How to improve Safety in the Workplace

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Published Date:03-07-2017
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1     INTRODUCTION The `culture’ of an organisation can be defined as `the way we do things around here’. As such, culture provides a context for action which binds together the different components of an organisa- tional system in the pursuit of corporate goals. Successful organisations tend to have strong cultures which dominate and permeate the structure and associated systems. Within these organi- sations nothing is too trivial or too much trouble. Every effort is made by every member to ensure that all activities are done the `right’ way. Thus the prevailing organisational culture serves as a powerful lever in guiding the behaviour of its members in their everyday work. The more that members repeatedly behave or act in ways that appear to them to be natural, obvious and unquestionable, the more dominant the culture becomes. Although there is a danger that the culture could become static and stagnate, in successful organisations, it tends to be dynamic and take on a life of its own, influencing, and in some cases determining, an organi- sation’s ongoing strategies and policies. An organisation’s culture, therefore, impinges upon and influences most aspects of work activity, affecting both individual and group behaviour at all levels in the workplace. Unless safety is the dominating characteristic of an organisation’s culture, which arguably it should be in high risk industries, safety culture can be viewed as that sub component of organisa- tional culture which alludes to individual, job and organisational features affecting and influencing health and safety. The prevailing organisational culture therefore will exert a considerable influence on safety. For example, those organisations that genuinely strive to achieve a quality culture by involving all employees in each step of the process will probably have a greater impact on building a positive safety culture. Organisations that use the idea of a `quality’ culture merely as a marketing device (i.e. achieving BS5750 or IS9000 solely by paper trails) or an excuse for cost- cutting exercises are more likely to ignore safety issues. In the former, the importance of safety as a performance criterion is likely to be accepted by all and may well be integrated into every aspect of the quality process. In the latter, because safety is more likely to be seen as a `bolt-on extra’, adding to overheads and production costs with little payback, it is likely to be rejected as a business performance indicator. A good safety culture, however, is believed to positively impact upon an organisation’s quality, reliability, competitiveness and profitability.     %The Concept of Safety Culture The Impact of Safety Culture on Quality An evaluation of the impact of safety culture on quality in 626 US organisations revealed that better work methods and reduced absenteeism had contributed to improved organisational performance, while also impacting on product quality. Similarly, construction industry studies have shown that projects driven by safety are more likely to be on schedule and within budget. The safety culture of Shell, for example, was shown to have had a significant effect on the progress and completion of a new natural gas liquid plant at Mossmorran, Scotland. Major investments in safety in the British Steel industry not only resulted in significant reductions in accidents with corresponding increases in productivity, but also led to increasingly positive attitudes about quality and safety. The Impact of Safety Culture on Reliability The impact of safety culture on the reliability of technological systems is thought to be indirect via organisational structures and processes: partly because the reliability of complex technical systems (e.g. manufacturing plant) is dependent on the quality of its structural components and sub systems; partly because human reliability is dependent on the variability of human error probabilities; and, partly because of the interaction between them. Nonetheless, reliability has been reported to improve by a factor of three, and sometimes by as much as a factor of ten, when quality improvements are initiated. It is likely, however, that some of these improvements are related to the use of better monitoring and feedback systems, both of which are vital safety culture features, and as a result of streamlining production processes. The Impact of Safety Culture on Competitiveness A good safety culture can also contribute to competitiveness in many ways. For example, it may make the difference between winning or losing a contract (e.g. many operating companies in the off-shore oil industry only select and award work to contractors with a positive safety culture); it may affect people’s way of thinking and lead to the development of safety features for some products which are then used as marketing devices (e.g. air bags in motor vehicles to protect occupants during a collision); and it positively impacts on employees’ commitment and loyalty to the organisation, resulting in greater job satisfaction, productivity and reduced absenteeism. The Impact of Safety Culture on Profitability Although a focus on safety has often been seen as non-productive expenditure demanded by law, it can also contribute to profit by minimising loss and adding to the capital value of an organi- sation. For example, construction industry research has shown that an investment of 2.5% of direct labour costs in an effective safety program should, at a conservative estimate, produce a gross  &   The Evolution of the Concept of Safety Culture saving of 6.5% (4.0% net) of direct labour costs. Similarly, an 82% decrease in lost-time accidents which resulted from a behavioural safety programme saved a manufacturing company an estimated £180,000 to £360,000 in compensation costs in just one year. These figures were considered conservative, as the estimated savings did not reflect those associated with a 55% decrease in minor injuries. In the normal course of events, generating this level of profit might require an extra 30% to 40% of production capacity. As the latter illustrates, the costs of accidents can be considerable. Previous estimates by the Confederation of British Industry (CBI) in 1990 suggested that the minimum non-recoverable cost of each accident was £1,500, whether investigated or not. Similarly, in 1993, based on research in six industries, the Health and Safety Executive’s (HSE) Accident Prevention Advisory Unit (APAU) estimated that only £1 in £11 lost as a result of workplace accidents is covered by insurance. Indeed the typical costs associated with accidents include: •lost production caused by: – time away from job by injured person and co-worker(s) in attendance – time spent by first-aider attending injured person – possible downtime of production process – possible damage to product, plant and equipment • time and costs due to repair of plant and equipment • increased insurance premiums • legal costs •medical expenses • compensation costs to injured employees • absenteeism • lower morale of employees leading to poor performance and productivity • unsatisfactory employee relations • low levels of motivation. As a whole, therefore, the available evidence indicates that an effective safety culture is an essential element of any business strategy, as it has so many positive effects on other areas of business performance. It also illustrates the point that safety culture does not operate in a vacuum: it affects, and in turn is affected by, other operational processes or organisational systems. THE EVOLUTION OF THE CONCEPT OF SAFETY CULTURE Traditionally, attempts to identify the most effective methods for preventing accidents have typically addressed two fundamental issues: • Whether or not employees should be provided with the maximum protection possible • Whether or not employees should be trained to recognise potentially hazardous situations and take the most appropriate actions.     'The Evolution of the Concept of Safety Culture Implicitly recognising that the potential for an accident is always present, the first approach is based on the fundamental belief that protecting an individual from the potential for harm, either by statutory means or via physical barriers, is the best way to proceed. The second approach is predicated on the fundamental belief that, if the individual possesses the relevant knowledge and skills, accidents will be avoided. Traditionally, attempts to improve safety in the workplace have addressed these issues via legislation, engineering solutions, safety campaigns or safety training. However, as a result of inquiries investigating large-scale disasters such as Chernobyl, the Kings Cross fire, Piper Alpha, Clapham Junction, etc., more recent moves to improve workplace safety have focused on the concept of an identifiable safety culture. Whilst incorporating all the traditional routes to improve safety, the concept of safety culture goes much further by focusing on the presence of good quality safety management control systems. Legislative Attempts to Improve Safety Legislative approaches to improving safety have their roots in the industrial revolution of the 18th and 19th centuries. Due to radical changes in technology and the development of new industries, many employees were exposed to all manner of hazards in factories and mines. During this period, the rising number of deaths and injuries led to immense public pressure for parliamentary regulation. Initial parliamentary reluctance, and much opposition from factory and mine owners, led to large chunks of this early legislation being repealed and then reintroduced as deficiencies became apparent. Importantly, however, this legislation introduced the notion of inspectorates for factories (1833), for mines (1842) and for the railways (1840), albeit that the inspectorates’ authority was fairly limited. Over the next 100 years a steady stream of legislation followed that further empowered these different inspectorates while also establishing many important principles, such as the mandatory reporting of fatal accidents, the provision of guards for moving machinery and the requirement to provide first-aid facilities. In 1972 the Robens Committee investigated the many shortcomings in safety management of the time, and made various recommendations that subsequently formed the basis of the Health and Safety at Work Act 1974. This Act placed the responsibility for all the previous Health and Safety Inspectorates under the auspices of the Health and Safety Commission (HSC) to bring about changes in safety management practices. The central idea was that the HSC would promote proactive self-regulatory safety management practices by influencing attitudes and creating an optimal framework for the organisation of health and safety. Unfortunately, this proved more difficult in practice than envisaged: partly because of the pervading influence of traditional accident causation models; partly because of `get out’ clauses provided by such qualifiers as `as far as is reasonably practicable’; and, partly because many employers had real difficulty in understanding what they were required to do in practice. Moreover, legislation can only be effective if it is adequately resourced and policed. This has not always proven possible as, traditionally, the number of inspectors available has been relatively small compared to the number of premises covered by the legislation. In the UK construction industry, for example, at the beginning of the 1990s, there were only 90 or so inspectors to police approximately 100,000 sites, not all of which had been notified to the appropriate authorities. In practice, this