Safety culture: transferring theory and evidence ... - Industrial Centre

Behavioural Research in Road Safety: 10th Seminarincreasingly important in bridging European and North American approaches to riskmanagement, to high reliability organisations, and to the investigation and prevention oflarge-scale accidents. The increasing globalisation of many systems of production andfinance, and dependence upon organisational systems as we approach the millennium andbeyond, means that these factors are of increasingly wider relevance.In traditional ‘high hazard’ industries such as nuclear, petrochemicals and aviation it isbelieved that organisational culture presents us with the next critical frontier in accidentprevention efforts as, increasingly, many of the more obvious technical and human factorsroutes for safety improvement are exhausted. Furthermore, attempts to measure andimprove safety culture are moving beyond these industries into more mundaneorganisational contexts where routine accidents occur (HSE, 1997). In the roadtransportation context one can pose the question of whether some part of the variance infleet driver behaviour, and consequent accidents, might be understood in relation to thenew theory and empirical research being generated by safety culture research?Moving from an initial concern with the modelling of organisational preconditions tofailure or hazard contemporary researchers and practitioners are now concerned to specifyhow knowledge of such factors might be used to enhance safety. Chernobyl again marks acritical juncture. Considerable evidence was available prior to 1986 of the very severeproblems of control posed by administrative failures of foresight in complex socio-technicalsystems (Turner 1976, 1978). And while the earlier Three Mile Island accident in the USAhad been interpreted, by Perrow (1984) at least, as evidence for the inevitability of seriousaccidents in certain forms of complex system (of which nuclear power plants were hisparadigm example), the organisational errors and violations of operating procedures whichcontributed in part to the Chernobyl disaster were interpreted by commentators to beevidence of a ‘poor safety culture’, both at this plant and within the former Soviet Unionnuclear industry more generally (OECD Nuclear Agency 1987).Of course, in the late 1980s this hypothesis stemmed much more from a rhetorical attemptto reassure Western publics that Chernobyl couldn’t happen here, than from any direct orsystematic social science analysis of the deep and complex issues involved in this question.Hence, our own research group’s review of the immediate post-Chernobyl discussions ofsafety culture critiqued its reduction to a combination of administrative procedures andindividual attitudes to safety (Turner et al 1989), which seemed to us to be at the expense ofthe wider organisational issues. What was crucially missing, both then and in manycontemporary treatments, was the shared characteristic of all social organisation andculture.Implicit in the original claims is the assumption that if the Chernobyl accident – or theKing’s Cross Underground fire in London, or the Exxon Valdez accident in Alaska – couldindeed be put down to a ‘poor’ safety culture, then there might surely be something, forwant of a better word, called a ‘good’ safety culture, which safety managers might thenpromote, design, or encourage in order to head off some of the worst consequences oforganisational-system failure? In the 1990s, therefore, interest in the topic of safety culturehas burgeoned as engineers, risk managers and nuclear safety practitioners, and evenindustrialists, have attempted to operationalize the concept and to judge its significance. Inparallel, both risk management consultants, and to a lesser extent the applied social scienceresearch communities, have responded with a variety of conceptual frameworks (of varyingdegrees of theoretical grounding) and a rapidly expanding empirical research literature,particularly in Europe (see Cox and Flin, 1998).50

Safety culture: transferring theory and evidence from the major hazards industriesorganisations. It also provides the conceptual foundation for an anthropological definitionof a safety culture as the set of assumptions, and their associated practices, which permitbeliefs about danger and safety to be constructed.Turner’s data also indicate that, despite the existence of warnings and potential signals of adeteriorating situation, a number of common information handling difficulties (such aswrong assumptions about the significance of warnings, communication problems,uncertainty about violations of regulations, and the tendency for over optimism) mean thatorganisations can effectively go into ‘cultural denial’ during the hazard incubation period.In particular intelligence gathering and interpretation is often bounded by administrativelydefined perceptual rigidities and frames of reference regarding what is a legitimate hazard toattend to. Anomalous events, warning signals and