Safety Culture and High-Risk Environments

A Leadership Perspective

Cindy L. Caldwell

• Editorial: CRC Press
• Año: 2017
• ISBN:
  9781351979351
• Edición: 1
• Categoría: Negocios y empresa
• Categoría: Operaciones

This book provides leaders in high risk industries a better understanding of how their values and behaviors can influence the organization's safety culture and improve its capacity to bounce back from failure. Examples are illustrated through case studies and practical tools are provided to evaluate and improve an organization's culture by improving leadership capability. This unique book integrates the areas of safety culture and high reliability from the perspective of leadership in a work team environment. Readers of the book will get a fresh perspective on safety culture and reliability that can be translated into practical steps for improving their organization through its leadership.

Section I

1	Understanding Organizational Factors in High-Risk Environments

Historically, accidents within an organization have been explained in terms of technology and human factors without taking into consideration the organization’ s values, beliefs, and behaviors. These cultural dimensions can also create limitations in organizational systems. In certain sectors, such as nuclear power and petro-chemical industries, the complexity of the organization–technology interface introduces unforeseen interactions among system components that have resulted in catastrophic accidents. High-risk industries such as the nuclear power industry became interested in culture in the early 1980s. The International Nuclear Safety Advisory Group (INSAG) first coined the term safety culture when referring to the failure at the Chernobyl Nuclear Power station (Sorensen, 2002). INSAG (1991) acknowledged that after a certain point in the maturation of safety systems, technology alone cannot achieve further improvements in safety; instead, organizational and cultural factors become more important.

1.1 SIMPLE TO COMPLEX

The early evolution of the management of safety-related programs in the United States began with a compliance-based inspection focus brought on by the Occupational Safety and Health Act (OSHA) in the 1970s. As a result, procedures, training, and tools were established and continuously improved to increase awareness, reduce risk, and ensure compliance. Although OSHA and its enforcement powers had a positive effect on safety in the United States, reducing fatalities and disabling injuries by more than 50%, there was limited attention to long-term performance or continuous improvement.

Likewise, for most of the twentieth century, accident theories were traditionally based on a closed-system approach that examined conditions, barriers, and linear causal chains that do not consider the complexity of today’ s working environment. The typical focus in the 1960s and 1970s was on technical faults and human error, which received international attention following the accident at Three Mile Island.

The accident at Three Mile Island was compounded when plant operators failed to recognize the warning indications of a loss-of-coolant accident due to inadequate training and human factors. In particular, a hidden indicator light led to an operator manually overriding the automatic emergency cooling system of the reactor because the operator mistakenly believed that there was too much coolant water present in the reactor (Health and Safety Laboratory, 2006). The Three Mile Island accident investigation’ s Kemeny Commission coined the phrase “ operator error,” which reflected the cause and effect thinking of the 1970s (Kemeny, 1979).

In a similar fashion, the compliance-based “ workplace inspection” approach of the 1970s gave way to behavior-based safety in the 1980s and early 1990s. Behavior-based safety was grounded in the belief that individual behavior could be changed by focusing on the behavior itself and the consequence of that behavior. The approach reinforced the idea that an unsafe behavior was the result of individual choice without regard for other organizational factors. Hollnagel (2009) has noted that many accident models still share a linear approach and are silent on the dynamic interplay among factors. Linear causality suggests that the effect is proportional to the cause. Causal explanations of incidents provide greater organizational control by placing blame on the specific individual without considering systemic issues behind the incidents. The organization socially constructs a view that the essence of safety is to prevent individuals from committing errors (Reiman and Rollenhagen, 2010).

Unfortunately, managing worker safety by regulatory compliance and addressing individual error does not address the risk of a catastrophic event. Catastrophic risks need to be treated differently from other risks. Executives can prevent catastrophic events through a holistic organizational focus on risk. Low-probability, high-consequence occurrences that have a high inherent risk such as Three Mile Island are called catastrophic events (Kleindorfer et al., 2012). Historically, catastrophic events have played an important role in the development and application of accident theory, so it is not surprising that an alternative view emerged from the Three Mile Island crisis.

Sociologist Charles Perrow disagreed with the human factors argument presented by the Kemeny Commission. Perrow (1981) proposed a sociological view of the relationship between reactor operators, their indications, and decision making under duress. Perrow (1984) explicitly stated that it was the system that caused the Three Mile Island accident, not the reactor operators. Perrow proposed that an association should be made between the errors and the system, as opposed to the errors and the operators. Perrow’ s 1981 paper included a description of a normal accident that later became normal accident theory. Normal accident theory is based on the unanticipated interaction of multiple failures. Perrow (1984) believed that if the system is both interactively complex and tightly coupled, there is no possibility of identifying unexpected events and the system should be abandoned.

Perrow’ s arguments aligned with limiting the human interface and were later reflected in a paper by Otway and Misenta (1980) that concluded by questioning whether the role of operator should be eliminated or redefined for less human intervention in emergencies. It was the safety community’ s negative reaction to Perrow’ s (1984) controversial ideas that led to much of the present-day thought on safety culture. However, it wasn’ t until many years after the Three Mile Island event that culture took on a more prominent role in the prevention and analysis of accidents.

