Becoming Ultra Safe By getting the culture right

Transcription

1 Becoming Ultra Safe By getting the culture right Dr. Mark Fleming Saint Mary s University mark.fleming@smu.ca

2 Workshop program Introduction and overview Features of a positive safety culture Safety Culture Maturity (SCM) Safety Culture Audit Improvement

3 Aims and objectives By the end of the workshop you should understand: the relationship between culture and safety the Safety Culture Maturity Model how to measure safety culture perceptions and systems supporting a positive culture

4 High Reliability Organisations V1.2

5 Piper Alpha

6 Organisational Factors in Disasters Despite the adoption of a full range of safety systems, complex systems broke down disastrously because the people running them failed to do what they were supposed to These were not simple individual errors but malpractices that corrupted the social system that made the organisation i function Blaming human error and hoping that a cure can be found for these random frailties is unlikely to work

7 Some 'holes' due to active failures DANGER Defences in depth From Reason 1997 Other 'holes' due to latent conditions

8 Safety improvement hierarchy Acciden nt / Incid dent rates Engineering Systems Behaviour/ culture Time

9 Reasons for Interest 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

10 Culture Culture has been defined as: A pattern of basic assumptions Invented, discovered or developed by a given group Learnt from coping with problems of external adaptation and internal integration That has worked well enough to be considered valid Is taught to new members (as the) Correct way to perceive, think and feel in relation to problems Schein 1990 p110

11 Iceberg model

12 Trade - offs & the Unrocked boat Protection Bankruptcy Better defences converted to increased production Increased investment in protection Catastrophe From Reason 1997 Production

13 Safety culture Safety culture refers to the shared perceptions among members of an organization with regard to aspects of the organizational environment that inform role behavior (Zohar & Luria, 2005, p616).

14 Culture and Safety Safety Culture Norms and Behaviour Safety Enabler/ Barrier Safety Interventions ti

15 Origins of safety culture A poor safety culture was identified as a factor contributing to the Chernobyl disaster by the International Atomic Energy Agency (1987) It is essential to create a corporate atmosphere or culture in which safety is understood to be and accepted as, the number one priority it p 300 Lord Cullen

16 High Reliability Organisations Preoccupation with failure (investigate all lapses) Encourage employees to report error Seek to develop deep understanding of issues Decentralised decision making to those with most expertise Attentive to frontline employee concerns

17 High Performance Work Systems Self-managed teams; decentralized decision making Reduced status distinctions Extensive sharing of information Extensive training Selective hiring of new personnel Compensation contingent on performance Employment security High quality work

18 Low accident companies High level of communication Good organisational learning Strong focus on safety Senior management commitment Participative style of leadership Skills training emphasis safety aspects Good working conditions High job satisfaction Promotion / selection based on safety

19 Positive safety culture elements Good organisational learning Workforce involvement Training Safety performance evaluation Communication Job conditions and satisfaction Commitment t to safety

20 Elements of a negative culture Major accidents/crises role ambiguity management complacency poor communication production and safety conflicts

21 Safety culture model External Factors Safety compliance Organisational environment Worker perceptions Safety motivation Management practices Safety systems Communication Supervision practices Management attitude toward safety Production pressure Status of safety Supervisor attitude Proactive safety behaviour

22 Safety culture and outcomes Safety culture questionnaire responses have been linked with accident rates in the following industries: Nuclear power (Lee, 1998) Offshore oil (Mearns, Flin, Fleming & Gordon 1997) Road construction ti (Niskanen, 1994) Chemical industry, (Donald & Canter, 1994) Manufacturing, (Brown & Holmes 1986), (Zohar, 2000)

23 Safety culture assessment Method frequently used: Self completion questionnaire Purpose Obtain a baseline Benchmarking Identify areas of strength and weakness Utility of results Mixed at best

24 Safety culture surveys are a bit like describing the water to a drowning man, they tell you how bad things are but do not help you to solve the problem. Phil Ley (safety manager)

25 Need for a new approach Many companies have conducted safety culture surveys and have difficulty in using the results to take action to improve safety There is a need for a simple framework to represent the current culture and what a better culture would look like Good safety interventions (e.g. behavioural safety) appeared to fail because because the company was not ready (mature enough)

