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Dramatic safety improvement starts with safety culture
By Ashley Johnson, associate editor
In May, a report issued by an independent investigation team concluded that the Upper Big Branch Mine-South explosion that killed 29 miners in West Virginia last year could have been prevented if mine owner Massey Energy Co. had followed basic safety procedures.
Investigators with the Governor’s Independent Investigation Panel called the disaster “man-made” and identified several problems at the mine, including a faulty ventilation system, inadequate rock dusting to prevent coal dust buildup and improperly functioning water sprays.
“Such total and catastrophic systemic failures can only be explained in the context of a culture in which wrongdoing became acceptable, where deviation became the norm,” investigators said in the report.
Incidents of that magnitude are rare, but poor safety performance – reflected in both injury and illness rates and worker attitudes – is still a concern. How does such a culture develop, and what can organizations do to turn around their performance?
Defining the problem
With 25 years in the safety field, Angelo Pinheiro, project health, environmental and safety manager at Houston-based Marathon Oil Corp., has helped several companies make dramatic safety performance turnarounds.
One case involved a large Middle East drilling contractor that was experiencing a high number of losses, injuries and fatalities. Employees represented 37 different nationalities, which created language and cultural issues. Many employees also came from countries lacking strong safety regulations. Tasked with turning around the safety performance, Pinheiro zeroed in on the company’s safety management system, which he called “bulky and unwieldy.”
“The system was written in English, which many employees did not understand,” Pinheiro said. “The first thing we did was essentially come up with a massive training and awareness program.”
The company brought in safety advisors to teach employees in their native language and explain the reason for doing things a certain way. It then took between two and three years for incident and severity rates to drop, according to Pinheiro, who emphasized the link between performance and culture.
“In my experience, safety performance is a function of the organization’s safety culture, which in turn depends on unwavering management commitment to safety in terms of time, effort and resourcing,” he said. “Safety culture develops over a period of years and can be sustained through education and motivation.”
He recommended the following steps to turn around a poor safety performance:
- Define the problem. Compile data on safety performance using incident reports, employee feedback and program audits.
- Analyze data for root causes and link them to specific failures of the safety management system.
- Prioritize areas for action. Develop safety improvement objectives and key performance indicators.
- Develop and implement action plans. Intervene when safety performance dips.
“Employee motivation and morale are key to turning around safety performance and must be maintained throughout the process,” Pinheiro added.
‘Drifting to disaster’
Pinheiro defined safety culture as “a mindset that has its roots in the organization’s policies, philosophies and management approaches.”
The public often learns the most about a company’s safety culture after a disaster, when the issue is in the news, said Mark Fleming, associate professor of psychology at St. Mary’s University in Halifax, Nova Scotia. He cautioned against assuming that a severe incident indicates poor safety culture and lack of an incident denotes positive culture.
“I think a better way of looking at it is there are cultural features that make a disaster more likely,” he said.
What are those features? Fleming cited three characteristics identified by human error expert James Reason as indicative of poor safety culture:
- Normalization of deviance: “It becomes acceptable to break the rules,” Fleming said, noting there are often degrees to this – some rules do not apply in certain situations or to certain people. “Usually what you find is this was not the first time that this rule was broken,” he added. The term is not meant to imply that the worker is a deviant person.
- Complacency: As Fleming explained, employees believe all possible hazards are controlled and managed, which suggests they have become complacent about risk.
- Tolerance of inadequate systems: “People start to accept that systems don’t work properly,” he said. “People work around it and try to make things work rather than say, ‘Look, this isn’t acceptable; we’re not doing it.’”
Fleming also included a fourth factor – work pressure – based on his own research.
Additionally, overemphasizing personal safety and failing to monitor other aspects may result in low injury and illness rates, but still leave an organization open to a low-probability, high-consequence event.
Organizations then end up not realizing that they are basically “drifting to disaster,” Fleming said. “We don’t know that our systems are falling apart until they actually fall apart,” he said.
Normalization of deviance was a focal point of the Governor’s Independent Investigation Panel report on the Upper Big Branch disaster. The team, commissioned by then-Gov. Joe Manchin (D) of West Virginia, was led by J. Davitt McAteer, who was head of the Mine Safety and Health Administration during the Clinton administration.
