Safety culture, energy-based hazard recognition, and SIF prevention
Author : Mary Jo Rogers, Rogers Leadership Group
09 March 2023
Serious injuries and fatalities (SIF) are emotional, tragic events that have a significant, lasting impact on organisations, communities, and families. Colleagues who have lost their lives at work are not forgotten – their stories take on a life of their own.
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In the ongoing pursuit of SIF prevention, organisations are breaking down SIF events and potential life-altering incidents to focus on behavioural and psychological drivers in safety culture and on the effect of energy-based hazard recognition.
There is growing evidence that SIFs have unique aspects that differentiate them from less severe incidents and injuries. In our work with safety critical organisations preventing SIFs, we have seen the dynamic interactions between leadership, safety culture, and hazard recognition and the difficulties that organisations encounter without proper attention to these underlying mechanisms. By better understanding safety culture and energy-based hazard recognition, leaders and front-line workers can make cognizant decisions that strengthen their abilities to prevent SIFs.
Safety culture, simplified
Paying insufficient attention to safety culture input can result from a lack of appreciation for what it really is and how culture affects performance. A useful definition of safety culture comes from guidance provided by the US Department of Energy: “Safety culture is an organisation’s values and behaviours, modeled by its leaders and internalized by its members, which serve to make safe performance of work the overriding priority to protect the workers, public, and the environment.”1
To accurately examine and understand your safety culture, you have to dig into the “organisation’s values and behaviours,” which can be challenging to view accurately from the inside or without the proper assessment tools. With the right tools, safety culture values and behaviours are revealed in perceptions, assumptions, data, and actions, for example, by the top leadership to the frontline worker, and in safety related processes, written or practiced.
Safety doesn’t battle with production, efficiency, or reliability – it supports them. Safety is ultimately the top priority and yet, it is foundational to operational excellence. In simple terms, what shuts down an operation faster than an incident due to unsafe work practices? Strong safety culture reinforces operational focus, asset management, continuous improvement, organisational agility, and process improvements that are vital to operational performance.
Safety culture signals and pitfalls
Organisations that have high standards, consistently address safety rule violations, and show steady declines in Occupational Safety and Health Administration (OSHA) rates are doing a lot of the right things over time. Hyper-focusing on all safety rule violations and low total recordable injury rates (TRIR) at the expense of attending to safety culture signals is problematic, however. Many industries have been seeing steadily falling TRIR, but a lack of progress in sustained reductions in SIFs, suggesting underlying problematic behavioural breakdowns are at work in these events. In fact, in response to the long-standing trend where total recordable injury rates do not predict work-related fatalities, the Campbell Institute has published a targeted approach to SIF prevention that includes leading indicators and precursors.2
It is tempting to feel satisfied with declining OSHA rates versus attending to the faint, contrary, or confusing signals coming from safety culture feedback. Leadership can get caught up in activities designed to keep OSHA rates low and reduce all minor safety rule violations, in part due to an assumption that this will prevent SIFs.
Deepwater Horizon - Image: Shutterstock
An example of this propensity was found in the investigation of the Macondo well explosion. In 2010, BP took pride in its safety metrics when the Deepwater Horizon catastrophe occurred and 11 men lost their lives. In retrospect, there were multiple safety culture red flags while at the time the organisation was “focused” on safety and had demonstrated positive safety metrics. Upon further investigation after the event, these good metrics turned out to be linked much more to personal safety (such as carrying coffee, slips, and trips) than process safety on the rig, for example. As summarised in Fortune magazine:
“BP had strict guidelines barring employees from carrying a cup of coffee without a lid – but no standard procedure for how to conduct a ‘negative pressure test,’ a critical last step in avoiding a well blowout. If done properly, that test might have saved the Deepwater Horizon.”3
Accident investigations, communication, and self-reporting
To understand the behaviours and practices that are falling through the cracks, assessment tools must be able to produce reliable and valid data, whether from interviews, observations, surveys, metrics, statistical analyses, or process reviews. Reliable and valid data (hence, results and recommendations) depend on the organisation's willingness to be self-critical plus allowing all employees to openly discuss and express concerns.
There are companies who have desirable OSHA rates, yet a proportion of frontline workers say that they do not or will not report a minor incident or first aid because they want to avoid perceived punishment by management. Valid metrics depend on reliable reporting and an environment where employees feel free to raise any concern or self-report a mistake without fear of recrimination, which fosters continuously improving safety culture.
Accident investigations also need to be conducted in a way that ensures that all personnel share their information, in order to get to the most accurate understanding of what occurred and what steps need to be taken to prevent recurrence.
Some organisations focus on holding people accountable for safety violations. If accountability involves providing some kind of negative consequences for minor safety rule violations, minor incidents, close calls, or first aids, it will likely hurt self-reporting, trust, and open communication about what is going on in the field.
