IMPACT OF EXPECTATIONS AND CULTURE ON PROJECT SAFETY PERFORMANCE

IMPACT OF EXPECTATIONS AND CULTURE ON PROJECT SAFETY PERFORMANCE Jamie C. Horwood and Paul R. Amyotte Department of Process Engineering and Applied Science Dalhousie University, Halifax, NS, Canada B3J 2X4; e-mail: paul.amyotte@dal.ca Key elements of an effective safety culture are examined in the current work by reference to a recently completed major fabrication project. This project involved the participation of three separate entities, each with varying expectations for a successful project. Each of the three companies had an extensive history of fabrication projects, and also a unique safety culture reflective of their project expectations. The attitude toward Safety, Health and Environment (SHE) differed among the companies as a result of the varying SHE histories and safety culture maturities. The current work provides a review of the outcome of project expectations in terms of an analysis of safety-related incidents and the remedial actions taken to improve SHE performance. Emphasis is placed on the lessons learned from the fabrication project, particularly in relation to the matching of safety cultures among project partners and agreement on a common set of safety performance expectations. It is anticipated that this work will be of value to industry as a case study highlighting the importance of safety culture as an integral component of an effective safety management system. KEYORDS: safety culture, safety management systems, case studies INTRODUCTION The fundamental issue of whether a company believes it is possible to achieve a higher standard of safety in essence whether a company believes safety is the right thing to do has recently been addressed in the excellent book by Andrew Hopkins. Hopkins (2005) describes three concepts that address a company s cultural approach to safety, and makes the argument that the three are essentially alternative ways of talking about the same phenomena: (i) safety culture, (ii) collective mindfulness, and (iii) risk-awareness. He further defines the concept of a safety culture as embodying the following subcultures: (i) a reporting culture in which people report errors, near-misses, and substandard conditions and practices, (ii) a just culture in which blame and punishment are reserved for behaviour involving defiance, recklessness or malice, such that incident reporting is not discouraged, (iii) a learning culture in which a company learns from its reported incidents, processes information in a conscientious manner, and makes changes accordingly, and (iv) a flexible culture in which decision-making processes are not so rigid that they cannot be varied according to the urgency of the decision and the expertise of the people involved. The concept of collective mindfulness (as described by Hopkins, 2005) embodies the principle of mindful organizing which incorporates the following processes: (i) a preoccupation with failure so that a company is not lulled into a false sense of security by periods of success, (ii) a reluctance to simplify data that may at face-value seem unimportant or irrelevant, but which may in fact contain the information needed to reduce the likelihood of a future surprise, (iii) a sensitivity to operations in which frontline operators and managers strive to remain as aware as possible of the current state of operations, and to understand the implications of the present situation for future functioning of the company, and (iv) a commitment to resilience in which companies respond to errors or crises in a manner appropriate to deal with the difficulty, and a deference to expertise in which decisions are made by the people in the company hierarchy who have the most appropriate knowledge and ability to deal with the difficulty. Hopkins (2005) claims that risk-awareness is synonymous with collective mindfulness (which is obviously closely related to the concept of a safety culture). He also describes a culture of risk-denial in which it is not simply a matter of individuals and companies being unaware of risks, but rather that there exist mechanisms that deny the existence of risk. Other researchers have come to conclusions similar to those of Hopkins (2005) in terms of the factors critical to the development of safety culture or collective mindfulness, or risk-awareness. For example, Olive et al. (2006) have identified several characteristics of a good safety culture: (i) a commitment to the improvement of safety behaviours and attitudes at all organizational levels, (ii) open and clear communication brought about by an appropriate organizational structure and atmosphere, such that people are encouraged to ask questions and do not feel intimidated or hesitant to raise issues for fear of retribution, (iii) a propensity for resilience and flexibility in adapting effectively and safely to new situations, and (iv) a prevailing attitude of constant vigilance. Similarly, Kadri and Jones (2006) list five underlying themes of an effective safety culture: (i) maintaining a sense of vulnerability, (ii) combating normalization of deviance (i.e. not sanctioning violations of established engineering or operational constraints on the basis of previous violations that did not result in negative consequences), (iii) performing appropriate and timely hazard/risk assessment, (iv) establishing an independent and unassailable role for 1