other issues that fall outside such framesare then very readily neglected or overlooked. Nor is the solution to the problems ofinformation handling simply to be found in more communication, since it is equallyimportant to avoid being overwhelmed by a barrage of noise in ill-structured risk situations.Hence the model points to the need for selective gathering and attention to high qualityinformation as a response to deep forms of uncertainty. Accordingly, we have argued that atthe heart of a safety culture is the way in which organisational intelligence and safetyimagination regarding risk and danger are deployed (see Pidgeon and O’Leary 2000).Safety cultureAs outlined above, the man-made disasters model defines disaster incubation in terms of adiscrepancy between some deteriorating but ill-structured state of affairs and the culturally‘taken for granted’ – more specifically the norms, assumptions and beliefs adopted by anorganisation or industry for dealing with danger. One implication of this analysis is thatculture is positioned at the heart of the system vulnerability problem, because of its role inshaping blindness to certain forms of hazard (ie those which are at variance with the takenfor granted). As Vaughan puts it with respect to the Challenger disaster, NASA’s cultureprovided ‘a way of seeing that was simultaneously a way of not seeing’ (1996, p394).The recurrent pattern of organisational and human failures coupled with mis-interpretationor concealment of ‘warnings’ also implies, in theory at least, that significant systemcharacteristics might be identified which are holistic – rather than strictly determining –indicators of the developing incubation period. It is therefore not surprising to find workdrawing upon this tradition moving on from purely retrospective analyses of failure cases topose the question of the predictiveness of the model, and in particular the conditions for‘safe’ organisation.The very public discussion of culture following Chernobyl did raise in our own minds thequestion of what a well-grounded sociological treatment of this issue would tell us? In thesociological and anthropological literature there are of course very many views on what isshared by, and defines the culture of, a social group. Sometimes culture is discussed in termsof observable behaviours (‘the way we do things around here’) and sometimes more as asystem of symbols or meanings (for example, as a shared cognitive model, or as the assemblageof stories, arguments, myths, rituals and symbols that permeate organisational life). Notethat the two approaches are to some extent interdependent, in that meaning often both53

Behavioural Research in Road Safety: 10th Seminarconstructs the ‘object’ of inquiry and is in turn constructed itself through observablebehaviour and material life.Our own approach to the issue, and that implicit in the man-made disasters model, viewsculture primarily in terms of the second tradition; that is, involving the exploration ofmeaning and the symbols and systems of meaning through which a given group understandthe world. A safety culture is in turn the set of assumptions, and their associated practices,which permit beliefs about danger and safety to be constructed (see, amongst others, Turneret al, 1989; Pidgeon, 1991; Turner, 1991). Such a culture is itself created and recreated asmembers repeatedly behave and communicate in ways which seem to them to be ‘natural’,obvious and unquestionable, and as such will serve to construct a particular version of risk,danger and safety.We have also argued, in more speculative fashion, that a ‘good’ safety culture might bothreflect and be promoted by at least four facets: senior management commitment to safety;shared care and concern for hazards and a solicitude over their impacts upon people; realisticand flexible norms and rules about hazards; and continual reflection upon practice throughmonitoring, analysis and feedback systems.In exploring safety cultures as a route to organisational resilience we must go beyondindividual attitudes to safety to the level of shared cognitions, and the organisationalstructures and resources which support (rather than constrict) the development oforganisational intelligence and safety imagination (Pidgeon and O’Leary, 2000) regardingrisk and danger.It is important to note finally, that to speak of an organisational safety culture as anhomogeneous entity glosses some significant complexities. First, the dynamic andpotentially unstable nature of culture. Second, some authors (eg Schein, 1985) haveembraced layered models of organisational culture – differentiating between core andperipheral aspects. Leading on from this, it is not as yet clear how the beliefs and norms of asafety culture stand in relation to an organisation’s wider culture and values, let alone tothose of wider society: such things as beliefs about security, achievement, benevolence andjustice.Some emerging findingsA growing and recent approach to organisational safety culture frames it in terms