisors need to be reviewed and the results clearly communicated to those concerned. Supervisors may have insufficient knowledge to spot certain cases of unsafe working. For example, a supervisor who was promoted from a fitter's background may simply not recognise a group of electricians under his control who were not following correct isolation procedures. Managers must not assume that supervisors will be effective in such situations. Training needs must be accurately determined. 3. Introduce training that describes the hazards and discusses the risks associated with unapproved working methods and hence the reasons why those rules and procedures are necessary. 4. Check that the equipment and tools used are well designed and that poor ergonomic design does not create a motive for the violation. If the design is poor, improve it. Copyright GEE Publishing Ltd Accidents, Behaviour and Human Error Types

8 2. Recognising the Causes of Inappropriate Behaviour Although many errors made by people are accidental, it is the deliberate or knowing deviations from approved rules and procedures that needs to be focused on when considering the link between the human factor and behaviour. 2.1 Why do People Choose to Violate Rules and Procedures? Rules are broken for many reasons. Some rules are broken to meet production deadlines. Others are broken primarily for the benefit of the individual. Violations are rarely associated with wilful acts of sabotage or vandalism. The factors that influence the likelihood of violations can be considered in terms of: 1. Direct motivators 2. Behaviour modifiers. The direct motivators form the underlying motives for an individual, or group, consciously deciding to break a rule. Although not motives in themselves, the behaviour modifiers influence the likelihood of violation. Behaviour modifiers can be both positive and negative. A useful approach to highlight factors likely to increase non-compliant behaviour involves the assessment of both direct motivators and behaviour modifiers. For example, cutting corners on a safety procedure may make life easier for an operator (a direct motivator). The likelihood the operator will decide to violate will be influenced by the effectiveness of the supervision (a behaviour modifier). Effective supervision will tend to reduce the likelihood of that violation occurring, whereas ineffective supervision will tend to increase that likelihood. However, without the presence of a direct motivator, the behavioural modifier will not, in itself, increase the likelihood of a safety rule being violated. By identifying direct motivators and the influence of the behaviour modifiers, many of the root causes behind violations become apparent and practical management actions can be developed. Management will then have greater confidence in their proposed initiatives. Without this knowledge the introduction of new initiatives can be an act of faith and, in some cases, the underlying causes of the problems will not be addressed. The effectiveness of any initiative may be significantly reduced. 2.2 Direct Motivators A direct motivator forms the underlying motive for an individual, or group, to consciously decide to break a rule or procedure. Seven such motives need to be considered Making Life Easier Safety rules and procedure often include factors that add to the difficulty of the job. For example, some jobs may need employees to don protective equipment that is uncomfortable to wear. Additional work, such as setting scaffolding, may be needed to perform a job safely. If this is 'only' required for somebody to perform a simple job, people may improvise to save the effort of assembling and disassembling the scaffolding or donning PPE. Poor design features often make a job much more difficult than necessary. Attention to the 'ergonomics' of equipment can reduce some violations. These design features increase the likelihood of violations: 1. Awkward or uncomfortable working postures 2. Difficulty in getting into or out of the operating or maintenance position 3. Personal protective equipment that is uncomfortable to wear or difficult to use 4. Poor environmental conditions of noise, dust, heat or coldness. Copyright GEE Publishing Ltd Recognising the Causes of Inappropriate Behaviour

