Safety Culture-Gap Management. Bob Arnold, SHEQ Director Canada, Europe and the Middle East

Transcription

1 Safety Culture-Gap Management 1 Bob Arnold, SHEQ Director Canada, Europe and the Middle East

2 Safety Culture-Gap Management A paper by Tony Putsman, Bob Arnold, John Carpenter, Graeme Walker, Peter Crosland from the Institution of Civil Engineers (ICE) Expert Health and Safety Panel David Ackerley from 2

3 The path of UK safety legislation Factory Acts 1802, 1819, 1833, 1844, 1847, 1850, Prescriptive, reacting to events 1856, 1878, 1901, 1937, 1959, 1961

4 4 Aberfan Disaster 1966 Killed 116 Children and 28 Adults

5 UK Health and Safety at Work Act 1974 Lord Robens Report Reform should be aimed at creating the conditions for more effective self-regulation by employers and workpeople jointly. Health and Safety at Work Act Section 2 It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees Prescriptive regulation dropped. 5

6 6 UK Fatalities since 1974

7 Comments on Safety Culture 7

8 Comments on Safety Culture From top to bottom the body corporate was infected by the disease of sloppiness. Mr Justice Sheen 1987 The Zeebrugge Ferry disaster 193 passengers and crew died

9 Comments on Safety Culture A concern for safety which is sincerely held and repeatedly expressed but which is not put into practice is as much protection from danger as no concern at all. Sir Anthony Hidden 1988 Clapham Train Crash 35 people died

10 Comments on Safety Culture Buncefield is a stark reminder of the potential result of a poor attitude towards safety. Gordon MacDonald, chair of the COMAH Competent Authority Strategic Management Group, 2005, Buncefield Explosions and Fire

11 Comments on Safety Culture Carolyn W. Merritt U.S. Chemical Safety and Hazard Investigation Board, November 2005

12 Comments on Safety Culture A good safety culture is the embodiment of effective programs, decision making and accountability at all levels. When we talk about safety culture, we are talking first and foremost about how managerial decisions are made, about the incentives and disincentives within an organization for promoting safety. Carolyn W. Merritt U.S. Chemical Safety and Hazard Investigation Board, November 2005

13 Comments on Safety Culture One thing I have often observed is that there is a great gap between what executives believe to be the safety culture of an organization and what it actually is on the ground. Almost every executive believes he or she is conveying a message that safety is number one. But it is not always so in reality. Carolyn W. Merritt U.S. Chemical Safety and Hazard Investigation Board, November 2005

14 SAFETY CULTURE AND THE SAFETY CULTURE-GAP 14

15 Safety Culture and the Safety Culture-Gap Organisations usually have: A top Top management (directors, partners, senior managers) A middle Middle-management (project management teams, service function teams) Operative Supervisors and the workforce 15

16 Safety Culture and the Safety Culture-Gap The Role of Managerial Leadership in determining Workplace Outcomes Prepared by the University of Aberdeen for the Health and Safety Executive

17 Safety Culture and the Safety Culture-Gap The Role of Managerial Leadership in determining Workplace Outcomes Prepared by the University of Aberdeen for the Health and Safety Executive 2003 To date, the path of influence between corporate level decision makers and site level managers is not well researched 17

18 Safety Culture and the Safety Culture-Gap Top Management Middle Management Supervisors and Workforce Do they like the middle managers? Do they respect supervisors and workforce? Do they like other top managers? Do they respect top managers? Do they like the supervisors and workforce? Do they know other middle managers? Do they know middle and top managers? Do they like middle managers? Do they respect the top managers? 18

19 Safety Culture and the Safety Culture-Gap The Role of Managerial Leadership in determining Workplace Outcomes Prepared by the University of Aberdeen for the Health and Safety Executive 2003 To date, the path of influence between corporate level decision makers and site level managers is not well researched...overall though, it is critical that a consistent and unified message, emphasising the priority of safety, is communicated throughout the organisation 19

20 Safety Culture and the Safety Culture-Gap Setting a safety culture difficult, but not impossible Company Values...overall though, it is critical that a consistent and unified message, emphasising the priority of safety, is communicated throughout the organisation 20

21 Safety Culture and the Safety Culture-Gap Health and Safety Culture. The most popular definition The way things are done around here. True. But this is an output. No reference to inputs. Needs measurable inputs and outputs to be useful 21

22 Safety Culture and the Safety Culture-Gap Health and Safety Culture. A definition: The combination of organisational Values, Behaviours Knowledge and Systems 22 VBKS

23 Safety Culture and the Safety Culture-Gap VBKS Values Unified messages used throughout the organisation Behaviours All levels. Conscious and non conscious. Note new Nudge and Shove theories Knowledge All levels. Education, training. Access to information Systems All levels. A description of how operations should be undertaken, including control systems and governance 23

24 Safety Culture and the Safety Culture-Gap VBKS planned VBKS actual The Safety Culture Gap is the difference between the planned and actual states of Safety Culture. 24

25 FINDING THE SAFETY CULTURE Safety Culture-Gap Management (SC-GM) Accident Investigation or A Mock Accident Investigation based on a Near Miss 25

26 Getting management information Naturally occurring data is negative accidents, ill-health, disease, injuries, near misses. The better you get, the less data you have, the deeper you have to dig. 26

27 Investigation vs Audit Undertaken over a long period if needed Scope limited to causes of accident Usually time limited Wide scope Note that audits often trigger the need for an investigation 27

28 Investigator vs Auditor Set out to prove there are problems Show auditee in a fair light Proof Evidence 28

29 29 Accident Investigation

30 Accident Investigation Root Cause Underlying Causes Immediate Cause Direction of Accident Investigation 30

31 Immediate Cause Human Error? Mechanical Failure? - Some examples. Careless error? e.g. operator in a bad mood Reckless error? e.g. knowingly took a chance with incorrect crane set up Management system induced violation? e.g. Insufficient time to check crane, as required, before set up Mechanical failure induced violation? e.g. warning light not working for several weeks Mechanical failure induced error? e.g. instrument panel giving incorrect reading 31

32 Underlying Cause For Values, Behaviours, Knowledge and Systems - + Good programs in place; understood and effective + Good programs in place but not adopted correctly + Inadequate programs in place + No programs in place 32

33 Root Causes typical scenarios The senior managers have set a safety culture throughout, and monitor its effectiveness. Success! The senior managers are well intentioned, but have not seen their intentions through into practice. Looks sloppy The senior managers have not addressed the safety culture. Inevitable poor safety culture 33

34 Direction of Influence Root Culture Underlying Culture Immediate Culture Direction of Influence; Culture and Leadership 34

35 35 PRESENTATION OF FINDINGS

36 Planned: Values Behaviours Knowledge Systems Immediate Cause Underlying Cause Root Cause Actual: Values Behaviours Knowledge Systems Immediate Culture Underlying Culture Root Culture 36

37 After the investigation Plan the improvements, if needed re Values Behaviours Knowledge Systems OHS TW QMS Critical Safety Prepare for next mock accident as part of the Safety Culture-Gap Management program 37

38 Summary Employer taking responsibility Health and Safety Culture Health and Safety Culture-Gap Management VBKS planned and VBKS actual Mock Accident Investigations 38

39 Questions? Contact details: Tony Putsman David Ackerley Bob Arnold 39