Safety Intelligence and Chronic Unease
20 July 2016
What makes a good manager for industrial safety? Psychologists who study hazard management have long been interested in this question. In this article for Hazardex, Rhona Flin, Emeritus Professor of Applied Psychology at the University of Aberdeen, examines some new approaches to this perennial puzzle, particularly in relation to senior managers.
We know from decades of safety research and accident analyses that there are certain managerial behaviours that facilitate better safety performance. These include:
i) open, authentic communication , especially with regard to balancing safety considerations against production demands.
ii) visible demonstrations of personal commitment to safety, e.g. prioritising safety training, risk assessments, maintenance backlogs; always following safety rules; talking frequently about safety.
iii) reinforcing middle managers’ and supervisors’ safe behaviours, e.g. rewarding them for stopping a job when risk levels become unacceptable.
In offshore oil engineering parlance, these visible behaviours could be regarded as ‘topsides’ – the structures we see above the sea level. But topsides are built on very strong structures hidden below the waves. Likewise, what supports the desirable safety behaviours in managers?
Can we find underlying characteristics on which they are based? Our research suggests that we also need to consider two characteristics in the mental make-up of senior managers. We refer to them as Safety Intelligence and Chronic Unease.
Why do some managers seem to understand the risks better and know what information they require to manage hazards? The Eurocontrol psychologist Dr Barry Kirwan, who has extensive experience of safety in air traffic control and the nuclear industry, suggested that some managers seemed to have a better ‘safety intelligence’ than others. In order to examine this novel idea, we set up a doctoral research project funded by Eurocontrol. Laura Fruhen began to study safety intelligence, supervised by Dr Kathryn Mearns, Barry and myself. A literature review was conducted plus a series of interviews with 72 senior managers in European air traffic control organisations, using open questions and scenarios with ambiguous situations.
It appeared from the results that safety intelligence is partly about having a better knowledge of safety matters (gathering and understanding relevant information), as well as judging risks. There are related skills, principally in problem solving and in knowing how best to deal with others (social competence).
Some managers were able to approach safety problems by reflecting on potential causes from many angles, considering multiple information sources and generating several solutions. This flexible approach to uncertain situations can support senior managers in not jumping to conclusions too early and to critically examine the causal factors behind a surfacing issue. This way of thinking allows senior managers to gain a closer estimate of the risks they are dealing with.
This can result in better control of uncertainties and help reveal ambiguity, as well as ways to deal with it. Breadth of thinking enables a more holistic approach and can facilitate anticipation of future problems. (See the Eurocontrol White Paper on Senior Managers and Safety (2013) which is based on this research: www.eurocontrol.int/news/safetyintelligence )
This process of extended information gathering which seems to be a hallmark of safety intelligence is related to ‘chronic unease’, a mind set in managers that negates complacency.
Hazardous industries require a suitable level of respect for their inherent risks. The September 2015 fire on the British Airways 777 jet at Las Vegas airport shows how quickly a routine departure can turn into a major emergency. Airline pilots regularly practise to deal with such events, providing them not only with fast reactions but also with a regular re-calibration of their awareness for ever-present risks in their flight operations.
Managers do not usually experience simulated crises with this level of frequency or the same degree of personal scrutiny. Consequently their internal risk-calibration may have loosened to a dangerous point of comfort with familiar operational hazards.
A list of major accidents, such as the Texas City refinery in 2005, Deepwater Horizon drilling rig in 2010 and Fukushima Daiichi nuclear plant in 2011, reveals the dangers of managerial complacency and the over-reliance on reassuring indicators of the apparent status of operational safety.
Automation, smart systems and layers of protective barriers can mean that actual risks are well hidden from both workers and managers alike. In the accidents mentioned above, the organisation’s proximity to danger was much closer than anyone realised.
Researchers studying high reliability organisations (HRO) have long been interested in how managers think about hidden (as well as not so hidden) hazards. Karl Weick wrote about the structural failures that caused the collapse of the Alexander Keilland drilling rig in Norway: “Part of the mindset for reliability requires a chronic suspicion that small deviations may enlarge”. In a similar vein, the term ‘chronic unease’ was used by James Reason, establishing a contrasting state to the complacency that can result from the absence of negative events and lead “people [to] forget to be afraid”.