9 2.2.2 Getting the Job Done Quicker or Saving Time Saving time is a common motive. Time saved may be judged as needed to achieve production, especially if the work schedules are unrealistic. Alternatively, time saved can be used to finish work early. Poor equipment design often needlessly extends the time required to perform a job. These design features increase the likelihood of violations: 1. Design features making a job excessively time consuming 2. Equipment that seems excessively slow to respond 3. Frequent false alarms or unreliable instrumentation Financial Gain The time saved through short cuts often results in higher bonus payments Practicality of Rules Although safety rules and procedures may have originally been appropriate, changes in working methods or personal protective equipment can result in some being impractical or inappropriate for some situations Unrealistic Operating Rules or Maintenance Schedules Some instructions and procedures are needlessly over-complex. For example, an operating instruction specified a pre-shift check that would take longer than the shift itself if it were strictly complied with! The machine would therefore never have been available for production. The desire to maintain production can lead to the workforce breaking such rules. There will be many situations where the rules and procedures are correct and necessary, however, the workforce may see them as unnecessary. It is therefore their perception of the need for them that is lacking Demonstrating Skill and Enhancing Self-esteem Some people break rules to show to themselves and others that they can achieve the task goals by adopting unapproved methods. This demonstrates that they have the skills to control the risks. The following section describes a typical work scenario where such behaviour is likely. Staff may see some rules as being introduced for those less skilled than themselves and following them undermines their own abilities. This may reduce their job satisfaction. They would violate the rules to show to themselves, and others, that they have exceptional skills and abilities. For example, a steel erector may elect not to wear fall-arrest equipment when working at a height. This type of behaviour is therefore likely to be stronger with groups or individuals who consider themselves as possessing higher than normal levels of skills, especially where they are employed in jobs requiring low demands on their abilities Deliberate Sabotage/Vandalism These rarely form motives for violations: however, they should also be considered. Such violations have been identified with contractors who are near to finishing a job. The vandalism occurs in an attempt to extend the contract to conduct the necessary repairs. 2.3 Behavioural Modifiers Copyright GEE Publishing Ltd Recognising the Causes of Inappropriate Behaviour

10 Subject to one or more direct motivators forming the 'desire' to deviate from the approved behaviour, the following nine behavioural modifiers will increase or decrease the likelihood of inappropriate behaviour depending upon the strength of their presence Pressure from Above to Cut Corners There are inevitably production pressures in industry. Management and supervisors will be concerned about maintaining production. While this should not reduce the level of safety, the actions of managers and supervisors may be 'seen' by employees as introducing 'pressure' or 'expectations' on them to maintain production at the expense of safety. It may not be the intention of the managers and supervisors to influence the safe behaviour of their workforce; however, such pressure may still be perceived to exist by the workforce. Whether real or perceived, pressure can influence employees to deviate from approved working methods. This pressure can, however, be positive whereby pressure is placed on ensuring staff strictly follow the safety rules and procedures Pressure from Colleagues Most people have a strong desire to 'fit in' with their workmates. This often results in a strong need to be seen to adopt the same working methods, whether good or bad, and be seen to have similar attitudes. Workmates can therefore 'pressure' an individual to conform to their standards. The term 'peer pressure' is often used and this usually has a strong influence on the behaviour of an individual. Peer pressure can be either negative or positive. In a good safety climate, the workforce will have a strong desire to be seen to follow the correct method of working. Anybody who fails to meet their standards will be letting the side down and will receive 'pressure' to conform to their high safety standards. New recruits will usually be trained in the approved methods of working. Once they return to their work groups this training can be ineffective if they see their workmates performing a job in a different way. The new recruit may consider their way to be just as good otherwise 'they would'nt be doing it' or may consider it more risky. Despite this the new recruit is almost certain to 'fall in' and work to that method in order to conform to the peer group method Perceptions of the Risks Accident rates can be higher in groups of people who estimate that the job risks are low. People are more likely to follow safety rules and procedures if they fully appreciate the consequences of deviating from them. People are more likely to violate if they underestimate these risks. The perception of risks is therefore an important factor affecting the safe behaviour of people. Improving these perceptions via some form of training is therefore a key target in the drive to improve behaviour. There are, however, a number of difficulties. People often consider the risks of strange or unknown situations as higher than they really are. On the other hand, people are often over-confident, or even complacent, about some familiar risks. People also tend to underestimate the risks from actions they choose to take compared with those risks that are imposed on them Perceived Benefits from Risk Taking Violations often follow a deliberate weighing up of the advantages and disadvantages of deviating from the approved procedures. Although many safety professionals focus on the employee's perceptions of the risks, it is probably more important to address their perceptions of the benefits. The benefits can be to the individual or the organisation. The following section discusses some common reasons why people think the organisation would want them to break certain rules. People are more likely to violate if they see some advantage to themselves. Advantages can be those addressed under the direct motivators (making their life easier, saving time, or financial benefits). Another perceived advantage may be that their superior will think more of them if they succeed and this may help them in future promotions. Although the benefits from the direct motivators may be tangible, the latter advantage is not. It is therefore their perception of this benefit that is critical. Copyright GEE Publishing Ltd Recognising the Causes of Inappropriate Behaviour