safety, and (v) ensuring open and frank communications across all levels. ithin the broader context of the organizational culture from which a safety culture is derived, Killimett (2006) has commented that high-performance organizations consistently show high trust, good communication, management credibility, and organizational value for safety. As noted by Glendon and Stanton (2000), safety culture is often identified as a fundamental part of an organization s ability to manage the safety-related aspects of its operations. Thus, a high-performance organization would be expected to employ a safety management system just as it would use a management system for other operational aspects such as environmental protection, quality control and assurance, and attainment of productivity goals. There is therefore a strong link between a company s safety culture and its use of a safety management system appropriate for the hazards and risks being managed (Amyotte et al., 2006). For example, many of the safety culture features identified above are directly addressed by the various elements of Process Safety Management (CSChE, 2002) elements such as Accountability: Objectives and Goals, Process Risk Management, and Incident Investigation. Against this background overview of safety culture and safety management, the following case study is presented. The central theme is that safety performance on an engineering project is a reflection of a company s project expectations which are, in turn, directly related to a company s safety culture. PROJECT AND COMPANIES INVOLVED The engineering work was a 16-month, major fabrication project involving three separate corporate entities (referred to in this paper as Companies X, Y and Z). Their project roles were: (i) Company X owner of the fabrication product, (ii) Company Y project contractor, and (iii) Company Z engineering procurement and construction (EPC) company. At the project outset, there was a shared expectation that safe production would be the first priority and a common understanding that the success of the project would depend upon the Safety, Health and Environment (SHE) performance. Throughout the duration of the project, however, the worksite experienced 193 incidents, of which 112 resulted in personal injury. There was clearly a mismatch between theory and practice. Company X (the owner of the fabrication product) is regarded as an industry leader in occupational safety and has a safety performance record that is well-described as bestin-class. The company s mature safety culture is typified by its high project expectations that:. There would be zero injuries over the life of the project.. Company Y (the project contractor) would provide leadership in safety principles and expectations from an upper management level by emphasizing the importance of the SHE plan to its project supervisors in an effort to develop a positive safety attitude among the workforce.. Company Y would provide knowledgeable project supervisors who were committed to safety.. The project workforce would be given the opportunity to participate in SHE policies, procedures and discussions.. A well-developed incident management system would be implemented to permit appropriate incident classification and remedial/follow-up measures, with the ultimate goal of monitoring incident trends to identify inadequacies in the project s SHE plan. This point in particular embodies the reporting, just and learning subcultures identified by Hopkins (2005). The prior safety record of Company Y (the project contractor) reflects that of the specific industry sector in which a production-oriented approach has historically been the norm. Therefore, the primary expectation held by Company Y was that its safety performance would be significantly improved from previous projects. It was recognized that the ability of Company Y to meet this expectation would ultimately decide the success of the project. Company Z (the EPC company) has a strong safety record reflective of its dedication to safe-work practices. Company Z s general safety expectations are similar to those of Company X, but for the project under consideration these expectations were redefined to be:. Project completion without serious injury to personnel (a softening of Company X s expectation of zero injuries).. An improved level of supervision, case management and incident reporting over previous Company Y experience (similar to Company Y s own expectation for its performance).. Personnel in supervisory positions taking a proactive approach to safety and leading by example to stress the importance of incident prevention in ensuring a safe and successful project (an enhancement of Company X s expectation in this regard). OUTCOME OF PROJECT EXPECTATIONS A thorough analysis of all safety-related incidents (193) was undertaken for the duration of the project. This analysis incorporated all reported first-aid (83), near-miss (81), medical-aid (10), restricted-work (10), and injurywithout-treatment (9) incidents; there were zero lost-time injuries. Figure 1, which shows the number of incidents for each project month, indicates an unacceptable incident rate during the first half of the project with a peak in number of incidents at the midpoint. These shortcomings meant that most of the safety expectations of the project stakeholders were either not met or were only partially satisfied:. Company X As evident in Figure 1, the expectation of zero injuries was not realized. As previously mentioned, the project experienced 112 personal injury incidents; this was regarded as a serious project shortcoming. 2

