Session 29

Safety Culture
Session 29
Safety Culture
Safety Culture - 3
Contents
What is Safety Culture?
Does Safety Culture Matter?
Characteristics of Culture
Teams in Safety
Creating (and destroying) teams

Competency
Competencies guidelines
Safety Culture - 4
What is Safety Culture?
What is meant by culture?
way things are done in a particular organisation, or
distinctive customs, achievements, products, and outlook of a
particular group (organisation)

What is meant by safety culture?
customs, outlook with regard to safety issues
what is a good safety culture?
distinctive customs which place safety in a key (pre-eminent) role
in the organisation
safety culture should be all-pervasive
reflected in organisational attitudes
influencing all major decisions
in practice, levels of safety cultures
Safety Culture - 5
Does Safety Culture Matter?


Space Shuttle Challenger
exploded just after launch on 28th January 1986
primary cause, failure of an O ring a seal between two
sections of a solid-fuel booster rocket
rubber ring expands to seal joint a failure mode is cracking
under low temperatures
Investigation by Prof. Richard Feynman
studies at NASA, and suppliers of systems
unreliability was well-known NASA had data on blowbys of the
seal
official position was that that small leakages were acceptable
Safety Culture - 6
SRB Seal
Primary O-ring
Secondary O-ring
Clevis
Tang
Unpressurised joint
- no rotation
Pressurised joint -
rotation
(effect exaggerated)
Gap opening
(0.042 - 0.06 in)
Inside Outside
Safety Culture - 7
Effects of Weak Safety Culture
Challenger, continued
various internal investigations had decided it was too costly to
fix the problem (documentation not the seal!)
prior to the Jan. 1986 flight, an engineer at the supplier had said
the flight shouldnt go ahead if the launch temperature was less
than 53F
when NASA challenged this, the company backed down, but the
engineer refused to change his recommendation
launch occurred at 29F, and the explosion occurred
Considered from a cultural perspective
management refused to accept engineering views that were
economically / managerially inconvenient
was this a good safety culture? does culture matter?
What were the characteristics of Columbia accident?
Safety Culture - 8
A Good Safety Culture
Leadership
senior managers (directors) involved and visible in safety
treating safety as a core value of the organisation
Staff attitude
buy into company policies
understand that prevention is better than cure
take (personal) responsibility for safety
Commitment
staff are empowered to take decisions that impact safety
Competency
is encouraged and rewarded
Policies and systems
encourage effective achievement of safety
include reporting and correcting problems
Safety Culture - 9
Destroying Safety Culture
Easily achieved by management
ignore reports on safety problems from concerned staff
oh, that will never happen ...
rebuke / penalise staff who identify safety problems
e.g. by blaming them for causing the problems
appeal to time / cost
we cant afford to fix that, it will take too long, cost too much
provide inadequate resources for safety activities
populate the safety department with people who have not proven
very good in other jobs
dont promote anyone out of the safety department
so its seen as a dead end
dont support training initiatives
Bureaucracy - make it to hard to do anything about safety
Safety Culture - 10
Aspects of Leadership
Positive signs
senior managers (directors) involved in
setting safety policy
communicating safety policy
e.g. Air Commodore endorsed incident reporting forms
key safety activities
including incident analysis
Actions speak louder than words

Worrying signs
senior managers are not accessible, or dont act on what they
hear regarding safety problems
N.B. Challenger, London Ambulance Service, Vickers Medical
staff dont know who is responsible for safety in their organisation
Safety Culture - 11
Teams in Safety
A team is a number of people associated in a joint action
the notion of joint action, and shared responsibility for the actions, is
central
In engineering, so-called teams often arent
divide and conquer to decompose to
individual tasks
often really groups, working on related parts
of a common problem, e.g. Microsoft
For safety, teamwork is essential
much safety work is interdisciplinary
no one individual has the necessary skills
the joint objective cannot be achieved without drawing together
different skills, and hence people
e.g., different team member roles in classical HAZOP
Safety Culture - 12
Destroying Teams
Teams are fragile
They need careful selection and nurturing
Hard to deliberately build effective team
but easy to cause teamicide (DeM&L)
defensive management
poor direction, so staff cant see when managers fail
bureaucracy
forms to fill in, no feedback
physical separation
separate offices, separate continents
fragmentation of peoples time
constant interruptions, e.g. Tannoys, e-mail
clique control
breaking up successful teams, so they dont become more
powerful than the manager
Safety Culture - 13
Positive Factors
Cult of quality
positive desire to achieve high quality results
Closure
easier to achieve in operating organisation than product
development another week with no reportable incidents
celebrating success helps
Management set strategic but not tactical direction
identify objectives, dont dictate all the steps
gives sense of ownership and hence commitment
may be impossible in operating organisation
procedures necessarily rigidly enforced
Heterogeneity
mix backgrounds, skill levels, etc.
Select appropriate team members
Safety Culture - 14
Competency
OED defines competent as meaning
1 suitable, fit, proper
2 answering the requirements of the case;
sufficient in amount, quality or degree
4 properly qualified
5 legally qualified or sufficient
In the case of safety the first four clearly apply
And the fifth may apply, at some stage
How do we recognise competency?
The ability to do a task well
Repeatedly and consistently
Competency is hard to judge
Schemes have been developed to help
Safety Culture - 15
Importance of Competency
Competency is important in any engineering discipline
It takes on greater importance in safety

Consider a range of disciplines
Electronics
We build, run and test circuits
Mechanical engineering
We construct, operate and test mechanisms
Structural engineering
We build structures and subject them to loads
Safety engineering
We analyse systems, and dont get feedback until things fail

Generally safety activities are open loop
Primary check on soundness is peer review
Safety Culture - 16
Importance Illustrated
Failures of understanding
Can impact safety
Will almost certainly be expensive
Extract from a discussion with a software engineer
why are you doing that?
its in the software development standards
why do you think its in the standards?
dunno
would there be a problem if you didnt do it?
it would be great! (the task was boring and lengthy)
it didnt add value and was removed from the standards
Shows effects of limited competence
The engineer, but more importantly the project manager
Safety Culture - 17
Competency Schemes
Are a variety of schemes
Some generic - applicable to many sectors
American Society of Safety Engineers (ASSE) in USA
National Registry of Safety Professionals and Other Registrants
Certified Safety Professionals (CSPs) - US-based, international
Based largely around examinations
HSE/IEE/BCS in the UK
General competencies for safety practitioners
Largely workplace/experience based
HSE Guidance on how to set up and run a Competency Management
Scheme (CMS) is currently out for consultation
Some industry-specific - applicable to operations staff:
Institute of Railway Signalling Engineers (IRSE) in the UK
Licensing schemes for Air Traffic Controllers
Safety Culture - 18
Competencies - further comments
Note also rise of competency requirements in contracts
becoming increasingly common for customers to require details
of engineering & management team qualifications as part of bid
process
complete argument of compliance with (UK) Def Stan 00-56
requires information about competence of key staff
New draft 61508 makes a competency scheme mandatory

Companies / organisations increasingly taking policy
decisions affecting staff competency in safety
e.g. Boscombe Down (UK military aircraft approvals) have (semi-
formal) policy that staff assessing safety cases should have
relevant qualification to Certificate level or higher - employer is
paying for necessary training
Safety Culture - 19
Coda
Culture is important in achieving safety
although it is hard to show causal links

Good safety culture requires
effective people
effective teams
effective processes
with focus on continual improvement
effective management
management alone cant create a safety culture
but they must lead
and they can easily destroy it