of a set ofindividual attitudes and practices within a hazardous work context, and in this way mapsclosely onto the earlier notion of an occupational ‘climate of safety’ (Zohar, 1980).Designers of quantitative psychometric climate scales aim to provide information on factorsinfluencing perceptions and beliefs within an organisation. One can then, in theory atleast, identify the factors which discriminate high from low accident plants, organisationsor workgroups. Whether the underlying ‘culture’ and ‘climate’ (as measured through suchquestionnaires) are one and the same is a point of some current debate (see Mearns et al,1998). Also, as Cox and Flin (1998) correctly point out, there is currently not enoughconsistent (or published) data to be able to test the reliability of existing definitions ormeasures. Nor, as we note above, is there sufficient theoretical debate around the various54

Safety culture: transferring theory and evidence from the major hazards industriesmeasures used. However, the emerging findings from those psychometric studies that arepublished, if taken with evidence and arguments from organisational accident and highreliability studies, do point to some of the issues that now appear to be most critical to safeperformance. The paper briefly discusses a number of these in turn.Management commitment to safetyA number of authors have argued that top management commitment is an essentialingredient of a safety culture (Cohen, 1977; Zohar, 1980; Pidgeon, 1991). This is particularlyimportant because attempts to promote enduring organisational change are unlikely tosucceed if senior management are not seen to be closely involved and committed toinitiatives. Employees will quickly sense where management’s true priorities lie (egoptimising production), and may conform to these tacit norms even when they conflictwith explicit policy statements (always running a safe fleet). According to Zohar (1980)one indirect sign to employees of management commitment will be the perceived statuswithin the organisation of the personnel directly dealing with safety. Confirming Zohar’sinitial work in this area, subsequent psychometric studies by Guest et al (1994), Flin et al(1996), and Cheyne et al (1998) all point to the issue of perceived managementcommitment – which is also bound up with the relationship of trust (or otherwise) betweenworkers and management – as critical to shaping attitudes towards safety and riskperceptions.Attitudes towards violations of rules andproceduresAccidents that result from violations of rules and procedures, and the tension between theneeds of safety and production, have been the focus of theoretical and empirical study bythe Manchester/Leiden research group (Free, 1994; Reason et al, 1994; Hudson et al, 1997).In safety climate studies both Cheyne et al (1998) and Mearns et al (1998) report attitudestowards violations (questionnaire items such as ‘accidents are tolerated as a part of the job’or ‘need to take shortcuts’) as one of the important determinants of overall safety attitudes.Vaughan’s excellent (1996) ‘historical ethnography’ of the events at NASA and itscontractor organisations prior to the Challenger disaster points to some of the reasons why‘violation’ can be come the rule rather than the exception. The technical reason for thisdisaster is now well known; the failure of viton O-ring seals in the solid rocket boostersshortly after the launch, leading to the structural break-up and catastrophic loss of thesystem and its crew. Vaughan points out that the shuttle and its operation were at thecutting edge of high performance aerospace systems, where it is often impractical to build inwide safety margins, or to adopt the course of conservatism in engineering design.Furthermore, decisions were constantly required under circumstances of imperfectknowledge. Under such prototyping conditions acceptable design limits and operationscannot be fully proceduralised in advance, and while there were rules designed to highlightareas of ongoing safety concern (of which the O-rings were one) there was also an elaboratesystem of other standard procedures at NASA that permitted ‘violations’ when necessary.Accordingly, the conventional hindsight interpretation of a rule violation as a wilfultransgression of set administrative procedures or design criteria is not useful. Under suchcircumstances what is to be regarded as a risk – and in particular what is judged anacceptable risk – becomes a question of social negotiation (see also Short and Clark 1993).55

