“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 major hazard 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 major hazard 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 and Nimrod have highlighted leadership failures as key issues. Boardroom decisions can have a significant impact upon major hazard 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 (or potentially 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 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.
“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 Report, 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).
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
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.
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.
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. Transcript of the podcast is available here.
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.