11 Surveys often show that people violate safety rules and procedures primarily to allow the company to achieve its targets. They perceive that the company would wish them to behave in a certain way despite the costs should their actions lead to an incident or accident. This perception is often derived from the visible actions of managers which may appear to place overriding attention on production. Although managers are likely to place safety high on their agenda it is usually their visible actions which influence the workforce. Managers need to be conscious of this and convey their safety commitment regularly and in visible ways Management and Supervisory Attitudes Senior management's commitment to safety is central to the behaviour of line managers, supervisors and the workforce. It is, however, the perception of this safety commitment that is important. For example, a senior manager may be totally committed to safety in his own mind. During the course of a day the manager may walk past a group who were not working strictly to an approved method of work. The manager may not have even noticed these people. If he did he may not have realised that a rule was not being followed. To this group, however, the lack of any reprimand or disciplinary action is likely to be seen as 'proof' of his low commitment to safety. Whatever the managers' real views of safety are, the workforce will tend to judge safety commitment on recent actions, or lack of them. Words alone will not work Likelihood of Detection An immediate disadvantage of committing a rule violation is being detected. The perception of the likelihood of being detected is therefore a strong factor influencing behaviour. For lone workers or those working at remote sites the likelihood of a supervisor visiting a site can be remote. When this does happen it is often possible to know in advance of a visit and amend poor working practices Effectiveness of Disciplinary Procedures A true deterrent requires both detection and appropriate disciplinary procedures. These have to be seen to be applied to all people who break a rule irrespective of their position in the company Accountability for Safety In many companies the cost of accidents is borne centrally and management are not made fully accountable for the situation which allowed the accident to happen. Accountability for safety can be less immediate and clear than accountabilities for production Complacency in an Accident-free Environment Finally, research has shown that people frequently become complacent in an environment in which there has not been a major incident for several years. This is almost a penalty for being successful. Management therefore need to be especially vigilant in these circumstances and ensure staff are constantly aware of what could happen rather than what has happened. Copyright GEE Publishing Ltd Recognising the Causes of Inappropriate Behaviour

12 3. Addressing Attitudes and Behaviour Accidents are a weak measure of unsafe working behaviour as the majority of unsafe behaviours often result in no accidents or incidents. Behaviour is influenced by a range of organisational, job and personal factors. Significant safety improvements may therefore be attainable by identifying and changing those organisational factors that change individual attitudes, motivation, risk perception or behaviour. For the distinction between the immediate causes of an accident and the organisational factors which increased the likelihood of the accident, see the following section. In recent years there has been a number of alternative approaches to modifying behaviour at work. In order to select the most appropriate approach, it is necessary to understand the different forms of human error. This is because different management actions are likely to be effective for each type of error. It is useful to consider errors as 'slips or lapses', 'mistakes' and 'violations'. The end result of each of these types of errors can be an incident or an accident. These incidents have been called 'active failures'. This is the final behaviour or actions that will lead to the incident. It is important, however, to recognise that the likelihood of these unsafe acts occurring would have been influenced by a number of failings that lie deeper within the organisation. These organisational failings are called the 'latent failures'. Typical examples of latent failures are: a training system that does not recognise the real demands of the job; rules and procedures that are impractical in some circumstances; and ambiguity of roles, responsibilities, authorities and accountabilities of supervision. Each of these latent failures may not by themselves cause an accident, but will tend to increase the likelihood of an accident. For example, a safe system of work may place reliance on the workforce being competent. This assumption would be severely challenged if there were major deficiencies in the training programme. 3.1 Tools for Change A common approach to promote compliant behaviour is to add more supervision to enforce rules or introduce new procedures such as more safety audits. Unfortunately, the bigger the underlying organisational failings that create the violation motives, the more resources are required to achieve compliance. Furthermore, these underlying motives may remain present and may still cause problems once the enforcement or other procedures have been relaxed. Two strategies are frequently adopted by organisations addressing the human factor issues. One strategy utilises behaviour-shaping packages that identify key behaviours and involve the workforce in regular monitoring, setting targets, and then widely communicating the results. The second strategy involves identifying and correcting those unique failings within an organisation that adversely affect attitudes and behaviour Strategy One: Behaviour-Shaping Programmes A number of commercial packages attempt to promote compliance by introducing procedures whereby the workforce regularly monitor the compliance level of key selected behaviours. These have often been linked to known incidents. Targets may be set and the results of various work groups openly displayed. Many organisations have found these approaches effective. While these programmes can be highly effective for underlying problems such as complacency or rule erosion, there will be some situations where their performance will be less effective. The following section discusses the risk of this approach attacking symptoms, but not the underlying problems.. These behaviour-modification procedures focus on observing key behaviours shown by the workforce. This approach will not be effective for unobservable behaviour, for example, by lone workers. A potential disadvantage with this strategy is that the organisational factors that created the poor attitudes and/or behaviour in the first place may not have been resolved. There is therefore the risk that when the monitoring and communication of poor behaviour have been removed the original behaviour will re-occur. These procedures may not address those organisational failings higher up in the organisation Strategy Two: Identifying and Correcting Organisational Failings In principle, attempts could be made to 'measure' the attitudes and motives for each individual. In practice this would Copyright GEE Publishing Ltd Addressing Attitudes and Behaviour

