It's The Culture

During the 1992 presidential campaign, president-elect Bill Clinton had a banner erected in his campaign headquarters that stated, "It's the Economy, Stupid". He did this to remind himself that the major issue in the campaign was the current state of the U.S. economy.

Today, most organizations would do well to remind themselves that the major determining factor in the performance of their safety process is the culture of the organization. Organizational culture can be defined as a shared set of assumptions, beliefs, philosophies, and perceptions that shape the behaviors of managers and employees. Culture can be described as an invisible force that, to a large degree, dictates how employees go about their work. In other words, culture defines what is really valued in the organization.

Many organizations struggle to improve safety performance through increased inspections, training, and enforcement activities. They often spend vast sums of money in hiring a safety staff to implement regulatory compliance-based safety programs only to become frustrated with the results. Even large corporations that spend hundreds of thousands of dollars in employee focused Behavior-Based Safety programs often find themselves disappointed with less than stellar results at the end of the day. In fact, a major reason that some BBS programs do not work is the failure to build a cultural foundation that will support the process.

Simply stated, safety does not occur in a vacuum. To achieve excellent results, an organization must work to create a culture that integrates safety into every task, every workday. Safety cannot be viewed as an add-on or something extra that must be done by workers and managers. Safety must be integrated into tasks to the degree that it becomes the way employees go about doing their jobs. Safety must be a core value and be driven throughout every level of the organization with accountability.

Consider the influence of culture on some of the following major accidents that have occurred around the world.

A study was conducted a few years back by Edwin Zebrowski of Aptech Engineering Services that compared the cultural "common threads" which existed between the organizations involved in four separate catastrophes. The events studied were the Three Mile Island Nuclear Power Plant meltdown incident, the explosion of the Space Shuttle Challenger, the Bhopal India chemical release and the Chernobyl nuclear incident.

The study was based on the results of the accident investigations conducted by the investigation boards or commissions. Some of the cultural commonalities that existed between both organizations were as follows:

1. It was unclear as to who was responsible for what.

2. There were rigid communication channels and large organizational distances from decision-makers to the field.

3. There was a mind-set that success is routine, fortifying a belief that "we're ok", we're in good shape as we are and there is no need for further improvement.

4. There was a belief that being in compliance with minimum regulatory requirements was safe enough.

5. There was a team-player emphasis with no tolerance for "whistle blowers". (The Challenger Investigation Board specifically went on to describe "a culture of silence").

6. Problems experienced from other locations (near-misses) were not applied as "lessons learned".

7. Lessons that were supposedly "learned" were not built back into the management system.

8. Design and operating features and flaws were allowed to exist even though they were recognized as hazardous elsewhere. (There was clear acceptance of defects and operational errors. It was known at Three Mile Island that controls were confusing and operators were not well trained. It was also known that the O-ring, which led to the Challenger accident, was defective. Defects and errors became accepted and ultimately institutionalized as "normal")

9. Safety (including analyses and responses) was subordinate to production, mission, and other performance goals.

10. Emergency drills, training, and procedures for severe events were lacking.

11. Safety and risk management resources and techniques were available but not used.

12. Authority, responsibility, and accountability for safety were undefined.

More recently, the board investigating the 2003 Breakup of the Space Shuttle Columbia stated "In our view, the NASA organizational culture had as much to do with this accident as the foam". The board found not only were there serious cultural issues that led to the accident, but went on to compare them to the cultural deficiencies that existed at the time of the Challenger accident. The board was amazed that many of the same cultural issues still existed years later, ultimately leading to the loss of the Columbia.

Some of the findings were: 

1. Lack of an overarching vision that would tie agency branches / divisions together to a common goal.

2. Acceptance of operational errors and defects. Foam loss had occurred on more than 80% of missions but was ultimately deemed an "acceptable risk". Failed sensors were not repaired. Of the 181 sensors in the shuttle's wing, 55 had failed or were producing questionable readings. Rather than repairing them, they were deemed to be unimportant and data gathering from these sensors was ceased.

3. Lack of clear flow of communication up and down from program managers. There was a failure of communication between engineers and managers. Managers waited for engineers to raise concerns but did not take it upon themselves to do so. The investigation board was shocked to find the same "culture of silence" as had existed in the Challenger explosion 17 years earlier.

4. The organizational structure and hierarchy blocked effective communication of technical problems. Concerns were filtered to the point that known errors / defects were communicated as "not a problem".

5. Ineffective leadership and poor decision-making. Lack of integrated management across program elements.

6. Safety personnel were present but passive and did not serve as a channel for the voicing of concerns or dissenting views. (One Navy Admiral stated in a presentation to Congress that the safety people spent most of their time telling people to put on their hard hats).

7. There was a low level of concern about safety and a high level of concern about "getting on with the mission".

8. Failure to use trend analysis and other risk analysis techniques including expertise and opinion that was readily available.

9. Reliance on past success as a substitute for sound engineering practice.

10. Evolution of an informal chain of command and decision-making process that operated outside of the organizations rules.

11. The safety system lacked resources, independence, personnel and authority to apply alternatives to problem solving.

One large lesson to be learned from studying commonalities between the Challenger and Columbia accidents is that if not managed, culture tends to revert. After the Challenger accident, efforts were made to change the culture. Ultimately, those efforts failed and the culture reverted back to the way it was in the pre-Challenger days. This points out the difficulty in changing culture and the need for a coalition of those in power to keep change efforts firmly on track.

