This post follows on the issue of whether safety culture is a concept unto itself or a state that is defined by many constituent actions. Some of our own thinking about safety culture in developing the nuclearsafetysim website and tools led us to prefer a focus on safety management as opposed to safety culture. Safety management includes the key “levers” of organizational performance (e.g., resource allocation, problem idenfication and resolution, building of trust, etc.) and the integrated effect of the manipulation of these levers results in a safety culture “value” in the simulation. Thus all the dynamics flow from actions and decisions to a safety culture resultant, not the reverse.
Dare I put forth a sports analogy? In baseball there is a defined “strike zone”. In theory the umpire uses the strike zone to make calls of balls and strikes. But the zone is really open to interpretation in the dynamic, three dimensional world of pitching and umpiring. The reality is that the strike zone becomes the space delineated by the aggregate set of balls and strike calls by an umpire. It relies on the skill of the umpire, his understanding of the strike zone and his commitment to making accurate calls. The linked article provides some interesting data on the strike zone and the psychology of umpires' decisions.
I thought I would use this question as an entre back into some of Professor Bernhard Wilpert’s work with what became known as the LearnSafe project. The LearnSafe website is worth visiting for insights into this issue and a number of others.
Two of the principal contributors to LearnSafe, Björn Wahlström and Carl Rollenhagen, published some of their interpretations of the study results in a 2004 paper, link below. In the paper they state:
“The data collected in the LearnSafe project provides interesting views on some of the major issues connected to the concept of safety culture. A suggestion generated from the data is that attempts to define and measure safety culture may be counterproductive and a more fruitful approach may be to use the concept to stimulate discussions on how safety is constructed. ” [p. 2]
The contribution of the LearnSafe project comes from the empirical data developed in the surveys and discussions with over 300 nuclear managers. It was found that the term safety culture was not frequently mentioned as a challenge for managing nuclear plants. Instead, much more frequently mentioned were factors that are commonly understood to be part of safety culture. Wahlström and Rollenhagen observe, “This would suggest the interpretation is that safety culture is not a concept for itself, but it is instead ingrained in various aspects of the management activities.” [p. 6]
This observation leads to the question of whether it is useful to put forward safety culture as a top level concept that somehow is responsible for or “produces” safety. Or would it be better to think of it as an organic process that continuously evolves and develops within an organization. This perspective would say that safety culture is more the product of the myriad of decisions and interactions that occur within an organization rather than some set of intrinsic values that is the determinant of those decisions.
The Federal Aviation Administration (FAA) took another step toward a new safety culture by reducing the emphasis on blame in the reporting of operational errors by air traffic controllers. “We’re moving away from a culture of blame and punishment,” said FAA Administrator Randy Babbitt. “It’s important to note that controllers remain accountable for their actions, but we’re moving toward a new era that focuses on why these events occur and what can be done to prevent them.” Effective immediately, the names of controllers will not be included in reports sent to FAA headquarters on operational errors…. Removing names on the official report will allow investigators to focus on what happened rather than who was at fault. Link to FAA press release.
As described in the linked article, workers at Electricite de France are raising concerns about conflicting pressures to work faster, achieve higher capacity factors and provide competitive electricity. EdF has long held a very high reputation for its nuclear operations, in part attributed to the national government’s central ownership and operating responsibilities. While it remains to be seen the extent of such concerns, it is apparent that central ownership does not provide a shield against many of the same pressures experienced by U.S. plants. The article also highlights the potential complications of heavy reliance on subcontractors if it leads to the loss of core competencies in the host organization.
As mentioned in a prior post we will be highlighting some of the work of the late Bernhard Wilpert, a leading figure in research on the role of human behavior in high reliability organizations.
Professor Wilpert emphasized the interaction of human, technology, and organizational dynamics. His tools for human factors event analysis have become the standard practice in German and Swiss nuclear plants. He is the author of several leading books including Safety Culture in Nuclear Power Operations; System Safety: Challenges; Pitfalls of Intervention; Emerging Demands for Nuclear Safety of Nuclear Power Operations: Challenge and Response; and Nuclear Safety: A Human Factors Perspective. Professor Wilpert was also a principal contributor to the LearnSafe project conducted in Europe from 2001 – 2004. See the following link for information about the project team and its results and look to us for future posts on the LearnSafe research. Link to LearnSafe project.
To delve a little deeper into this question, on Slide 10 of the NEI presentation there is a typical summary graphic of assessment results. The chart catalogs the responses of members of the organization by the eight INPO principles of safety culture. This summary indicates a variety of responses to the individual principles – for 3 or 4 of the principles there seems to be a fairly strong consensus that the right things are happening. But 5 of the 8 principles show greater than a 20 score negative responses and 2 of the principles show greater than a 40 score negatives.
First, what can or should one conclude about the overall state of safety culture in this organization given these results? One wonders if these results were shown to a number of experts, whether their interpretations would be consistent or whether they would even purport to associate the results with a finding. As discussed in a prior post, this issue is fundamental to the nature of safety culture, whether it is amenable to direct measurement, and whether assessment results really say anything about the safety health of the organization.
But the more particular question for this post is whether an assessment can detect complacency in an organization and its potential for latent risk to the organization’s safety performance. In a post dated July 30, 2009 I referred to the problems presented by complacency, particularly in organizations experiencing few operational challenges. That environment can be ripe for a weak culture to develop or be sustained. Could that environment also bias the responses to assessment questions, reinforcing the incorrect perception that safety culture is healthy? It may be that this type of situation is of most relevance in today’s nuclear industry where the vast majority of plants are operating at high capacity factors and experiencing few significant operational events. It is not clear to this commentator that assessments can be designed to explicitly detect complacency, and even the use of assessment results in conjunction with other data (data likely to look normal when overall performance is good) may not be credible in raising an alarm.