13 prove prohibitively expensive in time and effort and doubt is raised as to the ability of such basic measures to accurately represent true attitudes. Fortunately, we need not be overly concerned with trying to measure individual attitudes if the objective is 'simply' to identify and reduce the organisational factors that are likely to influence attitudes and hence the behaviour of the workforce. These organisational factors could include: training; management and supervision; job design and equipment design, and all of these can be 'controlled' by management. It is more effective to change the factors that influence individual attitudes than to attempt to change the attitudes themselves. If these organisational factors can be identified, practical management actions can be determined. The classification of direct motivators and behavioural modifiers allows approaches to be developed that identify the organisational factors present in a system which increase the potential for violations. They help management identify the best course of action to eliminate, or at least reduce, the potential for violations in a wide range of industrial situations. It is the perception of the workforce as to the strength of each direct motivator and behavioural modifier that is the key to individual or group behaviour. Questionnaires therefore present an ideal way of measuring these factors. The advantages and disadvantages of questionnaires over other techniques are addressed the following section. Strengths 1. They are quick to administer. 2. Findings reflect present attitudes and current changes taking place in the organisation. 3. They involve staff in identifying areas of concern, promoting ownership of the resulting improvement plan. Weaknesses 1. Findings are based on perception and may be influenced by factors unrelated to safety. 2. No factual information is obtained to gauge the level of expenditure warranted for improvements. 3. Findings may not identify relative weaknesses in the more direct causes of accidents/incidents (e.g. poor environment) Comparison of Two Strategies Each approach - behaviour-shaping programmes and identifying and removing latent failing - is assessed in terms of its ability (either '' or 'Poor') to address a number of common problems. Several entries are classed as 'mixed'. This is used to show where the approach may identify a problem but indicates that the outcome is not guaranteed. The table comparing the two strategies is given the following section. Common Problem Areas Poor rules and procedures Poor training in rules and procedures Poor workforce Behaviour-shaping Identifying Programmes: and Strategy Removing One Latent Failings: Strategy Two Mixed Mixed Copyright GEE Publishing Ltd Addressing Attitudes and Behaviour

14 commitment to safety Poor supervisor commitment to safety Ambiguity in roles, responsibility and accountability Poor working environment Insufficient resource allocation Ineffective supervision Complacency in accident-free environment Mixed Mixed Mixed Rule erosion Poor design features 'encouraging' violations Problems with lone workers Poor skills training Mixed Poor Mixed Copyright GEE Publishing Ltd Addressing Attitudes and Behaviour