Leadership must be tuned into safety culture impacts when making decisions around their communications and actions, particularly following a serious injury or fatality. After a life-altering event accident at work, employees at all levels have a range of reactions; they are shocked, saddened, grieving, concerned for the family, and potentially distressed about the work environment. Leaders are also distressed, and sometimes frustrated and desperate to prevent the next major event. How leadership handles the communication around the incident, the narrative of what happened and any implications, and actions taken in response can have a big impact – for better or worse – on the organisation’s safety culture.
Specifically, if the workforce mostly perceives that the injured or lost co-worker is being unjustly blamed or spoken of in a way that implies disrespect (e.g., that the worker was intentional or negligent), this is often seen as inadequate caring and a lack of respect for the worker. Communications or lack thereof can be perceived as a way to minimize the company’s liability and reputation by blaming the lost colleague at the expense of preventing the next SIF.
The ultimate impacts of punitive safety efforts and poor communication are decreased trust and credibility of management, which hamper adoption of changes or training even though they are intended to protect the worker.
What good safety culture looks like
We have found that safety critical organisations that have a strong safety culture supporting SIF prevention demonstrate the following characteristics:
- The frontline workers’ perceptions of safety (regarding current safety practices and outcomes, risks, etc.) are not substantially different from leadership’s perspectives on safety.
- Frontline workers feel comfortable reporting and do consistently report near misses, minor mistakes, and first aids because they perceive their leaders as fair and concerned about their well-being.
- Frontline workers raise safety concerns to supervisors, who follow-up, communicate the status of concerns, and pursue resolution.
- Leaders are seen as credible, consistent, and genuinely caring for the well-being of the workers.
- Safety standards and expectations are viewed as clear and accurate by personnel at all levels of the organisation.
- First-line supervisors spend time in the field, develop effective relationships with their crews, and understand, teach, and maintain safety standards.
Rather than emphasising minor safety events, particularly in a way that hurts safety culture, organisations can focus on conditions that have the potential to be life-altering. In addition to culturally influenced assumptions and behaviours, recent research on energy-based hazard recognition has shown that there are psychological challenges present in hazard identification and preventing SIFs.
Energy-based hazard recognition
Experts in energy-based hazard recognition state that “all injuries are the result of some undesirable contact between a person and one or more sources of energy.” Energy sources include gravity, mechanical, electrical, motion, temperature, and pressure, among others. Given the training and experience of the workforce, most organisations assume that “workers can see hazards that are present and anticipate those that emerge, when hazard recognition skills may not be as strong as assumed.”4
After a serious injury or fatality has occurred, the initial investigation often suggests that the hazard was obvious, and hence the workers “were complacent or negligent.” In hindsight, the hazards appear self-evident because everyone knows what led to a tragic outcome. But in the moments before the event, the worker may overlook some hazards because of blind spots that are common in human perception due to inherent cognitive challenges that need to be overcome.
Mary Jo Rogers, Rogers Leadership Group
As Dr. Matthew Hallowell, Executive Director of Safety Function, explains, some energy-based hazards and conditions make prediction and identification more difficult. In these cases, the individual would need to piece together multiple clues to recognise that the situation is more hazardous than they thought. Other hazards are missed when they emerge from unforeseen changes in the situation. Processing complex information sources and changes takes more mental effort or specific prior experience. While some energy sources and dangers are more readily available mentally, others require more effort or complex problem solving. The former spring from fight or flight types of physiological responses, while the latter hazard identification requires a lot of cognitive effort.
Energy-based hazard recognition training has been found to improve hazard identification because the energy sources prompt people to think all the way through implications and potentialities. Energy-based hazard training can help more experienced workers talk through possibilities and how energy sources work with less experienced workers.
Leadership’s efforts to improve hazard recognition need to take into account energy-based hazard identification as well as traditional approaches. Training needs to land in fertile ground in order to take root and strengthen defences against major incidents. That is, leadership needs to be seen as credible, genuinely caring for the worker’s well-being, and consistently making visible efforts to protect the workforce.
If the workforce and leadership at all levels recognize the unique challenges in preventing SIFs and work together, they can improve the organisation’s ability to prevent the next life-altering incident.
3. An Accident Waiting to Happen, Fortune Magazine, February 7, 2011, p.107
About the author:
Mary Jo Rogers Ph.D., President of Rogers Leadership Group, has 25 years of experience consulting to safety significant industries. PennWell Corp. published her book, “Nuclear Energy Leadership: Lessons Learned from U.S. Operators” in 2013. She conducts safety culture and leadership assessments and development programs. She has been managing partner at a global consultancy firm and a leader in development at Exelon Corporation. Mary Jo’s extensive background and training enable her to apply behavioural science principles, combined with real-world industry and business experience, to help individuals and organisations uncover the values, beliefs, and behaviours that may be limiting their performance.
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