Number of Incidents 30 25 20 15 10 5 2 5 14 18 12 15 26 23 21 18 10 3 14 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Time in Months Figure 1. Safety incidents as a function of project duration The expectation that safety principles and performance would be driven by Company Y management was only partially achieved. It was determined that safety leadership within Company Y was strongest at the site management level (project manager and below), not at the senior company management level. Similarly, the expectation that Company Y would provide knowledgeable project supervisors who were committed to safety was only partially realized. Through the work of an independent safety consultant, it was determined that while Company Z supervisors were dedicated to safety, some of the Company Y supervisors struggled to meet this expectation. This is attributed to the safety culture and priority differences between Companies Y and Z. As discussed in a subsequent section of the paper, Company X intervened midway through the project in response to the escalating occurrence of safety incidents. A major outcome of this decision was that the workforce was given increased opportunities to participate in safety discussions. Thus, the expectation concerning worker involvement in safety-related matters was achieved only during the later stages of the project. A significant project achievement was the meeting of incident management expectations for incident reporting and follow-up.. Company Y s expectation of improving on its historic safety performance was completely realized; the fabrication project was a major accomplishment for Company Y. ith the leadership and assistance of Companies X and Z, Company Y attained a significant milestone in terms of hours worked without a lost-time injury.. Company Z Despite the high number of overall incidents encountered during the project, there were no serious (disabling) injuries meaning that Company Z s expectation in this regard was met. The expectation of improved supervision, case management and incident reporting over previous Company Y experience was satisfied. Company Y management personnel were not generally regarded as safety role models for the workforce; safety initiatives taken by Company Y management were usually in response to pressure exerted by Company X. Thus, the expectation of Company Z concerning a proactive supervisory approach to safety was not met. FACTORS AFFECTING EXPECTATION OUTCOMES Many work- and safety-related factors influenced the outcome of the project expectations. These factors are briefly examined in the following sections before turning to a discussion of the overall lessons learned from the project. EFFORTS TAKEN TO MEET EXPECTATIONS In an effort to meet the project safety expectations, 14 significant actions were taken over the duration of the project. Most of these actions were effective in improving safety performance; the majority, however were reactive as opposed to being proactive. A sequential listing of the steps implemented is given below: 1. The first effort toward education was implementation of a Company Z program on behavioural aspects of safety. This was completed in the first quarter of the project with the objective of engaging all supervisors. 2. Early efforts were made with regard to safety walkthroughs and inspections in an attempt to demonstrate safety leadership. Participation included Companies X and Z, and eventually the Joint Occupational Safety and Health (JOSH) Committee. 3. An observation program was implemented during the first quarter of the project; this program included 3

regular attendance of safety advisors at the Job Safety Analysis (JSA)/Daily Planning Session (DPS) and toolbox meetings. The SHE department created a schedule and initially scored supervisors based on their observations at these sessions. It was later determined that the scoring program was too subjective to be implemented fairly so this aspect was discontinued in month 8. However, safety advisors continued to observe the discussions and to offer safety-related advice to supervisors. 4. An assessment of worksite safety practices was performed by Company X during a month-2 review. 5. An independent safety consultant was hired by Company X in month 5. 6. A safety incentive program was funded in month 6; this program was well-received by the workforce. 7. As the incident rate increased dramatically in month 7 (near-doubling over month 6), action was taken to integrate the previously separate Company X and Company Y SHE teams. 8. An audit of specific work practices was conducted mid-month 7; this resulted in significant improvements to these practices. 9. In response to a high frequency of eye injuries, a joint analysis among Companies X, Y and Z was conducted in month 7; this resulted in an improved eye protection policy. 10. In month 8, an extensive SHE assessment was conducted by Company X through an independent safety consultant as well as its own safety management system co-ordinator. 11. In response to the SHE assessment described in the previous item, a safety improvement management plan was developed by Companies X and Z in late-month 8. This was considered to be the reactive solution that regained control of the rise in safety-related incidents and saved the project from experiencing a serious, disabling incident. 12. Additional safety training was conducted by an independent consultant during months 10 and 11. 13. In an effort to encourage industrial safety awareness, a celebrity visit was arranged in month 11. 