“From top to bottom the body corporate was infected with the disease of sloppiness”Formal Investigation into m.v. Herald of Free Enterprise, 1987
The need for strong leadership at Board and senior levels in organisations has been understood for many years. Senior leaders set the vision and culture for an organisation, and their decisions have a direct bearing on safety outcomes. Analysis of past incidents has shown that inadequate leadership and poor organisational culture have been recurrent features.
Several publications from the UK HSE and industry associations outline what good safety leadership looks like (see Further information below).
Leadership in major incidents
Lessons from major incidents such as Piper Alpha, Grangemouth, Buncefield, Texas City, Columbia, THORP, Hatfield, and Nimrod have all highlighted leadership failures as key issues. Boardroom decisions can have a significant impact upon safety, but this has not always been recognised, as the impact may not be felt until months or even years later. Often, investigations focus on technical and management system failings, but there is a growing impetus for looking at the role of senior leaders during major accident investigations, and holding them accountable for their actions.
In particular, recent events have identified:
- A failure to recognise things were out of control, often due to lack of competence at different levels of the organisation.
- An absence of, or inadequate, information on which to base strategic decisions – including the monitoring of safety performance indicators at Board level.
- A failure to understand the full consequences of changes, including organisational ones.
- A failure to manage process safety (major hazard safety) effectively and take the necessary actions.
In most major incidents, information was available somewhere in the organisation suggesting that safety barriers were not sufficiently robust, but these weak signals were neither recognised nor acted upon.
For example, the CSB investigation into Texas City concluded that BP Senior Executives focused, measured and rewarded mostly personal safety performance, but not process safety; and they did not provide adequate resources to prevent major accidents.
In the case of the Nimrod XV230 catastrophe, the Nimrod Review led by The Hon. Mr Justice Haddon-Cave, was sub-titled “A failure of leadership, culture and priorities”:
“The fundamental failure was a failure of Leadership…lack of Leadership manifested itself in relation to the way in which the Nimrod Safety Case was handled, in the way in which warning signs and trends were not spotted, and in relation to inexorable weakening of the Airworthiness system and pervading Safety Culture generally” (Nimrod Review, 2009, p.491).
In the video below, The Hon. Mr Justice Haddon-Cave addresses conference delegates at Piper 25, June 2013 on the topic entitled “Leadership and Culture, Principles and Professionalism, Simplicity and Safety – Lessons from the Nimrod Review”. (The Piper 25 conference marked 25 years since the Piper Alpha offshore disaster in the North Sea, in which 167 workers died).
What can leaders do?
Leadership drives culture, which in turn drives behaviour. Good safety leadership involves integrating safety into business planning and decision making – and being prepared to challenge business decisions that may negatively impact upon risks.
There are several safety leadership characteristics that are key to influencing safety:
- Be credible: what leaders say should be consistent with what they do. Safety leaders seek concerns or challenges and commit to helping address these. Following up on commitments will build trust.
- Act: safety leaders act to address unsafe conditions, but also act proactively. They actively participate in safety meetings, audits and incident investigations. They share lessons and follow-up on actions, verifying that they have been effectively implemented.
- Vision: leaders drive safety excellence within the organisation. They can visualise what excellent safety performance looks like and can communicate this vision in a compelling way. Words are important, but actions are most important.
- Accountability: safety leaders create clear safety roles and hold those accountable. They provide the resources and tools that support safety performance. They set boundaries of what is and what is not acceptable risk.
- Communication: safety is communicated as a value, not as a priority that is traded off against cost and schedule. Effective safety leaders create opportunities to talk to employees and contractors about their concerns. They are visible at the workplace and are informed about the reality of work. They communicate their expectations for safety and explain how they and their teams will be held accountable.
- Collaboration: effective safety leaders encourage active employee participation to resolve safety issues. They value teamwork – asking for input on safety issues and help to resolve these. In particular, good leaders encourage collaboration across different teams or departments. They bring teams together and encourage discussion.
- Feedback: safety leaders provide recognition and coaching to encourage safe behaviours. They celebrate and reward successful safety performance. Feedback on behaviours and performance is constructive, timely and honest.
Leadership site visits
When senior leaders visit work sites, they often fail to make the most of these occasions. Such visits are opportunities to demonstrate visible safety leadership and commitment, listen to front-line staff, demonstrate core behaviours and recognise best practices. In his Working Paper discussing leadership site visits just before the Macondo disaster (see Further information section), Andrew Hopkins stated that “There is a tragic irony here. A major purpose of the visit was to emphasise the importance of safety, and yet the visitors paid almost no attention to the safety critical activities that were occurring during their visit” (p.3).
The following guidance is aimed at helping senior leaders to prepare for site visits.
- Before the visit, understand the key safety issues or risks for the site or project. Have there been any recent health or safety incidents, relevant audits, regulatory inspections, staff surveys etc.? Ensure that you are aware of current challenges.
- Find out when key meetings occur and decide which ones to attend. Discuss with local management what your role will be in these meetings – will you be presenting to the team?
- Prepare a list of topics or questions to ask when meeting with individuals or work groups. Be genuinely interested in their work and listen actively. For example, ask people what the key risks are in this work, what dangers they face and how these are controlled. What activities make the team feel uneasy? What key health and safety issues are not being addressed? What safety-related equipment is not operational – and why? How can safety critical activities be improved?
- Be visible to the workforce – speak to as many individuals and shake as many hands as possible. Do not restrict your meetings to site management.
- If the site has a set of lifesaving rules or golden safety rules, choose a couple of these and test understanding and whether these rules are working in practice.