The concept of organizational culture became popularized in the 1980s with bestseller books such as In Search of Excellence (Peters and Waterman, 1982) and Corporate Cultures (Deal and Kennedy, 1982). Emphasis was placed on the importance of employees as a resource and management as an influence on cultural change. Since the 1980s, the concept of organizational culture has been extensively studied and has become an interdisciplinary interest spanning the fields of psychology, sociology, and management. Culture is shared among groups of individuals and is not a characteristic of single individuals. It is something that members of an organization learn over time as the correct or wrong way of behaving in an organization. Schein (2004) describes culture in terms of three elements:

•Culture offers structural stability that provides meaning and predictability to the organization. Culture survives even when some members of the organization leave. Strong cultures put considerable pressure on people to conform.

•Culture often resides in the deepest subconscious part of a group.

•Culture influences all aspects of how an organization deals with its operations.

Using organizational culture as an instrument of control remains a source of debate and today many call for a more holistic approach to understanding culture that considers its many layers and complexity (Haukelid, 2008). The early concept of safety culture emerged from the popular view of organizational culture and it faces similar debates. Cooper (2000) noted that safety culture does not operate independently, but rather it is tied to other non-safety-related operational processes or organizational systems.

Since Chernobyl, numerous definitions of safety culture have appeared in the literature. The preponderance of definitions refer to culture in terms of attitudes and behaviors (Guldenmund, 2000; Hale, 2000; Lee, 1996; Ostrom et al., 1993; Pidgeon, 1991). Most definitions have focused on safety culture in high-risk areas such as nuclear power, mining, and transportation industries (Guldenmund, 2007, Wiegmann et al., 2001). The majority of definitions suggest that safety culture is a discrete entity that an organization “ has” and that culture can be understood in terms of perceptions and workplace behaviors. These definitions imply that culture can be changed.

The interest in safety culture stimulated related research in accident management. In 1985, a group of researchers at the University of California, Berkeley, initiated research on high reliability organizations (HROs) by examining organizations that operated virtually error-free, such as air traffic controllers, nuclear power plants, and the US Navy aircraft carriers (Roberts, 1993). Consequently, high reliability organization theory has become a prominent model to explain complex high hazard organizations that perform with a high level of safety, reliability, and system integrity. High reliability organizations and safety culture share key attributes. Weick and Roberts (1993) suggest that organizations become reliable by creating a positive safety culture and reinforcing safety-related behaviors and attitudes. Research on high reliability organizations strengthened the case for safety as a facet of organizational culture.

1.2 TWENTY-FIRST-CENTURY LEADERSHIP AND CULTURE

Leadership is acknowledged as a primary influence on organizational culture (Schein, 2004). It has been my experience that impactful leaders have an innate talent for developing an inspiring picture of a future environment that is based on their personal core beliefs and their vision for an impactful outcome. They are able to paint a vision that motivates people to action. Leaders connect with people and inspire them to rally around an effort. Leadership requires a strong sense of self. Leaders help people understand how they can contribute to a greater good and in the process develop themselves. Are these leadership characteristics sufficient to influence organizational change in the twenty-first century?

In recent years, traditional leadership relationships have been replaced with non-traditional leadership processes and complex interactions. The connectedness, support, and development of staff is more difficult. Organizations are more fluid. Extended enterprises have emerged that are independent and networked. Cultural context has become important as the lines of nationality have become blurred and culturally acceptable norms are shifting universally.

Changing markets, flatter, more fluid organizations, global partnerships, and extended enterprises have created a plethora of unique roles for twenty-first-century leaders. Weaknesses in leadership tied to safety culture and high reliability attributes are important contributing factors in the analysis of catastrophic events. Retrospective case studies of disasters highlight that after a certain point within complex systems, mature safety processes and technology alone cannot assure safety; additionally, and more importantly, the influence of organizational and cultural factors associated with leadership must be considered. Rather than thinking of leadership narrowly in terms of the leader– follower perspective, we must consider the complex relationships and interactions that are necessary to influence positive outcomes in the twenty-first century and how they influence the organizational culture. Six disasters are described throughout the book:

•The explosion and release of toxic gas from a Union Carbide plant in Bhopal, India, that killed thousands of Indian citizens and injured hundreds of thousands in 1984

•The loss of seven crew members in the Challenger disaster when an O-ring failure caused the liquid hydrogen-oxygen tank to explode in 1986

•An explosion and fire at the BP Texas City Refinery that killed 15 workers and injured 200 in 2005

•An underground explosion at Massey Energy’ s Upper Big Branch Mine in West Virginia that killed 29 miners in 2010

•The release of radioactive contamination following the earthquake and tsunami at the Japanese Fukushima Daichii Nuclear Power Plant in 2011

•The explosion on the Deepwater Horizon rig that released approximately three million barrels of oil into the Gulf of Mexico, killed 11 workers, and injured 17 in 2012

Socio-technical factors influencing the six disasters are used throughout the book to support the case for authentic leaders that cultivate reliable and resilient organizations. Authentic leadership was born from society’ s need to trust government and corporate motives given the constant scandal and turmoil associated with recent catastrophic industrial disasters and other events with global impact (Northouse, 2013). Authentic leadership focuses on values and building trust in the organization through transparent relationships, which aligns stakeholders and ultimately influences the organizational culture (Avolio et al., 2004).

1.3 A NEW GENERATION OF CHALLENGES

Although valid and necessary, the traditional elements of safety programs are insufficient to mitigate catastrophic incidents and achieve the desired level of performance in all aspects of business. These elements need to be unde...