Safety culture

Why “safety culture”?

The term safety culture made its first investigation appearance in the International Atomic Energy Agency’s initial report following the Chernobyl disaster (IAEA, 1986). Since then inquiries into major accidents such as the King’s Cross fire (1987), Piper Alpha (1988) and the Herald of Free Enterprise (1987) have placed safety culture into the spotlight. Having a positive safety culture is now seen as a prerequisite to, and foundation of, good safety performance.

Following the public inquiries into the Southall (1997) and Ladbroke Grove (1999) train crashes, the Health and Safety Commission stated that:

“Achievement of an improved safety culture on the railways is at the core of the whole programme of change initiated by Lord Cullen’s Inquiries . . . if an organisation has the right culture in place it will find the right people and the right technology to deliver safe and effective performance” (HSC, 2003).

“…the need for a positive safety culture is the most fundamental thought before the inquiry” (HSC, 2001a).

Following the Macondo (Deepwater Horizon) disaster in 2010, a National Commission stated that:

“Government oversight must be accompanied by the oil and gas industry’s internal reinvention: sweeping reforms that accomplish no less than a fundamental transformation of its safety culture” (p.217). 

The International Association of Oil and Gas Producers (IOGP) state that the advantages often associated with a strong safety culture include few at-risk behaviours, low incident rates, low turn-over of personnel, low absenteeism rates and high productivity. Such organisations usually excel in all aspects of their business (IOGP Report 452, 2013).

Defining safety culture

There are a number of definitions of safety culture, but one which covers the key elements is given by the UK Advisory Committee on the Safety of Nuclear Installations:

“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. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures” (ACSNI, 1993). 

A succinct and simple definition of culture is “the way things get done around here”. It is also described as “how people behave when they think that no-one is looking”. Safety culture is a sub-set of that wider organisational culture.

What’s the difference between safety ‘culture’ and safety ‘climate’

These two terms are often used interchangeably in the safety literature. Safety culture tends to refer to the behavioural aspects (‘what people do’) and the situational aspects of the company (‘what the organisation has’). Safety climate usually refers to psychological characteristics of employees (‘how people feel’), corresponding to the values, attitudes, and perceptions of employees with regard to safety within an organisation.

The largest influences on safety culture are:

• management commitment and style
• employee involvement
• training and competence
• communication
• compliance with procedures, and
• organisational learning.

The International Association of Oil and Gas Producers state: “A positive Safety Culture is a culture in which safety plays a very important role and is a core value for those who work for the organisation. This contrasts with organisations in which safety concerns are treated as marginal or an irritating diversion from the real business” (IOGP, Report 452, 2013).

What does a poor safety culture look like?

Symptoms of a poor safety culture can include:

• widespread, routine deviations from procedures
• failure to comply with the company’s safety management system
• management decisions that appear to consistently put production or cost before safety
• lack of learning from experience
• unwillingness to share safety information.

‘Just Culture’

Unfortunately, when companies talk about ‘safety culture’ they are often referring to staff failing to comply with rules or behaving unsafely. There can be a tendency to see safety culture as something that is ‘wrong’ with the workforce. However, a review of incidents in any industry shows that the culture and style of management is often more significant.

Organisations that have a blame culture focus on individual culpability for human errors, rather than correcting defective systems, processes and equipment. It is becoming increasingly recognised that there should be a shift from a blame culture to a just or fair culture. The discussion of blame most often arises following an incident and so investigators should have a good understanding of why human errors occur.

This short video “Just culture: Because we are all humans” (© Courtesy of EUROCONTROL) describes how a “just culture” has been defined as an environment in which staff members are not punished for any actions, omissions or decisions taken by them that are commensurate with their experience and training. However, gross negligence, willful violations and destructive acts are not tolerated.

A blame culture inhibits reporting, prevents the thorough examination of incidents, prevents learning and has a negative effect on staff motivation.

In the Ladbroke Grove Rail Inquiry Report, Lord Cullen commended to the industry “the development of a culture in which information is communicated without fear of recrimination and blame is attached only where this is justified” (HSC, 2001a).

In a Just or Fair Culture:

• Employees feel that they are able to report issues or concerns without fear that they will be blamed or disciplined as a result of coming forward. People are encouraged, and even rewarded for providing essential safety-related information; which enables warning signals to be highlighted, and helps organisations to learn and get better.
• The use of an accident and near-miss investigation procedure uncovers root causes and system failures.
• Supervisors and managers are trained in incident investigation, including human factors.
• Organisations have a system in place that enables the degree of culpability to be assessed.
• The boundary between the behaviours that are considered acceptable and unacceptable is clear and communicated to all.
• Confidentiality is maintained throughout investigations.
• Blame is attributed only when it is clearly deserved, for example when there is evidence of gross negligence, misconduct or deliberate violations of rules. Unacceptable behaviours are dealt with in a consistent, just and fair manner

Is human error a crime?

In 2017, a patient is prescribed a sedative prior to a full body PET scan, but she is injected with a neuromuscular blocker in error, and left alone. The drug leads to progressive paralysis, stopping her from breathing. The patient is found unresponsive, is resuscitated, but requires life support and dies several hours after the medication error.

The nurse who administered the medication, RaDonda Vaught, was found guilty of criminally negligent homicide on 25 March 2022.

Several things concern me about this case:

1. There was very little investigation or understanding of the human factors that may have contributed to the nurse’s behaviour. Was there a confirmation bias? Normalisation of behaviours? Alert fatigue? Inattentional blindness? High workload? Fatigue?
2. The focus of both the Board of Nursing Hearing and the criminal trial were the actions of one individual.
3. Several failures of the hospital were identified in investigations – significant enough for Medicare reimbursement to be revoked – but no action was taken against the hospital.
4. The National Medication Errors Reporting Program shows that the same error has happened in other hospitals.