15 4. The Use of Questionnaires and Incident Reports Some general purpose methodologies aim to identify critical factors in the chain of events leading to an incident in order to reduce 'carbon copy' incidents. Management need not, however, wait until there is an incident involving a violation. Intervention can be proactive. A better approach is to conduct an audit of 'potential violations' in a work environment. This can yield a profile of the organisational factors that are likely to shape behaviour. It is these factors that need to be addressed to promote compliance. This approach is more powerful than responding specifically to any actual incidents being investigated. As these organisational factors are likely to be influential in a wider range of potential violations, the resulting remedial actions would reduce both the violations identified and the many more that were not identified but which would also be influenced by the deeper latent failings of the organisation. The first stage in any attempt to promote compliance is to identify the common causes of inappropriate behaviour. 4.1 Use of Incident Reports An analysis of incident reports can be useful. This approach is favoured when there is a large number of well-documented reports and where a detailed assessment of the past can be reliably extrapolated to the future. This should not be done where significant changes to the organisation have occurred or are planned. The relevance of historical data to the present day (and the future) must be in doubt if there have been significant changes to key factors in the organisation that are likely to influence behaviour. Caution should be exercised if there has been downsizing, changes in working methods or management and supervisory methods, multi-skilling and skill loss through the early retirement of experienced staff. For companies with such a record of change, a questionnaire approach is likely to be more useful. 4.2 The Use of Questionnaires Some organisations begin the process of improving behaviour and safety culture with a comprehensive attitude survey on a sample, or all, of the workforce. Management should note that running an attitude survey will create expectations in the workforce. Delays in feeding the results back to the workforce, or delays acting on the results will be seen as a lack of commitment by senior managers and may jeopardise this and future initiatives. There may be certain attitudes in the workforce that reduce the likely success of new initiatives. These can be called 'attitudinal barriers'. The following section gives an example of this problem and how managers address it. Some organisations regularly introduce safety initiatives and these fail because insufficient resources are devoted in the long term to making them work. It would not be surprising, therefore, to find a general attitude among the workforce of a new initiative 'just being another passing idea'. They will therefore not give it a chance. Managers would need to first communicate the importance of this initiative and 'sell' the new idea to the workforce. Without this preliminary phase they will be much less receptive to a new idea - whatever it is. Managers must be clear as to the objectives of the questionnaire if it is to be effective. For example, management should decide whether the intention is to: 1. Assess the safety culture of the organisation/plant/work group 2. Assess the factors that influence compliance or violations 3. Measure job satisfaction 4. Identify barriers to future behavioural initiatives 5. Identify bench marking of progress to attitudinal/behavioural goals. There have been many different questionnaires used in industry. They vary in terms of the question design, questionnaire size and complexity, scoring system, etc. Some are designed to be applied to any industry and for all employees from management to trainee. Others are designed for specific groups of employees. Each has its advantages and Copyright GEE Publishing Ltd The Use of Questionnaires and Incident Reports

16 disadvantages. The most appropriate questionnaire depends to a large extent on the stage an organisation is at in a behaviour programme. For example, where an organisation has not previously considered in any detail behavioural issues, a general attitude questionnaire would often be most appropriate. The Health and Safety Executive's Safety Climate Questionnaire is an excellent general purpose tool. Another general purpose methodology was recently developed by the Human Factors in Reliability Group (HFRG) and published by the Health and Safety Executive (HSE) (HSE/HFRG 95). For more details see Further Information. Alternatively, if an organisation had prior involvement in behavioural programmes it may require a more focused investigation on a number of specific areas. In these instances a questionnaire developed specifically for that organisation's needs may be most appropriate General Purpose Attitude Surveys General surveys can provide useful comparisons with other industries. They can also identify any general underlying problems. As they have been used widely in a range of industries they also give confidence as a result of the use of a proven questionnaire. However, because of the need to keep questions meaningful for a wide range of industries and job types, compromises may need to be made when incorporating questions addressing specific working groups who have specialist tasks. Terminology must also be generalised to be as relevant to the nuclear industries, for example, as to small general workshops. It may therefore not be possible to aim specific questions at specialist jobs such as electricians. Also, many general purpose questionnaires present overviews of the underlying problems but do not necessarily provide an indication of the best route for tackling them. Some do not determine differences between the attitudes of managers, supervisors and the workforce. There is no ownership in the development of the questionnaire by the workforce or management. Problems can also occur in differentiating between cause and effect. Where fixed rating scales are used, they can also be limited in showing improvements as attitudes move closer to excellence Targeted Attitude Surveys Some organisations can benefit from the application of a more focused type of questionnaire. For example, where an organisation: is aware of its human factors weaknesses; has a vision statement to further improve its safety culture; and where suitable initiatives are in place, then the requirements from attitude surveys will be very different from the general purpose survey (see General Purpose Attitude Surveys). In these instances, attitude surveys that are developed to address specific needs can be more cost-effective. They can monitor progress towards the organisation's goals to ensure resources and initiatives are being effective and determine which, of many initiatives, are proving the most successful. They can be more efficient by focusing only on those issues that need to be looked at in detail. They can be specific to the tasks and problems of an industry. The format can reflect the vision statement and therefore the results can reinforce that goal as opposed to being couched in the terms of a safety culture model. They can identify whether specific training courses are being effective and can also determine any attitudes that form barriers to a vision or planned initiatives. The choice of questionnaire or incident analysis is summarised in the figure below. Copyright GEE Publishing Ltd The Use of Questionnaires and Incident Reports

