1. Safety Culture Moving up the Culture Ladder
Patrick Hudson
Tim Hudson
Hudson Global Consulting
Leiden University
Delft University of Technology

2. Chernobyl 1986
The “Chernobyl disaster” was the worst nuclear power plant accident in history
On April the number four reactor exploded and started a powerful fire that lasted for about 10 days

5. “ The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture….
…Cultural traits and organizational practices detrimental to safety were allowed to develop, including:
reliance on past success as a substitute for sound engineering
organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion …”

8. Deepwater Horizon
Welcome. We analised the deepwater horison disaster with bscat we now wish report our major findings

9. INSAG Definition 1991
Safety Culture is that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.

10. UK Health and Safety Executive
The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.

11. Alternative definitions
How we do things round here
What happens at 2am when there is no one to see you

12. A paradox - Asymmetry The definitions might be similar But
If I know your values, beliefs and attitudes I may still fail to predict your behaviour
If I know your behaviour, I have a good idea of what your values, beliefs and attitudes are

13. Which one do you prefer?

14. Approaches to Measurement
Surveys
Interviews
Incident analyses
All of these require you to have some notion of how you understand safety culture - in advance

15. Characteristics of a Safety Culture James Reason 1997
Informed - Managers know what is really going on and workforce is willing to report their own errors and near misses
Just - a ‘no blame’ culture, with a clear line between the acceptable and unacceptable
Flexible - operates according to need
Learning - willing to adapt and implement necessary reforms
Mindful and Wary - ready for the unexpected

16. But
These are all very hard to acquire
What we need is a roadmap

17. Measuring Safety Culture Conventionally

18. Safety Process Auditing 1
HRO Category
Item #
Item Description
Safety Process Auditing 1
The process for reporting hazards/safety concerns in my Business Unit is likely to identify any problems that could lead to a serious accident. 2
The process of accident and occurrence investigation in my Business Unit is effective at identifying the causes of these events. 3
My Business Unit has a successful process in place to identify any person who may pose a safety risk on the job due to unsafe behaviours. 4
Safety reporting forms in my Business unit are understandable and easy to complete. 5
Safety investigation reports are communicated to all employees so that everyone in my Business Unit learns the lessons. 6
Feedback regarding action to be taken following a hazard report or near miss in my Business Unit is provided to the person reporting. 7
Safety personnel in my Business Unit are influential in promoting safety. 8
I find safety directives in my Business Unit clear and easy to understand. 9
I am adequately trained to safely conduct all of my job assignments. 10
I have a clear understanding of who is accountable for safety in my Business Unit.
Safety Culture & Reward System 11
I am comfortable reporting safety concerns without fear of management reprisal. 12
Working safely is an integral part of all operations in my Business Unit. 13
Senior Management supports a climate that promotes safety. 14
Any employee in my Business Unit can request stopping or delaying an operation if he/she believes that an unsafe condition exists. 15
I am comfortable admitting to my Manager that I have made a mistake. 16
It would be difficult for me to ask my Manager for more time to complete a task. 17
I would be comfortable asking my Manager to release me from work due to personal problems. 18
I would not hesitate to advise my Manager when the schedule threatens safety. 19
There is a perceived lack of management commitment to safety in my Business Unit. 20
I believe my Business Unit is moving towards a fair and just culture. 21
I understand how the Just Culture policy applies to me. 22
I believe that Qantas Group is a safe place to work.
Risk Management 23
Deliberate violations of standard operating procedures are rare in my Business Unit. 24
I believe that employees in my Business Unit have become complacent regarding the recognition of unsafe conditions, due to our exemplary safety record. 25
I am concerned about the non-conformance with procedures that I have observed in my Business Unit. 26
Employees in my Business Unit carefully assess hazards during daily work operations. 27
I feel overly burdened by my daily work. 28
My Business Unit has effective processes in place to manage the risk of fatigue on the job. 29
I believe senior management show a genuine concern for employees when they are injured at work. 30
I am aware of my personal responsibilities to be fit for duty at all times. 31
My Business Unit provides adequate procedures for Preventing personal injury. 32
I believe action taken immediately following an injury is focused on ensuring employees well being. 33
I understand how human factors can affect my performance at work. 34
Sometimes I am so tired at work that I am not sure I can stay alert. 35
My Business Unit considers the risks of human error and non-conformance with standard operating procedures. 36
I believe information about risk and hazards is escalated to the right people to be managed. 37
I believe that the Airline that I work for operates safely. 38
I would challenge and report suspicious behaviour or circumstances.
Quality Assurance 39
Employees in my Business Unit are held accountable for poor work performance. 40
There are clear procedures in place for effective management of daily operations in my Business Unit. 41
I am aware how the Qantas Management System (QMS) applies to my role. 42
My Business Unit sets the highest standards in the industry for recruiting and hiring of its Employees.
Leadership & Supervision 43
I believe that my Business Unit does not provide adequate staffing. 44
I believe that employee morale in my Business Unit is high. 45
Senior Management can be trusted to keep their promises to all employees. 46
My Business Unit has adequately prepared employees for ongoing changes to business operations and organisational structure. 47
I believe Senior Management enforces the policies and procedures uniformly for all employees. 48
In my Business Unit a good communication flow “back and forth” exists between management and employees. 49
I have seen evidence that Senior Management cares deeply about safety. 50
My Business Unit is so focused on controlling cost that I fear safety may be compromised. 51
I believe senior management demonstrate and drive genuine commitment to safety. 52
Regular team meetings in my Business Unit are used to communicate issues and to correct any misunderstandings. 53
My Manager sets the example for compliance with procedures. 54
My Manager would never ask me to do something against company policy just to get my job done on time. 55
My Manager encourages reporting any safety discrepancies. 56
My Manager has clearly communicated the company’s safety goals to me. 57
My Manager can be relied upon to keep his/her word. 58
My Manager willingly provides advice concerning safety matters. 59
My Manager does not hesitate to correct unsafe behaviour. 60
My Manager listens carefully to employees regardless of job title.

