People come together and join
forces for a purpose. To carry this purpose out effectively and
efficiently, they create organizations. The sum total of those individuals'
shared beliefs, norms, attitudes, and behaviors is then reflected
in the organizational values, vision, goals, systems, functions,
policies, and practices. That can then be loosely said to be that
organization's culture.
The organization's culture develops over time. By its very
nature, culture ensures that its members continue conforming to
the governing norms, indoctrinating new members. To make any
substantial change to the organizational systems, one has to
change the culture. Changing the culture is difficult, and it
takes concerted effort to do so. To some degree, the
organization's culture is influenced by both internal
(leadership, people, and their interaction) and external
(business, national, legal, global, etc.) factors. All cultures
have subcultures.
Safety Management and Culture
The "safety culture" is a subculture of the organizational
culture and therefore constrained and influenced by it. The
safety culture may be defined as the truths, ideas, and beliefs
that all members of the organization share about risk,
accidents, injuries, and occupational health. An effective
safety culture can be described as the corporate atmosphere in
which safety and health is understood to be and accepted as an
important core value. The safety culture does not operate in a
vacuum. Business initiatives (restructuring, downsizing,
acquisitions, etc.), organizational changes, and management's
actions all affect the safety culture, and it in turn, over
time, affects the people and ultimately the organization.
Safety management is a much discussed and sometimes a
misunderstood topic. Over the years, many different theories on
improvement interventions have been tried and many of these have
had less than stellar results. Some would have you believe
safety should be management driven, while others propose an
employee-driven approach. Some will advocate behavioral safety
solutions, while others will look to internal systems as the
drivers of loss. All of these approaches have been around for
15, 20, and even more years—so why haven't we hit on the "mother
lode" of safety intervention with which to ensure superior
outcomes as yet?
Written and Unwritten Rules of Engagement
If you think about it, in every realm of our lives, there are
rules of engagement. These rules apply at work, in our social
life, and in our family life. In addition, if we further think
about it, these rules come in two varieties. They are in either
written or unwritten form. The written rules are there to tell
us how we are supposed to behave. In the work environment, these
are the policies, procedures, organizational and operational
systems, and rules of engagement.
The unwritten rules reflect the way we actually do behave.
The unwritten rules come about as a result of the individual's
understanding or interpretation of the written rules, their
perception of what they think is expected of them, or their
reaction to management's actions, prognostications,
expectations, and agendas. It also is an individual's way of
interpreting what he/she needs to do to be efficacious, given
the realities of the work environment. The unwritten rules help
employees cope and thrive within complex organizational
situations.
Unwritten rules tend to have side effects, some of which are
undesirable and result in low productivity, poor work quality,
inefficiencies, disruptions, and mistakes and may even cause
accidents, losses, or injuries. Think of this as it relates to
safety. The written rules represent safety programs, training,
etc., which are supposed to be there to keep workers safe. It's
the organization's "official" position of how its employees are
supposed to behave. The unsafe behaviors may be reflective of
the employees' perception of what is expected of them in terms
of performance, which may cause them to consciously decide to
take risks to succeed, which are contrary to the written rules,
with potentially unacceptable outcomes.
The unwritten rules also spring from misaligned
organizational systems—conflicting objectives that may be
compounded by the organizational climate. Much of these result
from pressures to achieve some goal set by management to be
carried out by supervisors. They in turn have to get the
workforce to accomplish this. In some organizations, the climate
may be such that supervisors do not feel "safe" to voice their
concerns associated with the difficulty of achieving the goals
given limitations in resources and are "forced" to achieve them
notwithstanding. In those cases, relaxing the performance rules
(cutting corners) may permit the workers to accomplish the goal,
but it increases risk. In many such cases, the goals are
achieved with little or no adverse side effects. This is known
as "normalization of deviance" (see my article of August 2014, "Normalization
of Performance Deviations").
Normalization of Deviance
Normalization of deviance is a phenomenon by which individuals,
groups, or organizations come to accept a lower standard of
performance until that lower standard becomes the "norm" for
them. This phenomenon usually occurs when individuals, groups,
or organizations are under pressure to meet schedule
requirements, conform to budgetary considerations, or deliver on
a promise, while adhering to expected standards or prescribed
procedures. Faced with a situation in which relaxing the
standards or procedures gets the "job done," they decide to
utilize lower standards or less robust procedures with the
expectation that, when things get back to "normal," they will go
back to utilizing the higher standards or procedures. This
generally does not happen.
The undesirable side effects result from the interaction of the
written rules, management's actions and behaviors, and the
employee's reaction to and/or perception of them. In
understanding this fundamental process, one is able to identify
the organizational drivers of undesirable outcomes (in safety):
namely, accidents, injuries, and losses. This understanding
accentuates the ineffectiveness of one of the key traditional
interventions such as safety training as an approach to combat
employees' unsafe acts. More importantly, this allows for the
modification of internal systems and procedures or their
alignment to one another so as to affect structural changes that
permanently eliminate the core drivers of loss and potentially
enhance the company's culture, climate, and, more importantly,
its bottom line.
Failed Solutions
Although well intentioned, there are simplistic views held by
some who try to improve safety performance by focusing on the
individual employee and the immediate physical work environment.