26 What is SCM Safety culture development is broken down into five stages or levels of maturity, from poor to good A number of similar il models currently in use (e.g. hearts and minds, shell) Five safety culture dimension/ elements Once the level has been established sites identify the actions required ed to move to the next level

27 Safety culture maturity elements Leadership Supervisor visible commitment Production pressures Workforce involvement Communication

28 Pathological Reactive Bureaucratic Proactive Generative Level 1 Level 2 Level 3 Level el 4 Level el 5

29 Pathological Why waste our time on safety? Information supports power and glory Loyalty and conformity is maintained through intimidation Reaction to problems Suppression Encapsulation

30 Reactive 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 Safety would improve if employees were more careful

31 Bureaucratic 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

32 Proactive 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

33 Generative We know why we do not have incidents Information supports the mission Information flows freely, honesty is valued Response to incidents: Global l fix: try to fix every example of a problem, share information with other stakeholders Inquiry: Get to the root cause of problem

34 What type of culture do you V1.2 have? Westrum (1998) identified three types of cultures for dealing with information: Pathological Bureaucratic Generative Do not want to know Messengers are shot New ideas are actively crushed May not find out Listened to if they arrive New ideas present problems Actively seek information Messengers are trained New ideas are welcomed

35 Safety culture assessment Safety culture workshops 2-3 hour sessions with sample of workforce Card sorting exercise, discussion Analysis and action planning Safety culture audit Self assessment external assessment Calibration i Action planning

36 SCM Process Senior management briefing and SCM card sorting exercise Organise workshops with a cross section of the workforce Give presentation about SCM and purpose of the session Split into pairs and give each pair a set of SCM Q-Sort cards Get them to select the card that most closely reflects their perception Get them to record their selections

37 SCM Process (cont) Workshops (cont) Record group results Describe current situation Discussion of level of SCM Identify actions to improve level of maturity Collate data Analyse results Develop action plan Feedback to workforce

38 Summary of responses for each element by level 100% 90% 10% 9% 17% 22% 80% 30% 41% 70% 51% 37% 60% 50% 40% 48% 48% 31% Generative Proactive Bureaucratic Reactive Pathological 30% 37% 20% 38% 14% 10% 0% 26% 7% 15% 9% 6% 0% 1% 1% 1% 0% 1% Leadership Supervisor visible Production pressures Workforce involvement Communication commitment

39 Overall summary of responses for each element ( 334 People) 4 3 Level % 88% 90% 71% 73% 0 Leadership Supervisor visible commitment Production pressures Workforce involvement Communication

40 Leadership Current situation Actions Good on the big issues Measure managers on Some managers actively the extent to which they involved demonstrate Variation between managers commitment to safety Provide leadership Health and safety not evident enough in day to day skills training for activities managers Some managers lack Senior managers to set required leadership skills the example/ coach subordinates

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

42 SCMIP elements Organisational learning Incident Investigation Team Workforce involvement Workforce Involvement Training i Frontline Worker Safety Training Supervisor Safety Training i Manager Safety Training

43 SCMIP elements Safety performance evaluation Manager Safety Performance Evaluation Supervisor Safety Performance Evaluation Communication Safety Communication Commitment to safety Planned Maintenance Rules and Procedures Managers Visiting the Worksite Supervisors Visiting the Worksite

44 How to use SCMIP Self assessment of systems supporting the safety culture Completed by safety department to assist in annual planning Completed by senior management team to form basis for improvement workshop Integrate into existing audit process External assessment of safety culture

45 Benefits of SCMIP Avoids need to survey employees Can be used by management team to assess current safety culture without raising employee expectations of change. Identifies specific interventions as the audit assess the presence and quality of safety culture indicators Can be used to identify improvement areas for contracting organisations

46 Improvement strategies Change management systems to support the desired culture For example perceived management commitment can be improved by: Providing managers with the skills to be effective safety leaders Motivating managers to change by monitoring performance (leading indicators) Rewarding effective performance

47 Safety Culture Change Peoples attitudes and opinions have been formed over decades of life and cannot be changed by having a few meetings or giving a few lectures (Mao Tse Tung)