meant that many companies could openly flout the 1974 Act with little chance of  (   Accident Causation Models prosecution. Indeed, many of them implemented safety improvement initiatives only when forced to do so by inspectors. As a result of recent European directives, the legislative focus has now firmly shifted to proactive management of safety rather than an inspection of sites/premises approach (i.e. the Management of Health and Safety at Work Regulations 1992 (MHSWR). Accompanied by an Approved Code of Practice (ACOP) issued by the HSC, these regulations came into effect in January 1993. One of the most important features of the new regulations is that the majority of the requirements are of an absolute nature, designated by the term `shall’, rather than `so far as is reasonably practicable’. Similarly, the emphasis has switched to the process of safety management rather than the outcomes: employers are now required to take steps to identify and manage hazards by undertaking formal assessments of risk. Thereafter they must plan, organise, implement, control, monitor and review their preventative and protective measures. These measures must be documented and fully integrated with other types of management systems (e.g. finance, personnel, production, etc.). In some high-risk industries (e.g. offshore energy extraction, mining and rail transport) companies are also required to submit a `safety case’ detailing precisely how they intend to put the regulations into effect. Although some may view the new regulations as draconian, much of the underlying rationale is derived from management theory and multi-disciplinary scientific research examining accident causation factors. ACCIDENT CAUSATION MODELS During the 19th and early 20th centuries many safety practitioners and factory inspectorates took the view that preventative physical measures such as machine guarding, housekeeping and hazard inspections were the best way to prevent accidents. This view was predicated on the belief that controlling physical work conditions would prevent the majority of accidents. Despite these types of precaution, however, accidents continued to increase at an alarming rate in British factories during and after the First World War. This led to the commissioning of government committees to examine whether accidents were caused by physical working conditions (situational factors) or individual characteristics (person factors). This differentiation was partly based on the hereditary versus environment debate brought about by Darwin’s radical theory of evolution, and partly because in-depth knowledge about the causes of accidents could lead to the appropriate counter- measures being applied. Accident Proneness Models In 1919, at the behest of these government committees, Greenwood and Woods from the Industrial Fatigue Research Board statistically examined accident rates in a munitions factory. Based on the notion that all munitions workers were exposed to the same levels of risk, they examined three     )Accident Causation Models propositions to try to identify the most worthwhile preventative measures. These were that: • accidents were a result of pure chance, and could happen to anyone at any time • having already experienced an accident, a person’s propensity for further incidents would be reduced (burnt fingers hypothesis) or increased (contagious hypothesis) • some people were more likely to suffer an accident than others. If the first proposition were correct, and no differences in accident rates were found for particular types of people, prevention could be focused solely on environmental demands and conditions. If the second proposition were correct, remedial actions could be concentrated upon only those individuals who had previously suffered an accident. If the third proposition were correct, people with low accident liability could be selected for jobs, while those who experienced multiple accidents could be asked to leave. An analysis of accident records divided into successive three month periods appeared to suggest that some people were consistently more involved in accidents than others, thereby supporting the third proposition. Despite the obvious fact that not all people are exposed to the same levels of risk in their work, these results and those of other studies led to the `Accident proneness’ model which dominated safety thinking and research for almost 50 years. In practice, the pervading influence of this approach meant that most accidents were blamed solely on employees rather than the work processes, poor management practices or a combination of all three, a response that can still be found in some organisations. Typically, investigations to discover the underlying causal factors were felt unnecessary and/or too costly with the result that little attention was paid to how accidents actually happened. Thus many companies felt they had little to do in the way of accident prevention other than select the right employees and weed out or re-educate those involved in more than one accident. Importantly, the findings of these types of study placed greater emphasis on the fallibility of people than on the interaction between working conditions and people, and this led to many companies inadvertently neglecting their real safety responsibilities. Heinrich’s Domino Theory Despite recognition by early researchers of the role that managerial and organisational factors played in the accident causation chain, most practitioners focused almost exclusively on the prominence of employee’s unsafe acts. To some extent this prominence, expressed in accident triangles to this day, reinforced the prevailing view about `accident prone’ people. This research led to Heinrich’s seminal work `Industrial Accident Prevention’, published in 1931. Heinrich postulated that accidents were caused by either an unsafe act, an unsafe condition, or both. Termed the `Domino’ theory, this work provided the first sequential theory of the accident causation process. Not only was safety behaviour demonstrated to play a greater role than previously thought (see Figure 1.1: Heinrich’s Domino Model of Accident Causation), but it also brought the interaction between behaviour and conditions (situation) into sharper focus for the first time.     