- Lead by example. Follow all of the site rules and obligations. Have the necessary safety equipment for the areas that you will visit.
- Ensure that you meet with local safety representatives or committees. Share your observations with them, and understand their concerns.
- Commit to taking action on any issues that are raised and follow-up.
The UK Ministry of Defence has produced a Safety Leadership Guide, subtitled “How listening and learning are our best defence”. This short document describes the importance of listening to staff, creating an environment where people feel confident to raise concerns, and learning rather than blaming.
It aims to support an environment where people are encouraged to speak up about mistakes (and the conditions that make mistakes more likely), so that lessons can be learnt from these mistakes.
The document stresses that it matters how leaders respond when things go wrong. This easy-to-read Guide includes a checklist that leaders can use to inform their responses to situations that they may find themselves dealing with.
Although written for the Defence sector, it provides helpful guidance for leaders in all industries.
“These people are closer to the action. They’re the ones standing on the deck, feeling the vibration in their shoes. Whatever it happens to be, they’re closer to the problem. They know something you don’t know, and your job at that point is to make it easy for them to tell you what that is. If you want a resilient system where errors don’t get propagated through the system, you really need to create an environment where it’s okay for people to tell you you’re wrong.”David Marquet, US Submarine Commander (“Safety Leadership Guide: how listening and learning are our best defence”, UK Ministry of Defence, May 2022)
Safety leadership and Corporate Manslaughter
The UK legislation Corporate Manslaughter and Corporate Homicide Act 2007 is a landmark in law. For the first time, companies and organisations can be found guilty of corporate manslaughter as a result of serious management failures resulting in a gross breach of a duty of care. The offence is called corporate manslaughter in England, Wales and Northern Ireland, and corporate homicide in Scotland. The offence is concerned with corporate liability and does not apply to directors or other individuals who have a senior role in the company or organisation. However, existing health and safety offences and gross negligence manslaughter will continue to apply to individuals. Prosecutions against individuals will continue to be taken where there is sufficient evidence and it is in the public interest to do so.
Further information on safety leadership
Safety Leadership Guide – How listening and learning are our best defence, UK Ministry of Defence, May 2022. This document describes how listening to and involving staff, and creating an environment where people feel confident to raise concerns, will create the conditions for learning – as well as safer and more effective operations. It outlines the benefits of openness and transparency in safety, and provides practical guidance for leaders in all industries. Written by Simon Robinson (operability.co.uk).
Hopkins, Andrew, 2011, WP 79 – Management walk-arounds: Lessons from the Gulf of Mexico oil well blowout, National Research Centre for OHS Regulation, Canberra. This Working Paper (WP 79) examines the nature of the site visit undertaken by senior managers from BP and Transocean to the Deepwater Horizon drilling rig just hours before the Macondo disaster. It provides guidance on what senior managers can do to focus their visits on major hazard safety, rather than personal safety (e.g. slips, trips and falls).
Shaping safety culture through safety leadership. (2013). Report 452, International Association of Oil and Gas Producers (IOGP). 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.
Leadership for the major hazard industries (HSE, 2004). INDG277(rev1) 10/04. This booklet was originally designed for the offshore industry, but is widely applicable to all major hazard, safety critical and complex industries. Contains introductory information on four key areas: Health and safety culture; Leading by example; Systems and Workforce.
Leading health and safety at work. (HSE, 2013). INDG417(rev1). Originally published in 2000, jointly by the Institute of Directors and the Health and Safety Commission. This guidance sets out an agenda for the effective leadership of health and safety.It is designed for use by all directors, governors, trustees, officers and their equivalents in the private, public and third sectors. It applies to organisations of all sizes. Includes a health and safety leadership checklist.
Corporate Governance for Process Safety – Guidance for senior leaders in high hazard industries, (June 2012), published by the OECD, representing 34 industrialised countries.
Safety Leadership Maturity. (HSE, 2013). A one-page table providing criteria to help assess the maturity of an organisation’s safety leadership in relation to high-hazard safety. Adapted from a UK HSE guidance document that I produced in 2013 whilst employed at the HSE.
Safety leadership in small business. A factsheet produced by Workplace Health and Safety Queensland (2015). Outlines why good safety leadership is important and where to start.
Management Leadership in Occupational Safety and Health – A practical guide. Luxembourg: Publications Office of the European Union (2012). This practical guide is aimed at managers who wish to show leadership in safety and health. It outlines why occupational safety and health is important, provides a management approach and a leadership self-assessment.
Leadership and Occupational Safety and Health (OSH): An Expert analysis, This report examines how good leadership practices can promote better occupational safety and health (OSH) behaviour amongst employees. It considers what are the necessary corporate leadership factors on which success depends. It does so by reviewing existing literature on OSH leadership. It also examines 16 detailed case studies from companies across the EU highlighting good practice, the type of activities that deliver achievements, innovative approaches, success factors and the role of stakeholders. In this report recommendations for improving OSH leadership are also made and explored.
A review of the literature on effective leadership behaviours for safety. (2012). HSE Research Report 952. There is widespread agreement between industry, regulators, academics and the press that leadership is a key component of a safe organisation. This view is widely supported by findings from almost all major incident inquiries and investigations. The aim of this review was to identify specific leadership styles, attitudes, behaviours and practices that represent effective leadership for safety.
Podcast – Director leadership (April 2008). Discussion with Judith Hackitt (Chair of the HSE board at the time of this podcast) about why health and safety leadership is important, working closely with the Institute of Directors (IoD), what’s expected of directors and board members – and more.
The Nimrod Review. An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006: A failure of leadership, culture and priorities. (2009). Charles Haddon-Cave QC. London: The Stationery Office.