2. Foundations of an Effective Safety Culture
Joe Engberg
Manager, Safety Program Support
Davey Tree Expert Company

4. Deepwater Horizon
22 April 2010

5. “What the hell did we do to deserve this?
...safety is our top priority.”
Tony Hayward
Ex-CEO British Petroleum
Culture and Leadership are two sides of the same coin. Leadership creates culture and culture influences leaders.

6. From where does safety come?
“Systems are not basically safe. People create safety (or don’t) while negotiating multiple systems goals.” Sydney Dekker
Safety is never the only goal.

9. Principles of Performance Excellence
People are fallible; even the best make mistakes.

10. After reading this sentence you will notice that the the brain doesn’t recognize the second the.

11. Errors An error is something you didn’t mean to do.
Active error: immediate consequences and we usually know who did it.
Latent error: delay before consequences and we may never know who did it.

12.
Challenger

13. Principles of Performance Excellence
Error-likely situations are predictable, manageable, and preventable.

14. Error Likely Situation ?

15. Poor / Vague Communication Over-confidence High Workload Work Stress
Error Precursors: “conditions that interfere with successful performance and increase the probability for error” – Top Picks:
Time Pressure
Distractions
Complacency
Poor / Vague Communication
Over-confidence
High Workload
Work Stress
Fatigue
Personality Conflicts

16. The Keys to Incident Prevention –
ANTICIPATE AND PREVENT ACTIVE ERRORS.
DISCOVER AND ELIMINATE LATENT CONDITIONS (caused by latent errors).

17. Principles of Performance Excellence
Individual behavior is influenced by organizational processes and values.

18. Peoples’ behavior at work reflects organizational processes and values
Peoples’ behavior at work reflects organizational processes and values. If you like or don’t like what you see, you are looking at a reflection of your organizational values – your culture.

19. “…leadership and culture are two sides of the same coin.”

21. Principles of Performance Excellence
People achieve high levels of performance due largely on the encouragement and reinforcement received from leaders, peers, and subordinates.
Principles of Performance Excellence

22. “…positive reinforcement has infinitely more value to a leader and the organization than negative reinforcement.”

23. Thoughts on reinforcement:
It is folly to reinforce one behavior and expect another, but it happens in organizations every day. Aubrey Daniels
The best time to deliver positive reinforcement is when people are engaged in the behavior that you want or like.

24. Feedback is information about performance with respect to a goal(s) that allows a person to improve performance.
1). It must tell you where you stand relative to a target or goal.
2). It should tell you what to do to improve.
If it doesn’t meet these two requirements, it is not effective feedback.

25. The only reason to give feedback is help increase performance.
Helping people succeed.
Give feedback on performance that the person can control.

26. Effective feedback is only about behaviors, never about the person.

28. Procedure Deviation Drift
Crew Observations
Incident Investigation
Rule Requirements (Believed Norm)
Performance Gap
(discovered by
Incident Investigation)
Deviation Drift (New Norm)
Standards
Safety Threat
Incident T1 T2 T3 T4
Time
Courtesy of Duke Energy

30. Principles of Performance Excellence
Incidents can be avoided by an understanding of the reasons mistakes occur and application of the lessons learned from past incidents.

32. “Human error is not the conclusion of an investigation
“Human error is not the conclusion of an investigation. It is the starting point.”

33. Anatomy of an Incident Incident Human Fallibility Programmatic
Active Errors:
Weak Skills, Failed, or
Nonexistent Barriers
Latent Errors:
Organizational Weaknesses;
Poorly Written Procedures, Failed, or
Nonexistent Programmatic Barriers,
Ineffective Leadership
Human
Fallibility
Programmatic
Barriers
Performance improvement is all about avoiding significant events (safety and production losses). The Reason’s model (Defense In Depth Model) is the best illustration of the causes of a significant event. Normally, programs are thought to be robust barriers to events (like a series of steel plates). However, errors accumulated over time that act as holes in the barriers (Reason calls this the “Swiss cheese effect”). Then an error or a generally acceptable action at an inopportune time triggers a sequence of events that passes through all the weaknesses in the barriers, resulting in a significant event.
In the model, the layers line up to show the worker, procedure, supervisor and manager layers in the organization. “Holes in the cheese….” represent the deficiencies that are either active failures or latent errors.
Latent Errors: Some of these holes lay in wait as latent organizational weaknesses. Then, with an initiating event the stage is set for the deficiencies to allow an error to occur (e.g., arrow through holes lined up in all 4 layers). The result of this scenario is the accident or injury that results from the error.
Best way to fight this scenario is to use the Corrective Action Program (detection and correction of error drivers) to identify “holes” in the cheese and rid the organization of the latent weaknesses that would jump up and cause events unexpectedly.
Active Errors: Other “hole” result from active errors caused by individuals - real time. These errors fall into 3 types; skill-based, rule-based and knowledge-based.
Best way to fight active errors is to provide workers, supervisors and managers the knowledge and tools needed to identify error-likely situations and effectively minimize their potential for error.
If there were no initiating actions there would be no events. This is called event Prevention - awareness of human error drivers, error reduction behaviors. And if there were no weaknesses in the barriers there would be no events. This is called Detection and Correction (Detection is identification of error likely situations and latent org. weaknesses and Correction is ensuring effective investigation and correction of causes). Mistakes will happen – but the more weaknesses in organizational barriers we can solve then the less likely a significant event will occur (finding and fixing the holes in the Swiss cheese).
Must do all 3 to be effective.
We don’t want to set up the individuals to be the last line of defense or the goalies of the organization; trying to stop “shots on goal”. How many days have you felt like the goalie – just blocking shots on goal. Don’t want just the last barrier of individuals because shots will get through – individuals can’t stop them all. The more time you have to spend defending the goal (dealing with error drivers or shots on goal) the more it takes away from the time you have to prevent errors – and over time, it significantly effects the individuals mental state in a negative way (people get tired of always being the goalie and staying in a a constant crisis management mode).
The prevention of human errors (a reduction in initiating actions) reduces the number of “shots on goal”.
The detection and correction of organizational barrier weaknesses (a reduction in the size and number of barrier weaknesses) reduces the number of errors that can get through the barriers to cause a significant event.
Organizational
Barriers
Leadership
Barriers
Initiating
Action
“Defense in Depth Model”
Dr. James Reason, Managing the
Risks of Organizational
Accidents, 1997.

36. “If you’re after getting the honey,
Then you don’t go killing all the bees.”
Joe Strummer & the Mescaleros