Sunday, April 18, 2010

Safety Culture: Cause or Context (part 1)

As we have mentioned before, we are perplexed that people are still spending time working on safety culture definitions. After all, it’s not because of some definitional issue that problems associated with safety culture arise at nuclear plants. Perhaps one contributing factor to the ongoing discussion is that people hold different views of what the essence of safety culture is, views that are influenced by individuals’ backgrounds, experiences and expectations. Consultants, lawyers, engineers, managers, workers and social scientists can and do have different perceptions of safety culture. Using a term from system dynamics, they have different “mental models.”

Examining these mental models is not an empty semantic exercise; one’s mental model of safety culture determines (a) the degree to which one believes it is measurable, manageable or independent, i.e. separate from other organizational features, (b) whether safety culture is causally related to actions or simply a context for actions, and (c) most importantly, what specific strategies for improving safety performance might work.

To help identify different mental models, we will refer to a 2009 academic article by Susan Silbey,* a sociology professor at MIT. Her article does a good job of reviewing the voluminous safety culture literature and assigning authors and concepts into three main categories: Culture as (a) Causal Attitude, (b) Engineered Organization, and (c) Emergent and Indeterminate. To fit into our blog format, we will greatly summarize her paper, focusing on points that illustrate our notion of different mental models, and publish this analysis in two parts.

Safety Culture as Causal Attitude

In this model, safety culture is a general concept that refers to an organization’s collective values, beliefs, assumptions, and norms, often assessed using survey instruments. Explanations of accidents and incidents that focus on or blame an organization’s safety culture are really saying that the then-existing safety culture somehow caused the negative events to occur or can be linked to the events by some causal chain. (For an example of this approach, refer to the Baker Report on the 2005 BP Texas City refinery accident.)

Adopting this mental model, it follows logically that the corrective action should be to fix the safety culture. We’ve all seen, or been a part of, this – a new management team, more training, different procedures, meetings, closer supervision – all intended to fix something that cannot be seen but is explicitly or implicitly believed to be changeable and to some extent measurable.

This approach can and does work in the short run. Problems can arise in the longer-term as non-safety performance goals demand attention; apparent success in the safety area breeds complacency; or repetitive, monotonous reinforcement becomes less effective, leading to safety culture decay. See our post of March 22, 2010 for a discussion of the decay phenomenon.

Perhaps because this model reinforces the notion that safety culture is an independent organizational characteristic, the model encourages involved parties (plant owners, regulators, the public) to view safety culture with a relatively narrow field of view. Periodic surveys and regulatory observations conclude a plant’s safety culture is satisfactory and everyone who counts accepts that conclusion. But then an event occurs like the recent situation at Vermont Yankee and suddenly people (or at least we) are asking: How can eleven employees at a plant with a good safety culture (as indicated by survey) produce or endorse a report that can mislead reviewers on a topic that can affect public health and safety?

Safety Culture as Engineered Organization

The model is evidenced in the work of the High Reliability Organization (HRO) writers. Their general concept of safety culture appears similar to the Causal Attitude camp but HRO differs in “its explicit articulation of the organizational configuration and practices that should make organizations more reliably safe.” (Silbey, p. 353) It focuses on an organization’s learning culture where “organizational learning takes place through trial and error, supplemented by anticipatory simulations.” Believers are basically optimistic that effective organizational prescriptions for achieving safety goals can be identified, specified and implemented.

This model appears to work best in a command and control organization, i.e., the military. Why? Primarily because a specific military service is characterized by a homogeneous organizational culture, i.e., norms are shared both hierarchically (up and down) and across the service. Frequent personnel transfers at all organizational levels remove people from one situation and reinsert them into another, similar situation. Many of the physical settings are similar – one ship of a certain type and class looks pretty much like another; military bases have a common set of facilities.

In contrast, commercial nuclear plants represent a somewhat different population. Many staff members work more or less permanently at a specific plant and the industry could not have come up with more unique physical plant configurations if it had tried. Perhaps it is not surprising that HRO research, including reviews of nuclear plants, has shown strong cultural homogeneity within individual organizations but lack of a shared culture across organizations.

At its best, the model can instill “processes of collective mindfulness” or “interpretive work directed at weak signals.” At its worst, if everyone sees things alike, an organization can “[drift] toward[s] inertia without consideration that things could be different.” (Weick 1999, quoted in Silbey, p.354) Because HRO is highly dependent on cultural homogeneity, it may be less conscious of growing problems if the organization starts to slowly go off the rails, a la the space shuttle Challenger.

We have seen efforts to implement this model at individual nuclear plants, usually by trying to get everything done “the Navy way.” We have even promoted this view when we talked back in the late 1990s about the benefits of industry consolidation and the best practices that were being implemented by Advanced Nuclear Enterprises (a term Bob coined in 1996). Today, we can see that this model provides a temporary, partial answer but can face challenges in the longer run if it does not constantly adjust to the dynamic nature of safety culture.

Stay tuned for Safety Culture: Cause or Context (part 2).

* Susan S. Silbey, "Taming Prometheus: Talk of Safety and Culture," Annual Review of Sociology, Volume 35, September 2009, pp. 341-369.

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