Consider another recent accident, the famous collapse of Big Blue, a 1500-ton crane that collapsed into the Miller Park Stadium in Milwaukee, Wisconsin in July 1999 killing three ironworkers. While setting pre-panelized sections of roof trusses, the crane collapsed primarily from a side-loading condition caused by high winds. In this accident, production and schedule were clearly favored over safety. A critical lift plan that did not allow for lifts to be made in winds over 15 mph was ignored. Management overrode concerns by safety personnel. The fact that other roof sections had been set and no accident had occurred set into a motion a mindset that "it's ok" (acceptance of error / defect as "normal").

Sound familiar?  Think about whether some of these issues exist in your own organization. The fact is that no amount of inspections, training, enforcement, or employee-focused behavioral observations will overcome these types of management system deficiencies. We can have safety programs until the cows come home, but until we deal holistically with the behavior of the overall organization, we are only deluding ourselves.

The key to safety excellence is organizational culture. Implementing safety programs without actively working to shape the culture sets up a "program" mindset.  To be truly effective, safety cannot be a "program". It must be an on-going process of continuous improvement. Supervisors working within a "safety program" traditionally tend to view safety as an "add-on" rather than a core responsibility. Under the safety program mentality, senior managers see safety as a "hand-off" or a department (similar to human resources). People in leadership positions tend to abdicate personal responsibility and involvement for safety and place it instead on the safety director. In extreme cases, the safety director is even held accountable for outcome results (accident rates, experience modifiers, etc.) for which they have little actual control.

Typical traditional safety programs built upon safety personnel conducting inspections are reactive systems at best. In fact, inspections by nature are reactive because we are looking for and hoping to catch something going wrong (unsafe act, condition, defect, etc.). The problem is-it's already gone wrong. The defect or the unsafe situation has already occurred. Under such a scenario, how many safety people would an organization have to hire to catch every error, every defect, every unsafe act and every unsafe condition, every minute of every day? Inherently, this is a flawed way to practice safety. Ideally, every person in an organization should be the safety director.

Moving to safety excellence requires moving the safety process upstream from a reactive system to one that is proactive. To do that requires an organization to develop culture of safety excellence. Building an effective safety culture requires several key steps.

The first step is to analyze the existing culture. To get anywhere, you must first know where you are. A good safety culture assessment should clearly define the current culture and provide statistical baseline measurements that will allow for measuring future progress as changes are implemented (you can't manage what you can't measure). Safety culture assessments commonly utilize well-designed perception surveys and a variety of interview techniques. What gets measured is just as important as how it is measured. Poorly conceived perception surveys often measure what people think about the safety program. Such surveys are of little value since they don't tell you anything about the underlying cultural elements that either drive or impede the safety process.

While surveys are good for providing measurable data, what they do not provide is input or feedback from those most affected by the culture. Specially designed interviews by trained third party interviewers are the best way to gain this valuable information. Obtaining this information properly also allows for validation of survey responses. A safety culture assessment that does not include the interview process is only a partial assessment.

The second step is to develop a strategic action plan for changing the culture. Changes should be implemented only after a thorough review of the assessment. The plan should be based on how the changes will affect the organization overall. The plan should be well thought out and identify specific actions, activities, who is responsible, measurement systems and timelines.

The third step is implementation of the changes. Culture change initiatives must be based on sound management principles and sound science. Far too many safety initiatives are based on anecdotal evidence ("sounds good, so let's try it") rather than proven science. Unfortunately today there are many "safety consultants" who make cookie-cutter or program type recommendations often based on what someone else did at another company.

Shotgun approaches that amount to "try this, then try that" are equivalent to repairing a car engine by replacing all of the parts one by one until you find the bad one. Effective interventions must be specific to the affected organization, they must actually improve the culture, and fit within a time frame that is reasonable, doable, and digestible. A common failure in culture change is "trying to bite off more than one can chew at one time".

The fourth step is the change management process. This step consists of measurement, reassessment, readjustment, and on-going evaluation. As changes become anchored in the new culture, it is important to recognize and reward the successes. As with any process, it is also important to identify and address any problem or lagging areas that need further improvement. 

While there are a number of reasons why some culture change efforts fail, the biggest one is failure to manage resistance. Resistance is a natural and normal part of any change effort. However, failure on the part of management to recognize it for what it is and to deal with it effectively is a sure fire way to undermine culture change. Resistance can take on many forms and people may go to extreme lengths to resist the changes. If management caves in at the first wave or two of resistance, they have already lost the ball game before it begins. It is imperative that everyone in the organization clearly understands the changes, their roles, responsibilities, and their specific activities as required by the new culture. It is also critical to have a coalition or steering committee of powerful individuals in the organization who keep the process on track.  

In summary, many organizations try to improve safety performance through "safety programs", quick fixes, or the use of stand-alone safety management tools such as an employee-focused behavioral safety process. A more holistic approach that not only incorporates effective safety management tools but also works continuously to shape a culture of excellence is the key to stellar safety performance.  

Lest we forget, let's all remember...It's the culture, stupid !!!  

Mike McCarroll, CSP

President & CEO

PROSAFE Solutions, Inc.