A Safety Culture: Understanding and Fixing Unsafe Acts

“The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.

Ideal culture

Reason considers an ideal safety culture "the ‘engine’ that drives the system towards the goal of sustaining the maximum resistance towards its operational hazards" regardless of current commercial concerns or leadership style. This requires a constant high level of respect for anything that might defeat safety systems and ‘not forgetting to be afraid’.

Complex systems become opaque to all employees and most management. Their designs ensure that no single failure will lead to an accident, or even to a revealed near-miss, and there are no timely reminders to be afraid.

Reason argues, that when there is an ‘absence of sufficient accidents to steer by’, that the desired state of ‘intelligent and respectful wariness’ will be lost unless sustained by the collection, analysis and dissemination of knowledge from incidents and revealed near misses.

It is very dangerous to think that an organization is safe because no information is saying otherwise, but it is also very easy. An organization that underestimates danger will be insufficiently concerned about poor working conditions, poor working practices, poor equipment reliability, and even identified deficiencies in the defenses-in-depth: the company is still safe ‘by massive margins’, so why rock the boat? Hence, without conscious efforts to prevent it, complex systems with major hazards are both particularly vulnerable to (and particularly prone to develop) a poor safety culture

Successful turnarounds don’t focus on fixing the blame

but rather on fixing the problems.

"Unsafe acts" are performed by the human operator. Unsafe acts can be either errors (in perception, decision making or skill-based performance) or violations (routine or exceptional).

Violations are the deliberate disregard for rules and procedures.

As the name implies, routine violations are those that occur habitually and are usually tolerated by the organization or authority.
Exceptional violations are unusual and often extreme. For example, driving 60 mph in a 55-mph zone speed limit is a routine violation, but driving 130 mph in the same zone is exceptional.

There are two types of preconditions for unsafe acts:

those that relate to the human operator's internal state and those that relate to the human employee's practices or ways of working.
Adverse internal states include those related to physiology (e.g., illness) and mental state (e.g., mentally fatigued, distracted).

A third aspect of 'internal state' is really a mismatch between the employee's ability and the task demands; for example, the employee may be unable to make visual judgments or react quickly enough to support the task at hand.

Poor operator practices are another type of precondition for unsafe acts, Usually the most most common. These include poor employee resource management, ...issues such as leadership and communication and poor personal readiness practices all fall under the supervision type...

Four types of unsafe supervision are: inadequate supervision; planned inappropriate operations; failure to correct a known problem; and supervisory violations.

Organizational influences include those related to resources management such as inadequate human or financial resources, organizational climate (structures, policies, and culture), and organizational processes such as procedures, schedules, oversight.

Successful turnarounds don’t focus on fixing the blame but rather on fixing the problems. Blaming culture is just that: blaming. And such blaming is often a blanketing of blame to shelter the true culprits. Cultures don’t pull down businesses or organizations. On the contrary, organizations pull down cultures. We don't plan to fail.....we fail to Plan.

A ‘good’ safety culture might reflect and be promoted by four factors

Senior management commitment to safety
Realistic and flexible customs and practices for handling both well-defined and ill-defined hazards
continuous organizational learning through practices such as feedback systems, monitoring, and analysis
Care and concern for hazards shared across the workforce

Only two of those factors fall within a management system, and leadership as well as management is necessary.

Human behaviors are influenced by multiple factors both internal to the individual and external (in the work or performance environment). Group behaviors have even more influences due to the interaction of individuals, processes and other factors.

Determining which behaviors are responsible for performance failures and then determining the root cause of such behaviors is a formidable – if not impossible – task. Also, changing one of several influences on behavior is not a guarantee you permanently will change future behavior. The majority of human behavior is autonomic or subconscious (habitual). Changing influences on conscious behavior does not automatically change subconscious behavior.

Your subconscious mind is always eavesdropping on your thoughts. In fact, it listens for verbal and nonverbal instructions. As it does no thinking of its own, it relies on your perceptions of events to know how to interpret and interact with life around you.

I’m convinced that so many change efforts – both personal and organizational, both conscious and subconscious - fall apart because those who want to catalyze the change don’t approach it as an evolutionary challenge: figuring out what needs to change, and how to make the new ways of operating easier, more rewarding and more normal than the old.