Investigators said the drive to produce coal was more important than safety for Massey Energy, and the company made allowances for hazards such as inadequate rock dusting and poorly maintained equipment – in effect, normalizing deviance.
Although Massey Energy denies that coal dust played a major role in the explosion, the Governor’s Independent Investigation Panel report stated that after a spark from the shearer ignited a small amount of methane gas, excessive coal dust fueled a stronger blast that “ricocheted” in multiple directions for more than two miles.
McAteer believes that a change in safety culture is possible, even after such a dire event, but it requires tearing up the problematic culture and retraining all workers – from middle managers and foremen to section supervisors.
“You have to make it so meaningful,” he told Safety+Health. Simply telling workers, “Oh, don’t do it that way; we do it this way,” is not enough. Instead, the directions must include consequences of failure to comply. “It’s not an easy task,” McAteer added.
He pointed to CONSOL Energy Inc. (formerly Consolidation Coal Co.), the owner of a mine near Farmington, WV, where an explosion in 1968 killed 78 miners. In the aftermath of the tragedy, Congress passed the Federal Coal Mine Health and Safety Act and, over time, CONSOL adopted a better approach to safety.
“You had this evolution then of a safety culture in one of the companies that had had a very bad record, and that evolution has continued, and to their credit, they have adopted a comprehensive safety and health program,” McAteer said.
However, improvement does not indicate perfection, he noted. According to an analysis conducted by the Investigative Reporting Workshop at American University in Washington, CONSOL and Massey Energy tied for the most mine fatalities – 23 each – from 2000 to 2009, although Massey had a worse ratio of deaths-to-production.
Given the fluidity of mine conditions, McAteer emphasized the importance of taking precautions so that when something goes wrong, the impact is minimal and contained.
Two types of change
Improving performance requires change. But Fleming was careful to distinguish between incremental change – changing the approach to a problem – and transformational change – changing how you think about approaching a problem. The latter means “changing your view of the world rather than changing activities,” he said. “Really, we’re very poor at that; it’s very hard to do.”
Crisis usually is at the heart of transformational change, Fleming said. When interviewing small construction companies in 2010 as a part of a Nova Scotia construction safety research project, he found that transformational change was tied to a personal or business driver, such as the death of an employee or loss of a major contract. In one case, a company owner’s son-in-law was killed while working on a project because proper procedures were not in place. When the owner talks about why he is committed to safety, he says he “killed his son-in-law,” Fleming said. The man now works to improve safety at his company as well as others.
Fleming highlighted the role of leadership in spurring change. In his opinion, even the most well-intentioned safety professional can achieve little without support from the top that extends beyond simply promoting safety in words.
In Fleming’s experience, leaders always say safety matters, but employees act based on the relative priority of safety. As he put it, “What are the things that are going to get rewarded or not rewarded in this organization?” In other words, if the manager always notices when employees are behind schedule but never praises them for safe behavior, it tells them to focus on working quicker, not safer.
To reduce injury rates at Collins Bus Corp. in South Hutchinson, KS, Mike Strickland had to confront complacency. When he joined the company in 2008, he was its first full-time dedicated environmental, health and safety professional. (Before, an employee had split the maintenance and safety duties.)
Strickland said the general attitude at the company was that a certain number of injuries was acceptable and part of doing business. He changed that thinking by combining education with “matters of the heart” – teaching workers to think about their families and safety at home and at work.
Injury rates fell significantly within two years. Although figures have since increased, Strickland cited evidence of a cultural shift.
“Now when I’m out on the shop floor, I’m getting employees who come up to me and say, ‘Hey, Mike, I want to talk to you about this. Here’s what I saw. Is this a problem?’ Before, I think people just sucked it up and went about their business,” he said. “There’s more of an open atmosphere in talking about safety issues, and people aren’t perceived as being whiners or complaining about things.”
Such cultural indicators may be just as important as incident rates. Fleming suggested that part of what sets safe companies apart is being aware of where they fall short.
“To be safe, you need to have a constant level of unease. When you start to feel you’re safe, then you’re not safe,” he said. “Ultimately, safety is a constant battle. You’re constantly trying to create this dynamic equilibrium where safety is being managed.”