The Culture of Care Diagnostic
14 August 2014
Senior managers often see a diagnostic or audit as a means of providing the assurance that things are as they should be. This paper by Derek Smith and Edward McCullough, respectively Chief Executive and Director Senior Partner of Optimus Seventh Generation, details an alternative approach to safety culture assessment that the company has developed, drawing upon High Reliability Organisation (HRO) principles.
If you go looking for assurance, you’re likely to get it. Those carrying out the assessment may use euphemisms such as “improvement opportunities” or “challenges”. If the task is to provide some overall assessment of how well the organisation is being managed, the chances are the assessment will be positive1.
We believe that leaders who want to go beyond assurance and pinpoint the unrecognised problems lurking beneath the surface need to avoid any suggestion that they are asking for confirmation that the system is functioning as intended. One way to overcome this is to ask the diagnostic to identify the most significant safety issues confronting the organisation or site. The Optimus Culture of Care Diagnostic (CCD) gathers evidence of safety culture by a combination of observation and audit of work products (permits, risk assessments, tool box talks, etc.) and perception-based surveys and interviews.
The CCD is interested in those aspects of resilience that are present, therefore it seeks to establish:
· The ability of the business to stop something bad from happening
· The ability to stop something bad becoming worse
· The ability to recover something bad once it has happened
Resilience is assured not just by the behaviours of people – it is also assured by the consistent application of processes and procedures, as well as the functionality of safety-critical equipment.
The CCD is also looking for defence in depth – what barriers and how many of them are in place? It is useful to contextualise this using a barrier model with the use of personal protective equipment (PPE) at one end of the scale as the weakest defence or barrier, and with the elimination of hazards at the other end of the scale as the strongest.
Between these two barriers we would hope to see others that would manifest themselves in a range of capabilities and activities. This would provide the business with the ability to detect hazards by fixed detection systems, hazard spotting and management processes and tools, adequate planning, and active monitoring. Hazards would be eliminated or mitigated by either fixed fire-fighting and containment systems, shutdown systems or the functional application of hazard management tools and processes and an intervention culture.
The glue holding all of the above together is the leadership exhibited by all levels of the organisation and the quality of communication and collaboration expressed. This leadership becomes manifested in the level of engagement of the workforce.
The diagnostic assessment is presented by mapping the dimensions of the culture [Authentic leadership, Control of work, Learning and development, Communication, Role of HSE function & Workforce engagement] on to a Culture of Care Maturity Ladder [with five steps from Generative: care is fundamental to who we are down to Pathological: we pay people, why should we care?]
This maturity ladder focuses on Care, which can be understood as a values-based approach to safety.
We have arrived at a number of key findings from the Culture of Care Diagnostics we have carried out to date.
The safety cultures within each industry sector tend to be similar
The Culture of Care Diagnostics have been carried out in high-hazard industries including upstream and downstream oil and gas assets, in marine, and in fabrication in the UK, in Asia, in Africa and the Americas.
We have found that the results within each sector tend to be similar. For example, UK Continental Shelf (UKCS) upstream has clustered around high-end reactive or borderline calculative in all dimensions.
Focus on Major Accident Hazards
Our findings are supportive of the recently-announced strategy by the UK Health and Safety Executive’s Energy Division of focusing on Major Accident Hazards. It is evident that high-hazard industries are becoming increasingly proactive in regard to their focus on process safety as well as major accident hazards. Our evidence however, suggests that hazard identification within risk assessments and permit to work systems remain dominated by personal safety hazards such as working at height, manual handling, etc. Control measures are therefore heavily weighted toward these topics.
Our experience when interviewing operations personnel is that they have a wealth of domain knowledge in regard to process safety and major accident hazards on site. However, this knowledge and understanding is not making its way into the control of work tools and informing those who access the asset. Some of these assets have equipment under high pressure, high temperatures, sensitive instruments, gauges, etc., that members of the workforce are working on or around. If we want to engage the workforce to defend the asset then we need to make them more informed of the significant hazards within the asset.
Leaders in mature safety cultures exhibit chronic unease
In relation to downstream the most significant finding was that, while our audit and observation evidence suggests upstream and onshore/petrochemical safety cultures have similar levels of maturity, those responding favourably to our perception survey question “how effective do you believe this organisation’s safety culture is?” was 30 percentage points higher on onshore assets.
One possible explanation of this is that these sites have personnel who have worked on the asset for long periods of time with most never having experienced a significant negative event. Consequently, we found little evidence of leaders and site personnel worrying about what could go wrong even when everything is “steady state”. As an example of this, during conversations with various operations teams, they tend to indicate that the “plant was well designed” and believe it will function as designed if required even though some of the assets were over 30 years old and operated with equipment bypassed or overridden and managed through operational risk assessments.
This finding has implications for the type of risk awareness, process safety awareness, cumulative risk awareness and leadership training that is appropriate within these types of environment to maintain a state of chronic unease and intelligent wariness of high consequence-low probability events.
How do international energy companies project their values?
The international upstream assets that we have assessed have been at the lower end of reactive, with the most significant shortfalls when compared to UKCS, being in the authenticity of the leadership and the level of understanding and application of the control of works tools. Our evidence has found that International energy companies are consistent in the communication of their values and standards globally, and also their desire to share and use “industry best practice”.