The dangers of complacency, especially for individuals and organisations working in more hazardous settings, were highlighted. For example, Gene Rochlin said that in an HRO, the absence of surprises over a long period of time was a reason for anxiety. Here, the lack of adverse events would be interpreted as a sign that the organisation’s error-detection mechanisms might be decaying, rather than creating a sense of comfort.
What is important is that managers of hazardous industries assume that they might not fully comprehend the complex systems they operate. Not all organisations maintain an imaginative and pessimistic approach towards risks.
Examples of this include Exxon Shipping Company, which was described as having failed to consider possible accidents of large magnitude and their potentially disastrous consequences prior to the Exxon Valdez oil spill in the Alaskan Sound. Or indeed the Buncefield tank farm explosion, where the HSE report into the causes concluded (p28): “Such a hands-off approach [by operator HOSL] was clearly insufficient oversight to achieve the stringent managerial framework required for the control of a major hazard site. As with [parent company] Total, it resulted in an unjustified confidence in the safety and environmental performance of the site.”
So if chronic unease is the desirable opposite of “unjustified confidence” – what actually is it? Laura Fruhen and I have been working on a study of chronic unease, trying to determine how it might work in managers to enhance safety. By studying the available descriptions, we defined chronic unease as a manager’s tendency to experience discomfort and concern about the control of risks.
This discomfort is not just concerned with threats and hazards per se, but rather with the manager’s sense of whether or not these risks are being sufficiently controlled and whether he or she is being provided with sufficient information on the status of these defensive processes. Therefore chronic unease should help managers to focus more on the inherent uncertainties in the day to day running of their operations. And how much chronic unease is appropriate for a given manager depends on the current work conditions, as well as their own personal characteristics.
It appears from our analyses that the extent to which managers experience unease is based on five factors. These are:
* Vigilance - The ability to notice and identify (weak) indicators of risks in the environment.
* Propensity to worry - A tendency to worry about risk and safety. This can include emotional and somatic reactions.
* Requisite Imagination - The ability to mentally project the development of a situation into the future based on its current state
* Flexibility of thought - The tendency to approach safety related issues from many angles, to think about them critically and to question assumptions.
* Pessimism - A personality trait reflecting a tendency to resist complacency and to anticipate failure.
The feeling of unease makes managers think critically about what is causing their discomfort, examining situations from more angles. This is the same flexible thinking we found in the safety intelligence study. This process encourages managers to look for information so that they can identify hidden risks and to determine which organisational activities to examine more closely. Therefore, chronic unease is a kind of ‘mental filter’ that helps managers to direct their attention to the issues giving them most concern. It enables senior managers not only to select the types of problems they should be focusing on but also helps them to detect less obvious issues that make them feel uncomfortable.
For senior managers, there is usually an overabundance of information – they constantly have to determine what to focus on and what to ignore. Chronic unease can function as a filter, helping managers to notice hazardous issues that are concealed behind more salient business concerns.
But could chronic unease for safety have negative consequences for managers making them anxious, constantly vigilant and driven by worry. Of course, extreme chronic unease could be harmful, because excessive worrying is associated with reduced well-being, stress and even aspects of anxiety and depression.
We suggest that the relationship between chronic unease and efficacy in safety management is as follows:
* Too little chronic unease and the resulting complacency means that warning signals are ignored, ambiguities are marginalised, there is no systematic search for negative indicators, and adverse consequences are rarely considered.
* Too much chronic unease and the manager is disabled by the level of anxiety with consequent deleterious effects on decision making, action and mental health.
* At the optimal level, which will be different for each person, the sense of chronic unease about organisational safety prompts the continued search for hidden threats, appreciation of the value of anomalies, and the risk of confirmation bias.
The desirable level of chronic unease for safety, is essentially a state of vigilance. The costs associated with chronic unease and the resulting vigilance are what James Reason described as the “price for safety” . We are now developing a questionnaire to help managers assess chronic unease and designing workshops on safety intelligence.
For details of papers – see www.abdn.ac.uk/iprc
About the author
Rhona Flin is Emeritus Professor of Applied Psychology at the University of Aberdeen. Her current research interests are on the management of safety, safety culture and non-technical skills. She works as an independent consultant in the higher risk industries.