Accident Causation Models In essence, the Domino theory asserted that accidents were caused by a sequence of events which encompassed five discrete stages. This began with a person’s heredity and environment which predisposed that person to behave in certain ways (such as being an accident prone person), and which led to either an unsafe act or the creation of an unsafe condition. In turn, either of these caused an accident which resulted in an injury. Heinrich asserted that each stage of the accident process was analogous to a row of dominos in line with each other. If one fell, it automatically knocked down all the other dominos. Neutralising any one of the first four would prevent the fifth: the injury. Heinrich concluded that the key domino was that pertaining to unsafe acts. This perhaps reflected his findings that approximately 80% of accidents were triggered by unsafe acts, with the remaining 20% being caused by unsafe conditions (known as the 80:20 rule). Although designers, engineers and the statutory bodies addressed many of the unsafe conditions by guarding against or legislating for the control of technological hazards, Heinrich thought that unsafe acts were caused by poor attitudes, a lack of knowledge and skill, physical unsuitability and an unsafe environment. This view led to much training and propaganda in attempts to change attitudes, the effectiveness of which was, and still is, questionable. Heinrich summarised his theory in terms of ten axioms of industrial safety that at the time were considered to be somewhat revolu- tionary, with the result that they tended to be ignored. Although some were relatively simplistic, the underlying rationale has become influential in current safety management practices. For example, axiom 7 which states `... the methods of most value in accident prevention are analogous with the methods for the control of quality, cost and quantity of production’, is not too dissimilar in intent to the Total Quality Management (TQM) techniques encompassed by, and advocated in, the current MHSWR 1992. Weaver’s Domino Theory Other theorists used Heinrich’s domino theory as the starting point for their own work. For     +Accident Causation Models example, in 1971 Weaver modified the original theory to propose that the last three dominos in the sequence were caused by management omissions. Expressed as symptoms of operational error (see Figure 1.2: Weaver’s Domino Model of Accident Causation) that interact with unsafe acts and/or conditions, Weaver drew on the notion of multiple causality due to underlying organisational factors. Although the unsafe act or condition was still the immediate cause, Weaver suggested that the underlying causes of operational error could be discovered by asking `What was the unsafe act? Why was it allowed to occur?’ and, `Were the rules and procedures known to all concerned?’. In essence, Weaver’s model placed the immediate responsibility for accidents squarely on the shoulders of poor supervision and line management, while also implicitly recognising the interaction between management systems and accidents. Adams’ Domino Theory Building on Weaver’s adaptation of Heinrich’s basic model from an industrial engineering systems perspective, in 1976 Adams changed the emphasis of the first three dominos to reflect organisa- tional rather than person features (see Figure 1.3: Adams’ Domino Model of Accident Causation). By doing so, he was one of the first theorists to move away from the discredited accident proneness approach. Importantly, Adams also implicitly recognised the notion of a safety culture by stating that the personality of an organisation was reflected in its stable operational elements. With reference to this organisational `personality’, Adams proposed that operational errors were caused: by the management structure; the organisation’s objectives; the organisation of the  ,   Accident Causation Models workflow system; and how operations were planned and executed. In turn these operational errors caused `tactical errors’ (unsafe acts or conditions). The essential difference here is that Adams explicitly recognised that tactical errors were the result of higher management’s strategic errors. Thus, Adams was one of the first safety theorists to specifically highlight the multiple interactions between organisational structures, systems and sub systems, and unsafe conditions and/or employees’ safety behaviour. Indeed, Adams’ work is reflected in Johnson’s Management Oversight and Risk Tree (MORT) published in 1975 which is an analytical tool set out in a logical- fault tree format that provides a systematic basis for detailed accident investigations. Although the scale and complexity of MORT has limited its practical application, it has proven to be of immense value for building theories of accident causation. This is partly because it recognises the interactions between physical (job), procedural (organisational) and personal elements, and partly because it has helped to discover that a number of parallel accident sequences develop over a period of time, prior to the various causation elements coinciding and interacting to produce an incident. This latter point, and others, was picked up and developed further by James Reason in 1993. Bird and Loftus’ Domino Theory In parallel with these developments by Adams from the perspective of management theory and total loss control, Bird and Loftus adapted Heinrich’s Domino theory to reflect the influence of management in the accident causation process (see Figure 1.4: Bird and