When Patrick Hudson emphasises the importance of culture he means more than occasional visits to the opera house or art gallery. Organisational culture and accidents are inextricably linked, Hudson says, and ultimately, the severity and frequency of accidents reflect an organisation’s culture.
‘When we look back, it always was the culture. Not just the big accidents but most of the smaller ones as well. People are trying to get the job done, so all too often, they were allowed to get away with dangerous behaviours.’
Hudson, who began his career in safety in the wake of the Piper Alpha oil rig disaster of 1988, in which 167 men died, defines an organisation’s culture as the common set of values, beliefs, attitudes and working practices that determine people’s behaviours.
A safety culture has five aspects, he says.
Leadership: Leaders are not afraid to do difficult things. Everyone knows where leaders stand on managing risks—either taking the risks or running them.
Respect: Individuals are respected as are the dangers they face. Experts are listened to, even when they are low in the hierarchy—this leads to being informed. Managers know what is really going on and the workforce is willing to report their own errors and near misses, which are often hard for them to say and for managers to hear.
Mindful: Everyone is wary and always ready for the unexpected.
Just and fair: A culture with clear lines between what is acceptable and unacceptable and ones that everyone agrees upon. What makes it just, is that there are well understood consequences, both positive and negative. What makes it fair is that everyone from top to bottom agrees where the lines are drawn and the consequences of crossing them.
Learning: The culture is willing to adapt and implement necessary reforms based on lessons learned. This is done even when reforms are expensive, and even when sacred cows have to be slaughtered.
Hudson has also mapped out five levels of safety culture, from the worst, to the best. (Hudson’s classification expands on one by sociologist Ron Westrum, who identified pathological, bureaucratic and generative safety cultures.)
In the pathological stage, management believes accidents are caused by stupidity, inattention and, even, wilfulness on the part of employees. Fine sounding messages may flow from on high, but the majority still reflect the organisation’s primary aims, often with ‘and be safe’ tacked on at the end.
The reactive stage is where safety becomes a priority after an accident. It can be a temporary stage for otherwise pathological organisations, or it can develop into the calculative stage, where an organisation puts safety processes and systems into operation. ‘Calculative cultures both have a process and use it,’ Hudson says.
Calculative organisations run the risk of going through the motions of safety management, Hudson says. He notes that ‘on the Deepwater Horizon, 110 staff on board were submitting an average of over 100 safety job cards every day—nearly one per person, per day—not that it helped.’
The transition to becoming a proactive organisation involves making the processes and systems that are now in operation truly effective. Proactive organisations use their processes and systems to anticipate safety problems before they arise.
In the generative culture all these elements come to fruition. In the proactive culture, the top of the organisation is still driving safety but has created the potential to let those who are the subject matter experts take responsibility and accept it as well.
Hudson describes generative organisations as ‘the lunatics that are running the asylum,’ but not in a negative sense. It is a state where safety awareness is spread throughout the organisation. ‘Top management stood back and it looked as if they had nothing to do as far as safety was concerned, or indeed, in production either. But then I realised that they have the hardest job of all—designing asylums to be run by lunatics.’
Westrum describes the safe return of the Apollo 13 spacecraft after an explosion in space as an excellent example of a generative response. ‘By contrast, the fumbling that led to the demise of Columbia space shuttle shows bureaucracy at its worst.’
Success is, ironically, a problem for organisations attempting to climb the safety culture ladder.
‘A common problem in organisations that are struggling on the borderline between the calculative and the proactive/generative levels is success,’ Hudson says.
‘Once significant improvements in outcome performance have been achieved management “take their eyes off the ball” and downgrade efforts on the grounds that the problems have been solved. But this is behaviour typical of the reactive stance and represents a reversion.’
An alternative model
In 2001, the Keil Centre in Edinburgh presented a draft for a ‘Safety Culture Maturity Model’ describing five levels that an organisation goes through while improving the safety culture. They are:
Emerging: Safety is seen as technical and procedural issues. Incidents considered a part of the job. Low interest in safety.
Managing: Safety can be solved with rules and following procedures. Lagging indicators are used as safety measurement.
Involving: Realise that operators must be involved to improve safety. Management realises that they sometimes are responsible for accidents. Employees understand their responsibility for health and safety.
Cooperating: General understanding that health and safety are important both ethically and economically. Safety measures are leading indicators.
Continually improving: There is a common understanding that there is an accident in the near future and the entire organisation is working to improve safety performance.
The Keil Centre uses the safety culture maturity model to do a comprehensive assessment of a site, department or team. The process involves staff from the main work groups on a site participating in a series of two-hour workshops in which they are asked to participate in a card-sort exercise and structured discussion based on the following ten elements:
- Visible management commitment
- Safety communication
- Production versus safety
- Learning organisation
- Health and safety resources
- Participation in safety
- Risk-taking behaviour
- Contractor management
Lessons from the ladder
The Hudson and Keil scales allow an organisation to assess how safe it is. This is the first step towards becoming safer.
But Hudson warns that the safety ladder also has snakes. Comfort, complacency and bureaucratic tendencies can make organisations slip.
‘Reactive organisations think that there is nothing better and anyone who claims better performance is probably lying. They do what they feel is as good as can be done. Calculative/bureaucratic organisations are hard to move because they are comfortable, even if they know that improvements are possible. The more advanced cultures, either proactive or generative, are probably easier to attain with small organisations. Large ones will inevitably be heavily bureaucratic unless active steps are taken to counter that tendency.’
The corollary of this is that small organisations can be as safe as large ones. ‘Small organisations are often frightened to develop management systems because they feel that they will commit more than they get back. I hope I have been able to argue that this is not the case. Small organisations are smaller, more focused and flexible. Small organisations are also much more likely to be able to develop past the calculative stage and become generative. The greatest single barrier to success for smaller organisations is the belief that it is too difficult. The opposite view is that, in the long term, it is more dangerous not to.’