Behavioural Research in Road Safety: 10th SeminarIn the case of the Shuttle the warnings of danger, which were recognised and taken veryseriously by many of those involved, were rarely equivocal: some were weak in theirimplications; others gave mixed messages about safety; and still others were embedded inconsiderable noise. Vaughan’s account shows how the significance of the available warningsfor flight safety, and the norms though which the risk was judged, were accordinglycontinually negotiated and re-negotiated through the working practices of the teams ofengineers. This worked well in resolving many of the safety problems with the Shuttle, butfor the O-ring seals a cycle of decision making was set in motion where signals of the‘deviant’ behaviour of the system were successively ‘normalised’ as acceptable through thestandard process of risk assessment institutionalised in the working practices of theorganisations. This process Vaughan terms the ‘normalisation of deviance’ and it wasrepeated throughout the history of the joint problems. By deconstructing the notions of‘safety norm’ and ‘violation’, it suggests also that attempts to investigate the micro-world oforganisational risk perception and decision making might take account of the dynamic waysin which risk is constructed by workgroups.Organisational sub-culturesSafety culture is often discussed as if it is a unified property that characterises anorganisation throughout. However, any large organisation, or set of co-operatingorganisations, will comprise different social sub-groupings (drivers and maintenance,production and managers, permanent staff and sub-contractors, site A compared to site B).For example, in aviation such sub-groupings are often associated with very differentattitudes towards safety (O’Leary and Pidgeon, 1994). Evidence for the existence of safetysub-cultures comes from studies in the workplace by Sinclair and Haines (1993), Gherardi,Nicolini and Odella (1996) and by Mearns et al (1998). The latter authors, in a large surveyof safety climate in offshore oil installations, note significant differences in attitudestowards safety between staff at different levels of the organisations studied (eg managers vsworkers), while far less differences between operators who were contractors compared tothose who were permanent staff. This latter finding might be explained by professional subculturesshared across the industry (ie attached to specific roles or levels of training, andirrespective of the organisation you actually work for) or the influence of the safety subcultureson a particular platform in moulding the attitudes of everybody working there.They speculate that the absence of a unitary organisational culture may not necessarily be abad thing as ‘it may always require some dissenting voices in the crowd to continuallyimprove the state of safety’. In theoretical terms different sub-cultures might indeed be auseful counter to the dangers of corporate myopia (Pidgeon, 1998).Organisational learningThere are very few contemporary treatments of safety culture that do not accordconsiderable importance to the goal of learning from incidents, accidents and other relevantexperience through such things as monitoring, incident analysis and feedback systems, asone part of an integrated safety management system (eg ACSNI 1993; Toft and Reynolds,1997). Curiously, the related questions of organisational politics and power are absent inmost theoretical models of organisational failures and many discussions of safety culturestoo. We would argue that organisational politics and power are crucial for determiningwhether a number of the goals of a safety culture will be met, and in particular that oforganisational learning (see Pidgeon, 1997).56

Safety culture: transferring theory and evidence from the major hazards industriesWhat seems to lie and at the heart of this issue is the institutional dilemma of blame.Danger and blame have been ubiquitous features of societies over the years, as one means ofdefending favoured institutional arrangements, and for this reason they underpin manycontemporary discussions of risk and safety too. Blame does of course bring positive, as wellas negative, possibilities for safety. In so doing it presents a dilemma of design.Responsibility without accountability for the worst excesses of accidents and disasters mayfail to motivate representatives of organisations to act in good faith. On the other hand,seeking a ‘culprit’ whenever an error has occurred may promote the avoidance of blamerather than critique and honesty. Hence, efforts to motivate people to act safely throughsanction may be self-defeating, resulting in the very state of poor or incomplete informationwhich is a pre-condition to system vulnerability.If politics and blame do corrupt the possibilities for organisational learning then surely themost important challenge resides here: in the ways by which such processes might becounteracted. More pointedly, we can ask what political, cultural, symbolic andinstitutional arrangement support the generation of organisational intelligence overcorporate myopia? As La Porte and Rochlin (1994) point out, the question then becomesnot, did the organisation learn everything it could from a specific incident or accident (forvery few will), but does an organisation recognise a need to handle safety intelligence betterin the future?The obstacles which blame and organisational politics place in the way of learning cannotbe expected to yield to simple