Loftus’ Domino Model of Accident Causation). This model takes the view that poor management control creates either poor     -Accident Causation Models personal factors (e.g. lack of appropriate training) or poor job factors (e.g. unguarded machinery). In combination, these two factors lead to either unsafe acts or unsafe conditions. In turn these cause an incident, which leads to losses related to people, property or operational processes. This model in particular has exerted a great influence on safety practices in some industries (e.g. chemicals and mining) by virtue of its subsequent development into an auditing tool (i.e. the International Safety Rating System (ISRS)) and its emphasis on cost savings and financial return. Reason’s Pathogen Model Although the above models have proved useful in identifying the sequence of events in the accident causation chain, they have largely failed to specify how and under what conditions each of the sequential elements might interact to produce accidents. Many practitioners have continued to blame the individual for the unsafe act, or merely identify and rectify the immediate unsafe conditions, rather than examining how and why the unsafe act occurred, or how the unsafe condition was created. A more recent causation model by Professor James Reason has largely overcome these shortcomings. Initially based on an analysis of the Chernobyl disaster in 1987, Reason likened the accident causation process to `resident pathogens’ in the human body. Similar in concept to physiological immune systems, Reason argued that all organisational systems carry the seeds of their own demise in the form of these pathogens. In 1988 Reason termed these resident pathogens as `latent’ failures. In much the same way as Johnson had identified that accident sequences develop over a period of time, Reason suggested that the `latent’ failures lie dormant, accumulate and subsequently combine with other latent failures which are then triggered by `active’ failures (e.g. unsafe acts) to overcome the system’s defenses and cause accidents. Reason proposed that `active’ failures were caused by poor collective attitudes or by unintentionally  %.   Accident Causation Models choosing the `wrong’ behavioural response in a given situation, both of which may result in a breach of the system. In later works, Reason recognised the limitations of his original resident pathogen model and, in conjunction with Wreathall, identified how and where latent and active failures might be introduced into an organisational system. This modified model suggests that pathogens are introduced into the system by two routes. • Latent failures caused by organisational or managerial factors (e.g. top-level decision-making). • Active failures caused by individuals (e.g. psychological or behavioural precursors). Illustrated in Figure 1.5: Reason’s Pathogen Model of Accident Causation, Reason’s model is based on the notion that all types of productive systems incorporate five basic elements. •High-level decision-making. • Line management co-ordination of operational activities. •Preconditions in the form of technology, manpower and resources. •Productive activities that require the synchronisation of people, materials and technology. •Defenses of some form or another to minimise the effects of potentially hazardous circumstances. Reason suggested that each particular element of the production model is associated with its own particular form of latent or active failure. Importantly, the principle pathogens emanate from the higher echelons and are spread throughout the system by the various strands of line management as they implement strategic decisions. These notions come across clearly through his description of the two ways in which system failures, or systemic pathogens, are introduced: types and tokens. `Types’ refer to general organisational and managerial failings, whereas `tokens’ are more specific failings relating to individuals. However, two different forms of types exist. • Source types which are associated with senior management’s strategic decisions. • Function types which are associated with line management’s implementation of senior management’s fallible strategic decisions. Analogous to Adam’s tactical errors, tokens also divide into condition tokens which comprise the situational (man-machine interface, workload, etc.) or psychological (attention, attitudes, motivation, etc.) precursors of unsafe acts; and unsafe act tokens that are further classified on the basis of whether they are caused by: • slips and lapses (skill-based errors) •mistakes (rule-based and/or knowledge-based errors) • volitions (deliberate infringements of safe working practices).     %%Accident Causation Models Compared to previous causation models, Reason’s 1993 pathogen model is fairly comprehensive, and makes an important contribution to safety management in so far as it identifies and distin- guishes between the types of error that might be made, and where they might be introduced into an organisational system. It also stresses the importance of identifying and rooting out possible  %&   Organisational Characteristics of a Good Safety Culture latent failures before they can be triggered by active failures. Like Adams before him, therefore, Reason shifts the main focus of accident prevention away from the operator’s unsafe acts and more onto the organisation’s overall management system, particularly in relation to the implementation of the organisation’s strategic decisions. ORGANISATIONAL CHARACTERISTICS OF A GOOD SAFETY CULTURE In parallel with the development of the accident causation models outlined above, researchers attempted to identify certain organisational characteristics thought to distinguish low accident companies from high accident companies. Conducted in the USA during the early 1960s to the end of the 1970s across a wide variety of industries, this research