The implementation of an improved safety culture requires an almost Sherlock Holmes ability to use observation and logic to identify where underlying loss potential resides in the workplace. Just as Sherlock searched a crime scene, the OHS professional must be sensitive and aware of subtle clues that may not be quite discernible in the work environment. While the Job Hazard Analysis provides us with the structure and nature of individual job hazards and risk by providing a way to analysis the interactions of job requirements (steps and task, tools/equipment/materials, the work environment, current polices, procedures, etc., and the people exposed to the job), JHAs are not enough to assure that the controls put into place remain effective. Human Performance Improvement The US Department of Energy “Human Performance Improvement” Handbook discusses that 80% of loss producing events are human error and 20% are due to equipment failures. However, a further analysis of the 80% shows that 70% of these human errors are due to organizational weakness and 30% due to human error! This 70% represents “undetected deficiencies in organizational processes, equipment, or values that create job conditions that either provoke error or degrade the integrity of controls.” These latent errors are embedded in the organization.
A study by the Institute for Nuclear Power Operations (INPO) refers to nine common weaknesses that can serve as as “warning flags” that can lead to serious incidents and degrade a safety culture. The INPO “concluded that these latent conditions are conducive to the degradation and accumulation of flawed controls and human-performance-related events.” These are warning flags of conditions that can defeat controls. Nine Warning Flags that can defeat controls within a Safety Culture While the Handbook is written for nuclear power operations, you use the flags with just a little interpretation to evaluate your workplace. Look for signs of the following nine warning flags that are adapted from the DOE Handbook:
- Overconfidence – The “numbers” are good, and the staff is living off past successes. Consequently, the staff does not recognize low-level problems and remains unaware of hazards.
- Isolationism – There are few interactions with other similar organizations, professional groups, regulatory and industry groups. Benchmarking is seldom done or is limited to “industrial tourism,” without the implementation of good practices learned. As a result, the organization lags the industry in many areas of performance and may be unaware of it.
- Defensive and Adversarial Relationships – The mind-set toward the regulatory agencies or professional groups is defensiveness or “do the minimum.” Internal to the organization, employees are not involved and are not listened to, and raising problems is not valued. Adversarial relationships hinder open communication.
- Informal Operations and Weak Engineering – Operations standards, formality, and discipline are lacking. Other issues, initiatives, or special projects overshadow plant operational focus. Engineering is weak, usually through a loss of talent, or lacks alignment with operational priorities. Design basis is not a priority, and design margins erode over time.
- Production Priorities – Important equipment problems linger, and repairs are postponed while the plant stays on line or in production. Safety is assumed and is not explicitly emphasized in staff interactions and site communications.
- Inadequate Change Management – Organizational changes, staff reductions, retirement programs, and re-locations are initiated before their impacts are fully considered. Recruiting or training is not used to compensate for the changes. Processes and procedures do not support strong performance following management changes.
- Plant Operational Events – Loss producing Event significance is unrecognized or underplayed, and reactions to events and unsafe conditions are not aggressive. Organizational causes of events are not explored in depth.
- Ineffective Leaders – Managers are defensive, lack team skills, or are weak communicators. Managers lack integrated plant knowledge or operational experience. Senior managers are not involved in operations and do not exercise accountability or do not follow up.
- Lack of Self-Criticism – Oversight organizations lack an unbiased outside view or deliver only good news. Self-assessment processes, such as management observation programs, do not find problems or do not address them; or the results are not acted on in time to make a difference.”
Safety Culture and Process Improvement An organization is the interaction of its beliefs, values, structure, the tools, equipment and materials in use, people, the social, physical and social environment necessary to reach its stated goals – the reason for its existence. Having an in-depth understanding and knowledge of all aspects of the organization, not just the safety rules and compliance criteria, is essential for a environmental, safety and health process to have a higher probability of achieving a successful safety culture over the long term.
US Department of Energy Human Performance Improvement Handbook, DOE-HDBK-1028-2009
Roughton, James, Nathan Crutchfield; Job Hazard Analysis. A Guide to Compliance and Beyond, Butterworth-Heinemann, 2008
Roughton, James; Developing an Effective Safety Culture: A Leadership Approach, Butterworth-Heinemann, 2002.