Latest / Safe As Podcast / E63: Should we, or even can we, analyse 'safety culture' in investigations?

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E63: Should we, or even can we, analyse 'safety culture' in investigations? · Safe As Podcast

• 0:06
  Safety culture is described by some almost as the Holy Grail.
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  James Reason poetically describes safety culture as like
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  a state of grace, something driven for but rarely attained,
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  where the journey is more important than the product.
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  But what is safety culture? Can we even agree?
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  Is it something an organisation has or what it is or even does?
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  The search for this nebulous state of grace mask more than it
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  reveals. Good everyone.
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  I'm Ben Hutchinson and This is Safe as a podcast dedicated to
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  the thrifty analysis of safety, risk and performance research.
• 0:44
  Visit safetyinsights.org for more research.
• 0:48
  Today's paper is from SCORCH 2015, titled Can we examine
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  Safety Culture in Accident Investigations or should We in
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  Safety Science? It's a discussion paper using
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  reasoned arguments and drawing on existing literature.
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  First, the paper nicely devotes some space for how safety
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  culture has been defined and conceptualised by many different
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  authors. One definition defined broader
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  societal culture as the systems of values, attitudes, beliefs
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  and behavioural meanings shared by members of a social group and
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  learned from previous generations.
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  Culture, itself a group level construct, is neither genetic
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  nor about individual behaviour. However, it exists within the
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  knowledge systems of individuals which are formed during
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  childhood and reinforced throughout life.
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  Because culture is informed by beliefs, interpretations and
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  behaviours, it's considered to be deep seated.
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  Culture, according to one, is not something that changes
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  rapidly, and traditionally culture has been applied to
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  large groups of people, such as those inhabiting nations in
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  geographic areas and members of tribes and religions.
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  But most importantly to remember for this, culture, even as a
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  construct, is about groups, not individuals.
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  Considerable confusion has ranged when it comes to safety
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  culture specifically. One issue is that it's often
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  conflated with climate. Nevertheless, despite the
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  confusion of defining safety culture, one among many
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  definitions is the shared and learned meanings, experiences
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  and interpretations of work and safety, expressed partially
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  symbolically, which guides people's actions towards risks,
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  accidents and prevention. Generally, it can be said that
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  safety culture describes the commitment of an organisation
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  employees at all its levels, devaluing the safe operation of
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  the system and practising those values in the manner in which
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  they interact with that system. For research, it's a little bit
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  more muddy. In fact, you can have different
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  perceptual camps around whether it's more functional, the
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  practises and beliefs of people. This tends to see safety culture
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  as something an organisation has, or whether culture is seen
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  more interpretatively, as in something the organisation is.
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  It's typically used less normatively, like to compare
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  against something else and use more descriptively just what it
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  is. Overall, this author argues
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  directly against assessing safety culture in accident
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  investigations, stating that directly assessing A construct
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  such as safety culture after the fact of an accident in an effort
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  to gauge its state before the accident is not supported by the
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  findings of research and of accident investigations.
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  A key reason is that limitations in our understanding and
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  measurement of safety culture preclude direct assessment of
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  safety culture in an accident investigations.
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  That's a direct quote indeed. Within this logic, concerns
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  about validity persist if measuring safety culture traits
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  through questionnaires. Many researchers have openly
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  challenged and criticised the use of questionnaires for safety
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  culture, suggesting it really can't capture culture.
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  It's more capturing surface manifestations like climate.
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  Further, ethnographic techniques which are really insightful and
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  used in other fields, particularly in sociology,
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  require quite a lot of time for typical investigations, probably
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  too much for most investigations.
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  Also, both company managers and operators may well believe that
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  their processes are safe and quoting the paper beliefs that
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  would be expected to affect the results of a direct assessment
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  of safety culture only discover the contrary is true from the
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  results of an investigation. What this suggests is that we
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  might believe that things are safe and things are operating
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  really well, but we quickly face the reality after a major
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  accident that what we believed about the world wasn't accurate.
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  This is evident in investigations where companies
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  with supposedly good that's even a thing safety culture
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  indicators exceeding regulatory requirements or positive audit
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  results or reduced occupational injuries still experience severe
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  incidents due to poor operational safety or other
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  misaligned beliefs around how safe they were operating.
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  The link between safety culture and process safety is also
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  mostly suggestive, as most research focuses on Occupational
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  Safety and safety climate, not process safety and very specific
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  process safety climates. Therefore, focusing on
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  Occupational Safety doesn't necessarily relate to enhanced
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  operational process safety. I skipped quite a lot in that
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  section, but next the author provides some suggestions on
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  what what else we can do. For one, instead of a direct
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  assessment, the author suggests that company practises
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  identified during the investigation can provide more
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  accurate insights into an organisation.
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  Operating cultures and climates. Now I say cultures and climates
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  plural because almost always there are multiple operating
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  subcultures. In fact, some typologies define
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  them as micro, mezzo and macro cultures and this includes
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  understanding how work is actually done, the perceptions
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  of hazards and the use and value of procedures.
