We know that safety cultures are not just created at the sharp end. For safety culture, we need to look deeper inside an organization—at its procedures, work practices, design, supervision, management, governance. This has been a very empowering idea, shifting our focus onto the context surrounding people’s work. But it has also been accompanied by burgeoning safety bureaucracies. In pursuit of safety culture, we now expect organizations to deploy vast systems—loss prevention systems, safety management systems, auditing systems—that hunt for all kinds of organizational and behavioral wrongs before they line up to cause trouble.
We risk becoming preoccupied with high-frequency/low-consequence things: not wearing safety glasses; having coffee in a cup without a lid. Then we mistake low counts on these for a safety culture—low counts that we tabulate, share with stakeholders, and celebrate. The fiction is that we have a safety culture because we have low numbers on irrelevant things, and the paperwork to show it.
And then we blow stuff up.
Safety bureaucracies can become so wrapped up in their own work, breathing their own air, reporting largely to and around themselves, that they become dissociated from what it means to practice. They can lose touch with safety-critical work and stand at an ever-greater distance from the operation. Yet managers may not be able to do what they once did without their approval. And so, safety bureaucracies become a substitute for competent supervision, and can disempower management. What they do is founded largely on faith, however—from the good intentions to save people from evil, to the fiction of proportionality between different loss events, to zero-vision as any more than a noble goal, to an OHS priesthood with its exclusive training, rituals, language, and moral imperiousness.
Such approaches to safety culture are plateauing, with typically less marginal return for each initiative. To give safety a future, we should not see people as a problem to control, but as a solution we can harness. We need to move from counting negatives to understanding what makes an organization normally successful. And we need the courage to question common wisdom and industry standards—confronting fiction with facts, and faith with enlightenment.
On the related issue of Just Culture, I was impressed by the Sydney Morning Herald weekend coverage of the infamous radio prank. Here’s just a sample of what I think is a typical of the coverage which was extensive.
http://www.smh.com.au/opinion/society-and-culture/a-tragedy-but-who-is-at-fault-20121208-2b29q.html
What surprised me, after the public and media outcry following Alan Jones “Died of Shame” comments about Julia Gillard father, was the measured responses and concern for the instigators of the prank. I think it makes an interesting case study for Just Culture. There’s even some evidence of the local rationality principal at play. If only we could have examples like this in response to workplace safety incidents.
Is the spread of a safety culture in an organization often identifiable through the manuals that have been growing over time (more pages, more procedures)? I think that this might help identifying the bureaucratic accountability. Any other thought?
Risk Management initiatives I would add to your list, Sidney. Many organisations claim ‘risk awareness’ (often including safety risk within this awareness) and have extensive risk management systems to prove it. The RMS includes checklists for conducting risk assessments on the most trivial of activities. Focus is again on the small stuff, which staff deride. Where it could make a difference on the big projects, the assessments seem to “miss” some of the basic issues, often because the participants do not cover the relevant disciplines or have appropriate experience. But because these are conducted in their masses, and any identified risks mitigated and tracked, a ‘good risk awareness’ culture is claimed and celebrated. And then something happens ….