14. An audit of the permit-to-work system was completed in month 14 by an independent consultant. One can clearly see the impact of a positive safety culture at work in the above listing particularly the safety culture of Company X. The various items speak to the elements of a learning culture (Hopkins, 2005), sensitivity to operations (Hopkins, 2005), commitment to the improvement of safety behaviours and attitudes (Olive et al., 2006), and performing appropriate and timely/ hazard risk assessment (Kadri and Jones, 2006). A question perhaps open to debate is whether these items impacted the safety culture of other project partners (particularly Company Y), or whether their impact was greatest on the safety climate at the worksite. [Olive et al., 2006 offer a helpful explanation of the difference between safety culture and safety climate. Although the terms are often used interchangeably, culture can be thought of as the background influence on an organization whereas climate is more in the foreground. As safety climate refers to workforce behaviours and attitudes at a point in time, climate changes more quickly and more readily than safety culture (Olive et al., 2006).] POSITIVE FACTORS Despite the disappointment of not meeting the majority of expectations, some actions did improve the safety performance onsite and hence, the safety climate as described in the previous section. Particularly important factors having a positive influence on safety expectation outcomes included:. The safety improvement plan (item 11. in previous list) that was developed in late-month 8 and implemented in month 9 with an aggressive training program to reintroduce foremen and supervisors to the onsite safety program. The positive effect of this factor is reflected by the overall decline in number of incidents per month as shown in Figure 1.. A field-level hazard identification program (pre-task checklist) introduced early in the project and reinforced with additional training in its use later in the project.. Excellent incident reporting by Company Y employees. It was verified through various safety program audits that few, if any, incidents went unreported. NEGATIVE FACTORS Numerous factors contributed to the deficiencies in meeting project expectations (each of which are traceable to shortcomings in one or more of the safety culture characteristics described in the Introduction):. Visual leadership from senior personnel within Company Y was lacking. Because managers did not stress the importance, in person, of working safely, many members of the workforce did not view safety as the top priority.. Project safety expectations were aimed higher than the local workforce was capable of meeting. The expectations that were placed on supervisors were too advanced for the safety maturity of both the workforce and the supervisors themselves. The findings of the month-8 SHE assessment indicated that many of the supervisors did not have formal safety training; project expectations should therefore have focused on ensuring adequate safety education of supervisory personnel.. The belief system of the specific industry sector in which Company Y works is that incidents will happen on every project and are an unpreventable aspect of the job. This factor was likely the greatest challenge in meeting the expectations of Companies X and Z. A local culture of production being the key to a successful project was especially evident with some subcontractors who were not committed to the safety goals of the project.. Building on the previous point, workforce unions and subcontractors were not engaged in the development of the SHE process soon enough. There was some resistance 4

to safe-work practices such as the field-level hazard identification program mentioned in the previous section, because the workforce was not included in safety-related discussions early and often enough. This resistance made refining of the SHE plan difficult and also created conflict between the workforce and safety advisors.. Safety was considered by Company Y to be an expense to be managed like other cost centres. hile it must be well-understood that there are not unlimited resources to devote to safety improvements, there are clearly instances where safety must win out over other considerations. A case in point was the reluctance of Company Y to provide appropriate and ergonomically-designed tools to perform certain tasks (in spite of several injuries arising in the course of using tools less fit for the task). LESSONS LEARNED Previous sections of this paper have emphasized safety expectations and the challenges that prevented the full realization of these expectations. The ultimate purpose of defining the project goals and analyzing the problems was to gain insight into the lessons learned from this particular project. These lessons have potentially wider application given that each is, again, related in some way to the safety culture characteristics described in the Introduction. Each of the following lessons was determined to be applicable to one or more of the parties involved (Companies X, Y and Z):. It is important to engage labour unions and the general workforce early with regard to safety issues and the development of procedures. The basic premise is that workers will take part in the safety program if they are included in its design. This approach fosters an atmosphere of communication and will help to build a stronger relationship between the SHE department and the workforce.. Subcontractors selected via an invitation-to-tender (ITT) process generally had more mature and effective safety programs than those brought onsite under purchase order. The ITT process itself offers the opportunity for an in-depth review of the SHE performance of subcontractors and suppliers. Acceptance of subcontractors on a sanctioned bidders list via purchase order may result in a greater need for reactive remedial measures.. Building on the