There is a whole industry that advocates safety standards,
programs, training, inspections, incentives, and punishment with
which to accomplish outstanding safety results. When the
interventions do not prove highly effective, these organizations
try to focus on one underperforming area. This does have some
immediate and short-term effect (Hawthorne effect), but in the
end, all of these interventions are doomed to produce inferior
results. This is an unfortunate result of the fundamental lack
of understanding, leading to wasteful utilization of resources.
Another misguided approach is to try to find an organization
that has a successful safety program and try to copy it. This,
too, is doomed to fail because that program was successful in
that particular organization with its unique culture,
leadership, systems, and people. To devise an effective safety
process that garners superior results, one has to identify the
salient components of that organization's particular culture to
make modifications or introduce changes to the existing
organizational as well as operational systems.
The United Example
Following is a good example of this. Several years ago,
United Airlines decided that it could do the same things
Southwest was doing, even better, thereby potentially taking a
big piece of Southwest's business away from it. United formed a
new subsidiary, United Shuttle. The team that designed the new
subsidiary essentially duplicated everything Southwest did. To
differentiate from Southwest, United Shuttle offered customers
seat assignment, which at the time Southwest did not, the
rationale being that people would not have to come to the
airport 1–2 hours early to secure early boarding and get a good
seat.
The launch of United Shuttle caused Southwest some concern. This
was illustrated by Herb Keller, then president of Southwest,
saying, "United has aimed a bullet at our heart and is trying to
put us out of business." Now, several years later, Southwest is
still going strong and profitable while United is struggling
with various aspects of the business. Although United was able
to copy much of Southwest's strategy and practices, it could not
copy the Southwest culture!
Taking a Holistic Approach
To achieve highly effective safety performance, one must
addresses the issue holistically. To do this, one needs to
identify the core drivers of risk, accidents, and occupational
injuries. The key players, who may inadvertently impact safety
outcomes, are senior, middle, and line management and, to a
lesser extent, the individual employees. Senior management makes
high-level strategic decisions, which middle management then
implement at a tactical level. This in turn flows to the line
supervisors, who carry out the plan at the operational level.
They accomplish this with their employees, the physical plant,
resources, and the overall operational plan.
So, where do the latent drivers of failures introduce themselves
into this system? They can occur in the thinking at each level
of management, as well as the communication between these
levels. Senior management may implement a strategic plan that is
not fully aligned with all aspects of the business and therefore
may impose latent stressors into the system. Middle managers may
devise plans and procedures that are not totally integrated into
the overall system, which creates its own stressors. Line
management employs the available workforce, plant, and equipment
to execute the somewhat deficient plan, adding even more
stressors to the system. All these stressors increase the
potential for adverse outcomes.
Another point to note is that some of the discrepancies may
result from poor communications or misunderstood expectations
across all levels. Hiring inexperienced workers, assigning
workers to tasks beyond their capabilities, and devising tasks
that are error-provocative all increase the potential for
failure. The individual employees then try to carry out their
tasks, burdened with a less than optimum situation. This then
impacts the decisions employees make daily and eventually may
result in discrepancies, leading to accidents, injuries, and/or
losses.
Therefore, to establish an effective safety culture, we must not
only address the psychological, behavioral, and situational
factors but also must devise a mechanism with which to drive it.
One way to accomplish this may be with metrics that not only
drive the "right" organizational behaviors but also provide
management with just-in-time information with which to
effectively manage the process. These metrics not only allow for
improvement but also help sustain it over the long haul. This is
especially important in the safety arena. The present-day safety
metrics (frequency and severity rates) do not tie into
organizational strategy, do not "speak" senior management's
language, are not aligned with business goals and objectives,
and do not provide operational information with which to quickly
and effectively intervene.
On the issue of the need for real-time information with which to
manage effectively, typically safety improvement strategies
start from an analysis of accidents and losses (historical data)
or from an undesirable event (accidents). This has proven to
garner limited success over time. What is needed in safety is a
proactive method with which to deal with the risk of injury
before it enters into the operational processes and to quickly
find those that have inadvertently materialized and neutralize
them. This may be accomplished with metrics that provide
real-time data with which to effectively impact results. We need
to look to some business methods (balanced scorecards) devised
and utilized in the last 2–3 decades that provide a
multi-perspective approach to dealing with performance.
Conclusion
In the past couple of decades, business has gone from strictly
financial measures to a plethora of different perspectives with
which to measure success, implement strategy, and innovate.
Business today uses input, output, process, progress, and
outcome measures, to name a few, with which to deploy strategies
and measure success. This same approach can and must be applied
to safety if we are to stand a chance of making a difference in
this area. So, a new scorecard must be devised for safety. This
scorecard technique should provide linkage between
organizational strategy and safety goals and objectives.
Another important point is that organizations exist in an
ever-changing environment. Successful organizations are able to
identify or, better yet, predict future changes and factor their
impact into their overall operations. Therefore, to stay
competitive, organizations must anticipate and respond to
multiple external and some internal drivers. The organization
must be a "learning" one if it expects to continue being
successful going forward. This too applies to safety. The safety
process needs to be integrated into the business and operational
processes as well as aligned with organizational goals to
contribute positively to the bottom line.
Rather than viewing the safety culture as shared values,
beliefs, and perceptions, it can be argued that the
organization's safety culture is a product of many goal-directed
interactions between people (psychological), jobs (behavioral),
and organization (situational) and the dynamic relationship
among these, as well as external factors that shape it.