discovered the following consistent features: • Strong senior management commitment, leadership and involvement in safety •Closer contact and better communications between all organisational levels •Greater hazard control and better housekeeping •A mature, stable workforce •Good personnel selection, job placement and promotion procedures •Good induction and follow-up safety training • Ongoing safety schemes reinforcing the importance of safety, including `near miss’ reporting. More recent research conducted in the UK at the end of the 1980s by the CBI revealed similar features. However, by incorporating lessons learnt from implementing TQM initiatives they also highlighted other essential features that included: • Accepting that the promotion of a safety culture is a long term strategy which requires sustained effort and interest •Adopting a formal health and safety policy, supported by adequate codes of practice and safety standards • Stressing that health and safety is equal to other business objectives •Thoroughly investigating all accidents and near misses • Regularly auditing safety systems to provide information feedback with a view to developing ideas for continuous improvement. Importantly, all the above features were also identified in a report produced in the early 1990s by the Advisory Committee on the Safety of Nuclear Installations (ACSNI) Study Group on Human Factors, indicating broad agreement about the specific factors that positively impact on safety performance. Although most of the features identified allude to the presence of organisational systems and modes of organisational behaviour, the ACSNI group also highlighted the importance     %'Towards a Model of Safety Culture of various psychological attributes that exert their influence on safety per se. These include perceptions about and attitudes towards accident causation, risk and job-induced stress caused by conflicting role demands and poor working conditions. The prominence of these psychological factors was also highlighted in a study at British Nuclear Fuels Ltd (BNFL), which showed that only 20% of the root causes of accidents were attributable to inadequacies of equipment and plant, with the remaining 80% being caused by people-based factors such as poor managerial control, worker competencies and breaches of rules. Based on this accumulated body of evidence the ACSNI Study Group suggested that for practical purposes, safety culture could be defined as: `... the product of individual and group values, attitudes, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety programmes. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures.’ TOWARDS A MODEL OF SAFETY CULTURE To a greater or lesser degree, each of the accident causation models described above recognises the presence of an interactive or reciprocal relationship between psychological, situational and behavioural factors. Heinrich, for example, identified the interactive relationship between behaviour, situations and person factors at operator levels, while his 80:20% rule implicitly recognised that the strength of someone’s behaviour, or the situation (e.g. workflow process) may exert different effects at different moments in time. The interactive relationship between management systems and managerial behaviour was also recognised by Weaver when he stated that accidents were symptoms of operational error. However, Adams’ far-reaching insights recognised the mutually interactive nature of the relationship between all three factors, and the time-related causal relationship between high level strategic decisions and tactical operational errors. Similarly, Reason’s pathogen model recognises that person, situational and behavioural factors are the immediate precursors of unsafe acts; that the strength of each may differ; and that it may take time for one element to exert its effects on the other two elements (e.g. the temporal relationships between latent (managerial) and active (operational) failures). Importantly, the work carried out to identify the organisational characteristics of a positive safety culture also emphasised the interaction between organisational systems, modes of organisational behaviour and people’s psychological attributes. Clearly, therefore, this interactive relationship between psychological, situational and behavioural factors is applicable to the accident causation chain at all levels of an organisation. Consequently, it can be cogently argued that culture is actually: `The product of multiple goal-directed interactions between people (psychological), jobs (behavioural) and the organisation (situational)’.  %(   Towards a Model of Safety Culture Viewed from this perspective, an organisation’s prevailing safety culture is reflected in the dynamic inter-relationships between members’ perceptions about, and attitudes towards, organi- sational safety goals; members’ day-to-day goal-directed safety behaviour; and the presence and quality of organisational safety systems to support goal-directed behaviour. Consistent with the idea that culture can best be described as `the way we do things around here’, the potency of this interactive model for analysing `safety culture’ resides in the explicit recognition that the relative strength of each source may be different in any given situation: e.g. the design of a production system may exert stronger effects on someone’s work-related safety behaviour than that person’s safety attitudes. Similarly, the interactive influence of each source may not occur simultaneously: e.g. it may take time for a change in safety behaviour to exert an influence on and activate the relationship with the workflow system and/or work-related safety attitudes. Thinking of safety culture in these terms, therefore, provides an organising framework to assist in ongoing practical assessments and analyses. As such, given the appropriate measuring instruments, the relative