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  The things that we should be exploring within investigations
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  and normal learning work can be more indicative and more
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  valuable than these sort of vague, nebulous captures of what
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  safety culture is. It's further said that company
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  practises identified in the course of the investigations can
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  reveal much more about safety practises and the operating
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  beliefs and provide insights, although probably indirectly,
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  into the company's operating cultures.
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  Moreover, the considerable data that AXE investigations
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  typically collect can better describe a company's actual
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  practises in their routine operations and could be obtained
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  from most direct assessments of safety culture.
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  So this approach is argued to provide a more accurate
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  description of an organisation cultures than any direct safety
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  culture survey data, perhaps with the exception of extensive
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  ethnographic efforts. This approach is suggested by
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  the author also allows a deep dive into more embedded and
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  masked operational organisational pathologies.
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  You know, production pressures, trade offs in favour of higher
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  workpaces, et cetera. Now this method that the author
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  provides suggests 4 key steps. First, is established
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  identifiable and accessible factors and two, then determine
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  if those are organisational factors.
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  You know, are they unintended deviations?
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  They involve multiple individuals, Are they created by
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  organisational conditions? Then relate these factors to the
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  proposed contributing factors of the accident.
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  And in other words, would that incident play that differently?
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  The introduction or removal of these organisational factors and
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  determine whether the organisation is ultimately
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  responsible, acting contrary to available or self evident
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  information, or failing to act when it was warranted in
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  hindsight. According to the author, this
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  method allows investigators to directly examine an organisation
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  role in the accident. Moving on to another line of
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  argumentation, it suggests that there's a disconnect between
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  cultural initiatives and operational safety.
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  That is, as argued by the author, even if a company
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  embraces, implements and maintains safety culture
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  characteristics, it's not assumed that an accident still
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  won't occur. They're focusing on certain
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  cultural elements like effective safety communications,
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  respectful work environment, questioning attitudes, et
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  cetera, may give managers a false assurance of safety, which
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  could be disconnected from operational safety.
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  For instance, the absence of accidents may obscure from an
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  organisation their actual system safety and functioning and
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  enhancing company beliefs in the positive aspects of their safety
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  culture, beliefs that may be unsupported.
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  Indeed, what it's what they're arguing is that by collecting
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  safety culture data, we might be building a false sense of safety
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  that's disconnected from actual operating practises.
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  Now importantly, according to the author, this line of
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  argumentation isn't to denigrate the need for recognising the
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  value of cultural elements of safety and practises and beliefs
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  and applications of these cultural elements to enhance
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  operational safety. However, the direct assessment
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  of safety culture and the belief that we can directly assess
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  safety culture is problematic. Ultimately, quoting the paper,
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  the highest safety priority of any company engaged in high risk
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  operations should be to operate those systems safely, managing
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  the risks. And if addressing safety culture
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  is conducted at the expense of operational safety, then the
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  effort would be self defeating. Instead, a range of other safety
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  management systems and system safety approaches are
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  appropriate, but ultimately it really should be getting us more
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  heavily invested and informed of our daily interactions with
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  hazards and risks. All right, so I've covered a
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  lot. What can we make of the
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  findings? Well, in all, the paper
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  concludes that directly assessing safety culture in an
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  Accident Investigation can be ineffective or worse,
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  misleading. The author asserts that the
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  information in an organisation normally collects in routine
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  operations in their learning activities and investigations
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  also can better describe a company's actual practises in
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  systems operations than ever could be obtained from even the
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  most direct assessments of these constructs of safety culture.
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  Also, the author suggests that understanding the differences
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  between perceived safety and actual safety might be a real
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  fruitful area of focus. In other words, the differences
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  between work is imagined, work is prescribed, our beliefs of
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  safety presses, work is done, the actual daily work.
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  That is, how can managers recognise whether their beliefs
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  regarding the operational safety of their systems accurate?
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  And what measures can they use to identify flaws in operational
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  safety, particularly after taking additional efforts to
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  maintain or enhance safety? That's a direct quote, by the
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  way. This overall seemed pretty well
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  aligned to the legal expectations for having proper
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  systems. It likely includes better
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  measures of safety in high risk industries.
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  This includes having measures with demonstrable links to
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  safety culture enhancements and the mechanisms by which those
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  safety culture elements theoretically or actually could
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  affect process safety and operational safety.
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  We need to better understand those potential interactions.
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  That is, how does tweaking these sometimes quite fuzzy, nebulous
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  safety culture elements actually affect downstream operational
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  factors? Finally, as a cautionary tale,
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  the author argues that retaining the services of consultants to
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  highlight safety deficiencies or continued positive safety audits
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  may provide managers with misleading information regarding
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  the safety of their operations. That's it on SAFE.
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  As I'm Ben Hutchinson, please help share, rate and review, and
• 12:17
  check out Safetyinsights org for more research.
• 12:20
  Finally, feel free to support Safe AS by shouting a coffee
• 12:24
  link in the show notes.