19. Safety Process Auditing1
The process for reporting hazards/safety concerns in my Business Unit is likely to identify any problems that could lead to a serious accident. 2
The process of accident and occurrence investigation in my Business Unit is effective at identifying the causes of these events. 3
My Business Unit has a successful process in place to identify any person who may pose a safety risk on the job due to unsafe behaviours. 4
Safety reporting forms in my Business unit are understandable and easy to complete. 5
Safety investigation reports are communicated to all employees so that everyone in my Business Unit learns the lessons. 6
Feedback regarding action to be taken following a hazard report or near miss in my Business Unit is provided to the person reporting. 7
Safety personnel in my Business Unit are influential in promoting safety. 8
I find safety directives in my Business Unit clear and easy to understand. 9
I am adequately trained to safely conduct all of my job assignments. 10
I have a clear understanding of who is accountable for safety in my Business Unit.

20. Conventional Safety Culture scores

24. Increasingly Informed
Increasing Trust and Accountability
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
PATHOLOGICAL
Who cares as long as
we're not caught

25. Increasingly Informed
Increasing Trust and Accountability
REACTIVE
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught

26. Increasingly Informed
CALCULATIVE
We have systems in place to
manage all hazards
Increasing Trust and Accountability
REACTIVE
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught

27. Increasingly Informed
PROACTIVE
Safety leadership and values drive
effective improvement
Increasingly Informed
CALCULATIVE
We have systems in place to
manage all hazards
Increasing Trust and Accountability
REACTIVE
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught

28. Increasingly Informed
GENERATIVE (High Reliability Orgs)
HSE is how we do business
round here
PROACTIVE
Safety leadership and values drive
effective improvement
Increasingly Informed
CALCULATIVE
We have systems in place to
manage all hazards
Increasing Trust and Accountability
REACTIVE
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Safety is important, we do a lot
every time we have an accident
PATHOLOGICAL
Who cares as long as
we're not caught

29. Safety Culture indicators
chronic unease
safety seen as a profit centre
new ideas are welcomed
GENERATIVE
resources are available to fix things before an accident
management is open but still obsessed with statistics
procedures are “owned” by the workforce
PROACTIVE
we cracked it!
lots and lots of audits
HSE advisers chasing statistics
CALCULATIVE
we are serious, but why don’t they do what they’re told?
endless discussions to re-classify accidents
Safety is high on the agenda after an accident
REACTIVE
Safety Culture Ladder
well researched definitions
calibrated questions on laminated cards to assess status
can be used at all levels in the organisations
can be used to identify differences (perceptions) at various levels in the organisation
can be used to identify differences between parts of the organisation
can be used to assess progress over time: where were we, where are we, where do we want to be
Starting point for putting HSE improvement on the map.
Do tests (see last slide for meaning of background colours)
If you want to reach a higher level it is also necessary to assess the readiness to change.
PATHOLOGICAL
the lawyers said it was OK
of course we have accidents, it’s a dangerous business
sack the idiot who had the accident

30. Measurement Bias
When we measure, people score themselves higher than they ‘actually’are (from behaviours)
This makes for a poor scientific instrument
More accurate if we use randomised presentations to choose from
Alternative is to ask for Aspiration first
No one has ever wanted to go down!