influence of each component can be determined in any given situation, so allowing either highly focused remedial actions or forward planning to take place. Indeed, the merits of this interactive framework for analysing safety culture become apparent if we separate the ACSNI Study Group’s working definition of safety culture into its component parts. For example, `individual and group values and attitudes’ refers to members perceptions about and attitudes towards safety goals; `patterns of behaviour’ refers to members’ day-to-day goal-directed safety behaviour; and, the `style and proficiency of an organisation’s health and safety programmes’ indirectly refers to the presence and quality of organisational safety systems to support goal-directed safety behaviour. Moreover, the second section implicitly recognises the `reciprocal’ relationship between each of these elements, acknowledged in paragraph 80 of the ACSNI report which states `... the whole is more than the sum of the parts. The many separate practices interact to give a much larger effect’. It becomes clear that this working definition of safety culture alludes to the reciprocal relationship between an organisation’s safety management system(s) (SMS), the prevailing safety climate (perceptions and attitudes), and daily goal-directed safety behaviour (see Figure 1.6: Cooper’s Reciprocal Safety Culture Model). Since each of these safety culture components can be directly measured in their own right or in combination, it is possible to quantify safety culture in a meaningful way at many different organisational levels, which hitherto has been somewhat difficult. Accordingly, the organising framework also has the potential to provide organisations with a common frame of reference for the development of benchmarking partnerships with other business units or organisations. This latter point may be particularly important to industries where there is substantial use of specialist sub-contractors (e.g. construction and offshore), as people from different organisations will be able to communicate in the same language. Additionally, it provides a means by which the prevailing safety culture of different departments can be compared usefully. The practical utility of the interactive framework is further enhanced by the fact that the model can be applied to each individual component (see Figure 1.7: Cooper’s Reciprocal Safety Culture Model     %)Towards a Model of Safety Culture Applied to Each Element). For example, because we can measure people’s perceptions and attitudes about the prevailing safety climate via psychometric questionnaires, it is feasible that we could discover that a work group’s levels of perceived risk (i.e. person factors) is determined by their perceptions of the required workpace (i.e. job factors) and management’s commitment to safety (i.e. organisational factors). Similarly, we might discover that the implementation of motivational strategies to improve employees’ levels of safety behaviour is affected by the levels of commitment (i.e. person factors), competing goals (job factors) and quality of communications (i.e. organisa- tional factors). These relationships also apply to safety management systems where person factors (e.g. safety training) will interact with job factors (e.g. man-machine interfacing) and organisational factors (e.g. allocation of resources). In recent years, many of these relationships have been empirically examined in a wide variety of industries by the author and found to hold true, providing support to the notion that safety culture can be meaningfully analysed by using the model to focus on its constituent components: i.e. safety management systems (situational), safety climate (perceptual) and goal-directed safety behaviour (behavioural). Safety Management Systems Safety management systems are integrated organisational mechanisms designed to control health and safety risks, ongoing and future health and safety performance, and compliance to legislation. In principle, a good safety management system mirrors that for quality management systems, in that it should be a fully integrated and cohesive system centred around policies, strategies and procedures that provide internal consistency and harmonisation. The development of such a system should be seen as a practical way of creating the awareness, understanding, motivation and commitment of all personnel, while also optimising an organisation’s health and safety performance per se. In this way safety becomes everyone’s responsibility. Nevertheless, because safety management is dependent upon many organisational activities, this diffusion of responsi-  %   Towards a Model of Safety Culture     %+Towards a Model of Safety Culture bility requires every activity to be reviewed and integrated into a holistic process. Although this may pose considerable challenges that have resource implications, the evidence suggests that the benefits will tend to more than outweigh the costs. The main challenges are more than likely to be associated with changes to spans of control (i.e. management systems), communication systems (i.e. organisation structure), co-operation (e.g. management styles), and competencies (i.e. training). Each of these are central features of the MHSWR 1992 which place a statutory duty on organisations to actively manage safety, and as such are clearly related to the development of a safety culture. Management Control Systems Managing safety is in many respects exactly the same as managing productivity, quality or other functional areas of operations. Ironically, however, one of the primary causes of accidents is poor managerial control. Accordingly, it makes good sense for organisations to have clearly stated and measurable safety objectives, monitoring procedures and regular feedback so that deviations in safety performance can be instantly recognised and rapidly dealt with. Because these