previous lesson, audits of major subcontractors can be helpful in verifying their work practices and safety program implementation. Such audits should be conducted with a frequency proportional to the risks subcontractors both pose and exhibit onsite.. Individual awards for safety recognition were wellreceived and were found to be an effective incentive for safe-work practices.. To overcome the mentality of being reactive rather than proactive in safety matters, an extensive safety orientation for all parties involved should be conducted prior to project commencement. This orientation session should deal with management expectations concerning safe production rather than focusing exclusively on rules and penalties. Through better understanding of the safety plan, supervisors will hopefully be better prepared to identify hazards and prevent incidents.. Dedication and commitment of the entire workforce is essential for improved safety performance. A partnership approach with contractors would be more beneficial than mandating safety procedures to them. Once the contractors have been selected, it would be valuable to conduct a gap analysis of their SHE programs in relation that of the project lead/owner. The gaps should be addressed with a bridging document to allow contractors to use their own familiar procedures with necessary revisions. This should be more acceptable to the contractors as opposed to adopting a new SHE program, and should also shorten the learning curve to make the required transition.. Safety stand-downs should be planned prior to conducting high-risk activities that have historically led to workplace incidents. This proactive approach has a positive impact whereby workers reflect on their safety accomplishments and goals as opposed to a reactive, potentially negative approach.. During the first half of the project, the SHE department learned the significant lesson that its members should act as advisors and not as enforcers. Traditionally, safety advisors have been referred to as safety officers and expected to function as such; with the modern concept of line managers having primary responsibility for safety performance, safety advisors should act as mentors/coaches. ith this approach, the possible friction between the workforce and safety advisors has a better chance of giving way to a trusting relationship.. Personnel who have primary safety responsibility on a worksite (e.g. a site safety lead) must be unquestionably committed to the safety of the workforce and completely receptive to advice offered to improve overall safety performance. If this does not appear to be the case across all parties involved in a multi-partner project, then the merging of the partners SHE site teams may prove to be valuable.. Case management i.e. managing the reassignment of injured workers requires an appropriate focus. During the project, efforts were directed primarily at getting the injured person back to work to avoid a losttime incident. In some cases, this meant that people were placed in positions peripheral to their expertise; such action has the potential to leave employees discontent with their new role and with the safety program in general. A case management program should therefore facilitate meaningful alternate or slightly modified work for an injured party, thus assisting in the healing process and ensuring the worker remains an active member of the workforce.. Safety performance should be measured not only by number of incidents reported, but also by the severity of incidents. This is a recognition that risk is a measure of both incident frequency and consequence severity.. Comprehensive supervisor training during the later stages of the project had an extremely positive effect on safety performance; such training should be implemented at the earliest possible stage. Management 5

leadership in identifying the need for supervisory safety training and equally important, in allocating the resources for such training is critical to addressing safety culture deficiencies. CONCLUSION In a multi-partner project such as the one described in this paper, it is critical that all participating parties express the same expectations toward safety and be dedicated to meeting those expectations. It is entirely possible that there will be a mismatch in safety cultures among the parties involved; project safety expectations represent a good means of identifying such differences in safety culture. Remedial steps can then be taken to bridge the gaps before the project commences. REFERENCES Amyotte, P.R., Goraya, A.U., Hendershot, D.C. and Khan, F.I., 2006, Incorporation of inherent safety principles in process safety management, Center for Chemical Process Safety, American Institute of Chemical Engineers, Proceedings of 21st Annual International Conference Process Safety Challenges in a Global Economy, orld Dolphin Hotel, Orlando, USA (April 23 27, 2006), pp. 175 207. CSChE, 2002, Process safety management, 3 rd edition, Canadian Society for Chemical Engineering, Ottawa, Canada. Glendon, A.I. and Stanton, N.A., 2000, Perspectives on safety culture, Safety Science, 34: 193 214. Hopkins, A., 2005, Safety, culture and risk: the organizational causes of disasters, CCH Australia Limited, Sydney, Australia. Kadri, S.H. and Jones, D.., 2006, Nurturing a strong process safety culture, Process Safety Progress, 25: 16 20. Killimett, P., 2006, Organizational factors that influence safety, Process Safety Progress, 25: 94 97. Olive, C., O Connor, T.M. and Mannan, S.M., 2006, Relationship of safety culture and process safety, Journal of Hazardous Materials, 130: 133 140. 6