solutions. In some high-risk contexts solutions evolved overtime, as with civilian aviation incident reporting and monitoring (see Pidgeon and O’Leary,2000). Such monitoring (of, for example, air near-misses) is held by many to make a positivecontribution to collective learning in the industry, and through this to safety (see Chappell,1994). The question of how a reporting or monitoring system can be successfully embeddedwithin the local social and political contexts (sometimes both organisational and national)where it will be expected to operate is invariably not posed, and inattention to such issues isa major factor when such systems do not work as intended, or do not work at all.Concluding comments: culture andfleet driver behaviourThe study of safety cultures and climates presents a relatively new and expanding area ofresearch activity. Although safety culture has not yet been extensively studied in thecontext of driver behaviour, possible avenues for future research are suggested in relation tofleet safety and the transferability of methods and findings from the high hazard context.For example, we might ask whether a significant proportion of the variance in fleet safety isindeed attached to the organisational unit of analysis (as experience in other industriessuggests this will prove to be so)? It would be easy to claim that tools, results and findingsmight be readily transferred to the domain of road fleet safety. Experience suggests thatwhile many of the broad principles will find applicability in this new domain, contextualdifferences will inevitably require research instruments that are closely attuned to the fleetsafety domain. Matters are not helped here because, as Flin (1998) rightly points out, thereare a variety of customised safety culture measures now on offer, grounded in different57

Behavioural Research in Road Safety: 10th Seminarindustrial contexts, and with few attempts to reconcile underlying frameworks or toconduct meta-analyses across (often) confidential data bases. Accordingly, a combinationof qualitative and quantitative research might be needed first to identify the importantcontext-specific issues in relation to fleet driver safety.However, some lessons are suggested by our review of existing research on safety culture.Inevitably these issues interact with one another, but a first concerns the unit of analysisadopted. Driver behaviour research and intervention tends, for obvious reasons, to focuseither upon the individual driver or engineered solutions that change the driver’senvironment. In considering fleet safety the organisation should be considered as much apart of the ‘environment’ as is the physical layout of roads. Accordingly, attention shouldfocus not only upon the individual driver, but also the attitudes of company managementand line supervisors (who will influence driver behaviour through their own commitmentto safety). An hypothesis here would be that changes in fleet safety attitudes are alreadyunderway in companies and industries where safety has become a key business priority, orwill be easy to instigate in such companies. Likewise, the issue of occupational sub-cultureshighlights the potential for training to cover some of the softer issues, such as attitudestowards violations and the balance to be struck between performance and safety. Finally,mechanisms for organisational learning, such as confidential incident reporting systems,have begun to be taken up in a variety of industries. While such systems are unlikely to beappropriate to every fleet driver context, and are certainly very difficult to instigate(Pidgeon, 1997), with larger organisations they might bring considerable benefits as well ashelping to underline the wider commitment to safety both across industries and withinorganisations that is a part of an effective safety culture.ReferencesACSNI (1993) Advisory Committee on the Safety of Nuclear Installations: Study Group onHuman Factors. Organizing for Safety. Health and Safety Commission, London.Chappell, S.L. (1994) Using voluntary incident reports for human factors evaluations. InN.A Johnston, N. McDonald and R. Fuller (eds.), Aviation Psychology in Practice. AveburyTechnical Press, Aldershot.Cheyne, A., Cox, S., Oliver, A. and Tomas, J.M. (1998) Modelling safety climate in theprediction of levels of safety activity. Work and Stress, 12, 255-271.Cohen, A. (1977) Factors in successful occupational safety programs. Journal of SafetyResearch, 9(4), 168-178.Cox, S. and Flin, R. (1998) Safety culture: philosopher’s stone or man of straw? Work andStress, 12, 189-201.Flin, R. (1998) Safety condition monitoring: lessons from man-made disasters, Journal ofContingencies and Crisis Management, 6(2), 88-92.Flin, R., Mearns, K., Fleming, M. and Gordon, R. (1996) Risk perception and safety inoffshore workers. Safety Science, 22, 131-145.Free, R. (1994) The Role of Procedural Violations in Railway Accidents. PhD Thesis,University of Manchester.58

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