issues relate to both individuals and organisations, there is a need for the same types of supporting structural systems and sub system that are used for TQM. Commonly termed `management by objectives’ when applied to organisations, and `goal-setting’ when applied to individuals or workgroups, the process of setting a specific goal or objective is known to exert a strong influence on performance. In essence, goals work by focusing people’s attention and actions on the achievement of a desired end or target. For example, a corporate philosophy encapsulated within a `vision statement’ such as: `Safety is THE number one priority. We firmly believe it must take precedence over all other business activities’ specifies the direction and actions a company wishes to take. Goals therefore pose challenges that serve to mobilise people’s effort, boost their determination and motivate them to search for better and safer ways of doing things. However, people also require the means to monitor and measure their progress to ensure that the goals are being reached. In the same way that TQM systems might utilise statistical process control (SPC) or `just in time’ (JIT) inventory controls, the monitoring of safety performance can be conducted by a variety of methods at many different levels in an organi- sation. This may be carried out by some form of organisation-wide safety management system audit that compares actual safety management practices with those laid down in the organisation’s safety policies, rules and procedures. Similarly, highly visible features such as accident rates, compensation costs, or number of days since the last lost-time accident may be used as gross, ongoing safety performance indicators. Irrespective of the particular safety system features being monitored, the main purpose is to provide information feedback by which the organisation can compare existing practices with advocated procedures, and take any necessary remedial actions. Performance feedback is a particularly important component of the functioning of any system as it prevents decay and facilitates change. The supply of rapid and easily understood feedback is known to encourage error correction, problem-solving and organisational learning. It also serves to  %,   Towards a Model of Safety Culture positively affect people’s motivation by signalling the boundaries of what the organisation considers to be proper performance. Organisations, however, are not automatically self-correcting. Therefore, the process of attending to, interpreting and acting on performance feedback becomes especially critical when it relates to safety. There is no point, for example, in asking the workforce to report near misses (feedback) if the issues raised are not addressed immediately or within a reasonably short time span. All too often the credibility of near miss systems is fatally damaged either because of management failures to act or because the systems and sub systems become overloaded. Communication Systems and Organisational Structure Ensuring that information feedback is available to the right people at the right time means that an effective communications system needs to be in place. Inevitably, the system will be judged by how well it can cope with bi-directional horizontal and vertical flows of information that emanate either from within the organisation or from external sources such as suppliers or statutory bodies such as the HSE. In some instances, changes in the structure of an organisation may be necessary simply because safety management involves a greater flow of information outside the normal vertical lines of communication. In much the same way as cross-functional management is crucial to the success of TQM, safety management may require the formalisation of horizontal arrangements for organised communication between departments, or business units. Similar to the principle of internal markets, examples of horizontal activity might include each organisational sub-unit being both a customer and supplier of safety-related information. For example, as a customer, the maintenance department receives `products’ from purchasing (the supplier). These products are then regularly monitored in situ by maintenance personnel. Each time a problem or `failure’ arises with the product the maintenance department becomes the supplier, by routinely sending information back to the purchasing department (who has now become the customer). As this scenario illustrates, the more direct and shorter the communication link the more effective the system is likely to be, as delays and duplication of effort are avoided. One of the many types of organisational arrangement known to improve co-ordination and communication is a matrix design where the normal vertical hierarchy is overlaid with horizontal communication channels (see Figure 1.8: Example of an Organisational Matrix Design). A matrix-type design results in people communicating more on the basis of who has relevant information rather than who reports to whom. In turn, this leads to reduced information processing demands from a tighter coupling of the communication system. Other advantages reside in the design’s ability to be applied to the whole organisation and/or individual functional departments, and to reduce organisational or operational segmentalism while explicitly linking the whole structure with external factors and technological change. Importantly, this type of structure lends itself to the vertical and horizontal auditing of the system’s effectiveness in controlling risks advocated by the HSE. Moreover, because flexibility is the essence of a matrix design, it allows dynamic responses to unforeseen events by incorporating the conflicting requirements of both uniformity and diversity pressures. It therefore simultaneously overcomes problems associated with tight functional     %-

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