17 5. Further Information HSE, 1995, Improving Compliance with Safety Procedures - Reducing Industrial Violations HMSO, ISBN This is priced at 20 and is available from HSE Books. HSE, 1998 Health and Safety Climate Survey Tool HSE Books. The HSE's Safety Climate Questionnaire. The Safety Climate Questionnaire is available from the HSE in electronic form. It presents short questionnaires to the workforce, supervisors and senior managers. The computer package develops the questionnaires and analyses the results. The software provides an impressive package to assist in interpreting the findings. HSE / HFRG Methodology. A questionnaire-based methodology is presented to enable the non-specialist to identify the presence of organisational factors that increase non-compliant behaviour. The questionnaire needs only to be administered to a sample of the workforce. A number of practical suggestions are provided to help management improve those factors that predispose violations. Copyright GEE Publishing Ltd Further Information

18 Key Questions Management suspects that some rules are regularly infringed. Where is the best place to start? See Recognising the Causes of Inappropriate Behaviour. Why is it important to distinguish between the different forms of human error? See Types of Human Error. Are all instances of rule-breaking violations? See Types of Violation. What motivates people to deliberately break a safety rule? See Why do People Choose to Violate Rules and Procedures? Should the emphasis be on improving safety attitudes or behaviour? See Tools for Change. How do people know which type of questionnaire survey most suits their needs? See The Use of Questionnaires. What does the term 'safety culture' really mean, and why should management devote efforts to assessing and improving it? See Recognising the Causes of Inappropriate Behaviour. Is there any difference between safety culture and safety climate? See Introduction. Copyright GEE Publishing Ltd Key Questions

19 Troubleshooter Previous Successes not Repeated Elsewhere Q. A multi-skilling initiative was applied across the company. It worked well in some areas but failed in others. While the attitudes of the electricians appear to be improving, those of the fitters appear to be worsening. Where did the company go wrong? A. Problems can arise when managers try to introduce a top-level initiative across these 'mini cultures'. For example, the initiative to introduce some multi-skilling for both electricians and fitters may be seen as positive for the electricians if it makes their life easier in not having to wait for a fitter to remove a cover plate, or other items, to gain access to electric circuitry. Fitters, on the other hand, may see this move as the first stage of the plant becoming less dependent on their skills with electricians being gradually asked to do more and more of their work. At the same time the fitters may see themselves as never being allowed to become involved in more than very simple electrical tasks. Job security would therefore be affected. Managers must recognise that there are different ways of improving attitudes and behaviour and that the approaches that worked with one group may not work well for a different group. A further factor also needs to be considered. For an initiative to work, those who will be affected will need to be receptive to the idea. It is useful to consider if there are any 'attitudinal barriers' that prevented those people 'buying into' the idea. For example, some companies have a track record of many initiatives being introduced, each with a short life. This can occur as managers fail to maintain initiatives such as regular toolbox talks or audits. With such companies, a common barrier is that people feel a new initiative is 'just another idea that will fizzle out'. They will therefore not commit themselves to a new initiative. Managers would need to 'sell' a new initiative by emphasising its importance and demonstrating senior management's commitment to it. It may only be after these 'barriers' are removed that the staff seriously consider the new initiative. See Error Type: Violations. Using Results from Attitude Surveys Q. Our company has started to use the Health and Safety Executive's safety climate tool. The results are very interesting but management are not really sure where to start making improvements. Where do we begin? A. This tool can generate an enormous amount of useful information. As a result it can be difficult to see the 'wood for the trees'. It is important that managers separate 'cause' and 'effect' when looking at the data and resist any temptation to respond to symptoms before the underlying causes have been considered. Presenting and discussing key results with the workforce and managers will often generate new ideas for improving attitudes and behaviour. See General Purpose Attitude Surveys. Copyright GEE Publishing Ltd Troubleshooter