The Washington State Nurses Association released a statement following the conviction:

“the hospital failed to provide adequate patient safeguards, encouraged workarounds of existing safety systems, and even engaged in a cover-up of the incident”.

The criminalisation of medication errors has the potential to drive human errors underground. How can organisations learn from that which they do not know? How will we learn from how “work is done” if staff are afraid to come forward? Can a nurse’s behaviour be viewed in isolation of the complex system in which she was working?

To read my full analysis of this case study, see this article on Is human error a crime?

Are surveys or questionnaires useful?

The majority of tools available to understand safety culture are questionnaire based and tend to focus on measuring the attitudes and perceptions held by employees towards safety (safety climate). These tools typically tell us less about why, and in what way, variables impact upon the decision making and behaviour of staff.

Assessments of culture are most successful when a variety of data collection methods are used to ‘triangulate’. Documentation reviews and behavioural observations should be used in conjunction with employee focus groups and questionnaires. Skilled interviewers or assessors can measure working behaviours and the effectiveness of safety processes and systems, which is likely to provide a more objective evaluation than a survey.

I have written elsewhere about “Safety Culture Discussion Cards”, which are a great way to aid discussion and reflection about safety culture by any person or team. They are also a practical tool to help companies to continue the conversations in the gap between safety culture surveys. They can be downloaded here in several languages.

Personal responsibility

Although safety is a shared responsibility, many organisations have initiatives around the concept of ‘personal responsibility’. Here’s a short animation-style video produced by TOTAL that can be used to introduce this concept.

 

Key principles of safety culture

• Safety culture is about what people do (safety-related behaviours); how people feel (individual and group values, attitudes and perceptions) as well as what the organisation has (policies, procedures, structures and systems). These three aspects are interrelated and therefore not mutually exclusive. Any intervention on safety culture must consider all three aspects.
• A company’s safety culture is shaped by corporate practices and organisational behaviour, and so a full picture can’t be gained from just focusing on the perceptions of staff.
• If you collect data (from surveys, talking to staff etc) then communicate the findings back to those involved – and take action.
• Interventions on safety culture should not just explore attitudes and behaviours of the front-line workforce, but also question and challenge managers and leaders.
• Rather than trying to influence safety culture directly, you may find it helpful to focus on a specific topic (such as procedures, fatigue, competence). How you go about this intervention could have a significant effect on a range of predictors of a positive safety culture (such as involving staff, listening to their concerns, making leaders more visible and taking visible action to improve).
• Creating a positive safety culture takes a great deal of time and effort; perhaps over several years; and is not a one-off process.

Further guidance on safety culture

Safety culture. Extract from HSE publication Reducing error and influencing behaviour (HSG48, ISBN 978 0 7176 2452 2, Second edition, published 1999). Includes a list of the key factors which influence an organisation’s health and safety culture – and which are also linked with better safety performance.

HSE Inspectors Toolkit – Safety Culture. Short extract from a toolkit produced by the UK HSE’s Human Factors Team for use by non-specialist Inspectors. Includes a brief Question Set used by HSE Inspectors, which organisations in any industry will find useful to assess their safety culture.

Shaping safety culture through safety leadership, The objective of this report is to raise awareness among leaders in the oil and gas industry of the way their leadership shapes safety culture. It explains what safety culture and safety leadership mean, and specifically describes the leadership characteristics that can influence safety culture. Report 452, International Association of Oil and Gas Producers (IOGP, 2013).

HSE and Culture, This brochure does not provide any hard-and-fast rules, but is intended to assist the industry in improving its HSE culture. Petroleum Safety Authority (PSA), Norway.

Information Paper – Safety Culture. This Information Paper, published by Australia’s offshore energy regulator NOPSEMA, provides information about a safety culture model and how it might be used to guide the development of safety improvement initiatives. It provides information that organisations may wish to consider in relation to their safety culture programs. National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA, 2014).

Understanding safety culture in air traffic management, Although written specifically for Air Traffic Management (ATM), this document provides a simple introduction to safety culture for all industries. It provides examples of ‘Disablers’ – those factors that prevent development of a positive safety culture – and ‘Enablers’, factors that facilitate the process. You may also find Annex A helpful, a semi-structured interview guidance sheet. European Organisation for the Safety of Air Navigation (EUROCONTROL, 2006).

Summary guide to safety climate tools.  This guide should assist those in the oil and gas industry who are interested in measuring and assessing the existing safety climate in their organisations. It reviews six safety climate questionnaire-based tools that have been developed, with the aid of Health & Safety Executive (HSE) funding. Offshore Technology Report, OTO 1999/063 (HSE, 1999).

Safety Culture Maturity Model.  This report describes the development of a draft Safety Culture Maturity Model (SCMM). This model will assist organisations in establishing their current level of safety culture maturity and identifying the actions required to improve their culture. Offshore Technology Report, OTO 2000/049 (HSE, 2000). 

A guide to selecting appropriate tools to improve safety culture, This document provides information about tools which can be used to improve Health, Safety & Environmental (HSE) performance. It provides guidance on determining which HSE tools are most appropriate for your organisation, based on the HSE culture ladder which describes five levels of HSE culture. Report No. 435, International Association of Oil and Gas Producers (IOGP, 2010).

A review of safety culture and safety climate literature for the development of the safety culture inspection toolkit. The purpose of this report is to summarise the main findings from the literature that can be used to guide the development of the Safety Culture Inspection Toolkit for Her Majesty’s Railway Inspectorate (UK HMRI). The review focuses on a limited number of indicators that are known to influence safety culture – Leadership, Two-way communication, Employee involvement, Learning culture, and Attitude towards blame. HSE Research Report 367 (2005).