32. Measurement

33. Aspiration 2 years later

34. Detailed scores

35. Using the Ladder Decide where you are now Decide where you want to go
Support the process of getting there

36. What does work Choose activities, processes and systems that
Are characteristic of more advanced safety cultures
Can easily be made to become “how we do things round here”
Use standard management skills to ensure change takes place

37. Moving up the ladder
In Place
In Operation
Effective
Permanent

38. Moving up the ladder again
In Place Pathological -> Reactive
In Operation Reactive -> Calculative
Effective Calculative -> Proactive
Permanent Proactive -> Generative

39. Increasingly Informed
GENERATIVE (High Reliability Orgs)
HSE is how we do business
round here
Permanent
PROACTIVE
Safety leadership and values drive
effective improvement
Effective
Increasingly Informed
CALCULATIVE
We have systems in place to
manage all hazards
In Operation
Increasing Trust and Accountability
REACTIVE
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Safety is important, we do a lot
every time we have an accident
In Place
PATHOLOGICAL
Who cares as long as
we're not caught

40. Warning Survey techniques are what students get taught by faculty
There are well known methods to analyse survey materials
We may be measuring the wrong things very accurately rather than the right things as best we can

41. The Process Safety Culture Ladder
Discipline dimension
Dimensions include
-Senior Management
-Rewards of Good Performance
-Respect for Technical Expertise
-Contractor expertise
-Competence & experience
-Standards, Procedures
-Change
-Planning & design
Discipline is primarily self-discipline, because it follows naturally from the understanding of how hazardous processes are controlled. The reasons for allowable non-compliance are used for learning and improvement.
People know that compliance with standards, rules and procedures is usually the right thing to do, regardless of whether there are severe consequences for non-compliance. There are variance procedures if compliance is seen to create problems.
The organization lays considerable emphasis on compliance and failures are treated severely. Discipline is set by external authority, from above. People are compliant because they feel they have no choice.
Disciplined behaviour is for wimps. Rules are for other people as those who have the seniority that implies experience can make their own minds up.
Dimensions from UYC
-Audit
-Benchmarking
-Incident investigation
-Who causes accidents?
Safety Culture Ladder
The best way to understand our culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before.
Looking at it like this provides a route map, where every team, or company has a certain level of cultural maturity and can see which rung of the ladder they are on, where they have been and what the next step looks like.
The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, that we call the Generative.
Pathological, is where people don’t really care about Safety let alone Health and the Environment, and are only driven by regulatory compliance and or not getting caught. We probably all recognise this from the past but is something we have hopefully move beyond. People say things like “it’s a dangerous business”,
Reactive, is where safety is taken seriously, but only when gets sufficient attention after things have already gone wrong. People say things like “you have to understand it is different here”, “you have to look out for yourself”, or “those who have the accidents are those who cause them”.
At the reactive level managers take safety seriously, but feel frustrated about how the workforce won’t do what they are told. ‘If only they would do what they are supposed to’, ‘we need to force compliance’.
The next level, Calculative, is where an organization is comfortable with systems and numbers. The HSE-MS has been implemented successfully and because HSE is taken very seriously, there is a major concentration upon the statistics – bonuses are tied to them, contractors are rated in terms of their safety record, not just because they are the cheapest. Lots of data is collected and analysed, we are comfortable making process and system changes. There is a plethora of audits and people begin to feel they have cracked it. Nevertheless businesses at this level still have fatalities and are surprised when these occur.
Proactive is where Shell is aiming for. It is moving away from from managing HSE based on what has happened in the past to really looking forward. Not just working to prevent last week’s accident, it is starting to consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, as well as in management statements of intent. Unlike the Calculative, where the HSE department still shoulders a lot of the responsibility, in Proactive organisations the Line begins to take over the HSE function, while HSE personnel reduce in numbers and provide advice rather than execution. Indicators become increasingly process-oriented
o       Are we doing the right things, - rather than just focused on incidents
o       Have we had any accidents?
It is quite simply about creating an environment that encourages the behaviours and beliefs that will deliver lasting improvements in our performance both HSE and beyond.
- As an organisation climbs up the ladder there the level of informedness and trust increases with people offering to accept accountabilities (‘you can count on me’) rather than just being told they will be held accountable for some outcome.
Informedness is about mangers knowing what is happening in their organisation and where all the problems are, and the workforce knowing exactly what managers expect – no mixed messages. Because managers and workers are aligned, this builds two-way trust. Because people know what is expected and are trusted to do it, there is less need for bureaucracy, audits and supervision, so workload decreases from after the Calculative stage
Generative organizations set very high standards and attempt to exceed them rather than being satisfied with minimum compliance. They are brutally honest about failure, but use it to improve, not to blame. They don’t expect to get it right, they just expect to get better. Management knows what is really going on, because the workforce is willing to tell them and trusts them not to over-react on hearing bad news. People live in a state of chronic unease, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next.
Do what you can get away with to win.

42. Thank you