However, we have found that rather than there being a performance consistent with these company standards, performance is based on the effectiveness of the local management and supervision. From a leadership perspective, this standard is normally explained as “what is possible here” or “blamed” on the local culture and an inability to influence this. This is not consistent with research (Mearns & Yule, 2009) that has found that company culture can influence and override national culture, and therefore the expressed values and standards of the company can be delivered through a leadership team that has been given the skills to be authentic and engage the workforce.
Our evidence has found that the extent of the leadership provided is manifested in how control of work is applied. Significant numbers of the workforce are aware of the policies and procedures and the tools, but don’t properly understand them or how to use them. For example, some assets do not have documents in the local language. Hazard awareness and risk perception skills are lower and therefore the efficacy of the control of work system and tools is undermined.
Translating the organisations safety goals into workplace behaviours
Onshore fabrication results have tended to be at the lower end of reactive across all dimensions with findings of low level non-compliance with process and procedure and industry best practice. Rightly, in our view based on our evidence, Susan Mackenzie, head of offshore energy at the HSE recently stated: “.. the risk of being injured in a fall, slipping, straining your back or being affected by chemicals offshore is lower than in the majority of workplaces onshore. These risks are already well-managed offshore”.
Based on evidence from an Optimus cultural improvement program, it is possible over a period of time for a fabrication yard to achieve an improvement of one maturity level through training and coaching of leaders and the workforce. In particular we were able to help address one of the gaps identified in our perception surveys, the ability of supervisors to translate the organisation’s safety goal into meaningful behaviours for the workforce. The international energy company having structures fabricated at this yard wanted to leave a legacy of a more mature organisation where personal safety risks were as well managed as they are offshore and this was achieved.
The control of work tools are fit for purpose but the outcome they produce depends on the quality of leadership and workforce engagement with safety
Interestingly, our analysis has shown that all of the organisations we have measured have a control of work system and the supporting tools to deliver the safety performance they desire, it is how these systems and tools are applied that is consistently identified as a contributory factor in lower than expected outcomes.
Leadership is identified as a key influencer in our findings. Authentic and effective leadership can be an enabler to safe and reliable operations or at times “blind” to dangers due to a focus on what gets done over how it gets done. High hazard industries covet technical knowledge and our findings support the anecdotal evidence that many managers and supervisors are promoted due to their technical capabilities with limited or no focus on providing them with the training and coaching that will enhance their leadership skills. This has generated consistent evidence of control of work systems being used at times as a means to an end, rather than the planning and preparation heartbeat of the organisation, shaping and influencing decision making.
We have found that those organisations that are operating at more mature levels have leaders who are creating time to manage by walking around creating followers and therefore a workforce engaged with safety and the safety tools. Many leaders self-report that they do ‘manage by walking about’, but this is often to ask the question “when will you be finished” more than to function test that the control of work system and its tools are functioning as intended, that “we are doing what say we are doing” – the “how is the job going?” question.
The perceived effectiveness of the safety culture varies at different levels of the organisation
Our research clearly shows that senior and middle managers tend to perceive the safety culture to be one maturity step higher on the maturity ladder than supervisors and workers. These results are similar to those found by the Step Change in Safety Workforce Engagement survey as presented at the Workforce Engagement Support Team launch event.
It is worthy of reflection that the further you travel up into the organisation, the safer it is perceived to be. This is something that all leaders should be mindful of and need to inform themselves as to why this is the case. Is their perception based on the same information and richness of experience as those close to operations? If not, why not?
At Optimus we have experienced feeding back the evidence of a Culture of Care Diagnostic to a senior leader and being told “nobody has ever brought that to me”.
Mindful leaders know that bad news does not naturally flow upwards in organisations and therefore they must make time to visit sites regularly to “see for themselves”. Leaders would do well to adopt the “self-conscious auditing” of Winston Churchill when he made the terrible discovery that Singapore was far more vulnerable to a land invasion than he first thought. Why didn’t I know? Why didn’t my advisors know? Why wasn’t I told? Why didn’t I ask?
On investigation of recent disasters within the energy industry it has been identified that before the event there were warning signs and weak signals known about and spoken about within the organisation. Leaders thirst for good news or a lack of interest in actively looking for bad news meant that these warning signs were not dealt with by those most equipped to do so.
Some concluding thoughts
At the beginning of this article we talked about high hazard industries wanting to know how to improve their safety culture and having an aspiration that they will become generative, acting in the ways of a High Reliability Organisation. HROs act on weak signals, warning signs and leading indicators.
Our evidence is that lagging indicator data is still used as a strong measure of performance: “We have not had an LTI for a year so our culture is OK” is a common belief. Focusing attention on these measures will not mature the culture in a high hazard environment to a level of resilience that gives it defence in depth. Our experience has found that those organisations actively using leading indicators have a more mature safety culture. The aviation industry would never publish data on the lost time injuries, days away from work or first aid frequency of their staff to prove the safety of their aircraft.
While we recognise the need for more data and also that several of the diagnostics may have been influenced by being commissioned in response to an event, in this article we have highlighted patterns that are the weak signals and warning signs that those who wish to improve the maturity of their safety culture will pay attention to.
Our experience is that the way the patterns play out differs between organisations and therefore what to do to increase the maturity of safety culture and how to do it also differs, but the starting point is the Culture of Care Diagnostic.
Ref 1: Hopkins, A., (2009). Failure to Learn: the BP Texas City Refinery Disaster. Sydney: CCH Australia Limited.