The term âsafety cultureâ first gained prominence in 1984 after the Bhopal disaster, and became increasingly popular after the worldâs worst nuclear accident at Chernobyl in 1986. But a few decades later, a radical overhaul of its existing assumptions is needed if safety culture is to remain relevant. We will need to take stock of the various definitions and approaches and move forward, especially in the light of the Covid-19 pandemic.
A solid reference point is the idea that safety culture expresses âthe way we do things around here in relation to safetyâ. Amongst both practitioners and academics, there is a consensus that safety culture reflects a proactive stance to improving safety in operational environments. It is also instructive to consider an accident where there is widespread agreement about the lack of safety culture as a key underlying cause â one such example is Deepwater Horizon.
Case Study: Deepwater Horizon and the Absence of Safety Culture
Eleven lives were lost; five million barrels of oil were spilled into the sea; BP spent tens of billions in fines, alongside economic claims, disaster response efforts, and clean-up and restoration programmes, not to mention the massive reputational damage inflicted.
President Barack Obama created the National Commission in 2010, shortly after the disaster, for the purpose of independently and impartially investigating the causes of the oil spill in the Gulf of Mexico. The troubling symptoms of a disaster-in-the-making could have been picked up far earlier with a much stronger safety culture. The National Commission drew attention to the industryâs safety culture in its report:
The immediate causes of the Macondo well blowout can be traced to a series of identifiable mistakes made by BP, Halliburton, and Transocean that reveal such systematic failures in risk management that they place in doubt the safety culture of the entire industry.1
How did the crew at Macondo come to describe it as âthe well from hellâ, whilst BPâs Vice President of Drilling Operations said it was ââŚthe best performing rig that we had in our fleet and in the Gulf of Mexico?â2 You could be forgiven for thinking that they were talking about different oil rigs altogether. The oil rig crew and senior management were not only talking a different language, but their views on safety culture appeared to be at opposite ends of the spectrum.
What we know from the National Commissionâs report is that key safety systems were intentionally switched off. For starters, the physical alarm system on the rig was disabled a year before the disaster. A crucial safety device to shut down the drill shack if dangerous gas levels were detected was also disabled, or âbypassedâ. This last fact had not gone unnoticed â indeed, the Chief Technician had previously protested to his Supervisor. The response he received was truly astonishing, indicating a much wider malaise: âDamn thing been in bypass for five years. Matter of fact, the entire fleet runs them in bypass.â3
The catalogue of management failings did not end there. There was no procedure for running, or interpreting, what in the oil and gas business is called the ânegative pressure testâ to show that the well was safely sealed with cement. The crew were not, therefore, able to decipher critical data that would have alerted them to the danger signs. To make matters worse, there was no procedure for calling back to shore for a second opinion about confusing data. And there was no formal training for the crew, especially in response to emergency situations.
By far the biggest failing was the failure to learn from a near-miss incident in the North Sea just four months earlier. The basic facts of the two incidents were essentially the same, but the North Sea near miss did not reach the level of catastrophic blowout. Tragically, the lessons from the North Sea incident werenât communicated to the crew at Deepwater Horizon. The critical learning remained frustratingly âlocked awayâ in the system. Had this learning reached the right personnel in time, it may have prevented the disaster.
An âoperations advisoryâ containing the critical information was sent to some of the fleet in the North Sea, and a PowerPoint presentation was created for the purposes of learning from the incident. Neither made it to the Deepwater Horizon crew. This fitted part of a pattern of ââŚmissed warning signals, failure to share information, and general lack of appreciation for the risks involvedâ.4 In these circumstances, the very notion of safety culture seems quite alien.
Safety Culture: Content and Characteristics
The field draws from a range of contributions, often using âcultureâ in a more general sense as a departure point. Several notable writers have added their own unique perspectives â for example:
Hofstede (1991) speaks of culture as the collective programming of the mind, a kind of âmental softwareâ that distinguishes one group of people from another.5
Bang (1995) suggests organisational culture is a set of common norms, values and world views that emerge when an organisationâs members interact with each other.6
Reason (1998) analyses safety culture in terms of five interlinked subcultures (informed, learning, reporting, just and flexible cultures) based on incident analyses.7
Guldenmundâs (2000) interpretive model contains three layers: unconscious and unspecified basic assumptions, espoused beliefs and values, and artefacts.8
A recent review of the safety culture literature by Cooper (2016) over the previous 30 years has usefully described an emerging consensus from academic research and public enquiries into safety disasters.9 In Cooperâs view, there are six major safety culture characteristics:
Management and supervision (e.g. visible safety leadership)
Safety systems (e.g. formalised strategic planning)
Risk (e.g. risk appraisal, assessment and controls)
Work pressure (e.g. safety versus productivity)
Competence (e.g. knowledge, skills and ability of people)
Procedures and rules (e.g. codified behavioural guidelines).
These six characteristics are no doubt a useful starting point in highlighting some of the fundamentals of safety culture. But far less is said about the agents of safety culture change, or the psychological tools needed to change or improve any of the characteristics.
As a result, there is a real need to think beyond analytical approaches that pay scant attention to the psychological flexibility required to make positive changes. Here, we are shifting the emphasis to the psychology of habit formation, and what needs to happen through awareness to change unsafe behaviours into safe ones.
Mindfulness practice, which creates the awareness required to change, can be used as an effective âhabit releaserâ. It seems pointless to talk about change or improvement in safety culture, without providing the tools or agency for it to occur in the first place.
Safety Culture in the Age of Pandemics
The future of safety culture is incredibly important if we wish to meet new challenges, especially in the era of global pandemics. It is an ideal time to scrutinise the whole concept and improve upon it.
The M4 approach takes the view that safety culture is much more than just shared assumptions, norms, values or a set of characteristics. With the right tools and a multi-level approach, it is possible to change and improve safety culture. A great many current approaches focus on content, rather than process, and rarely discuss the agents of change. Without a doubt, this is a missed opportunity.
We must be able to understand the process of how people come to think and act the way they do, with the goal of fully enabling change. The psychological tools for achieving this are provided by the mindfulness approach. Deploying these tools helps to âunfreezeâ existing safety cultures, whilst providing the catalyst for new action. We are interested not only in the safety of workers, industrial processes and procedures, but also in the safety of whole societies.
To set the bar higher, we need safety leaders to be not just visible, but mindful. We need risk awareness to be present in an everyday sense, just as much as we need risk assessments and controls. We need safety rules and procedures to be mindfully enacted. And when they need changing, this needs to involve a high degree of consciousness to break old habits and form new ones.
The Covid-19 pandemic has clearly demonstrated how safety is of everyday relevance to every worker and citizen globally. Commitment to safe behaviour is required by everyone, whether they are working or not, and a unified 24/7 effort is necessary. To reduce the rates of transmission and infection, national governments, organisations, workers and citizens must work with the same safety goals in mind.
The pandemicâs hammer blow to the world on multiple fronts fundamentally affected our everyday existences and restricted our freedoms. It reached indiscriminately into every home, office and business across the globe. Workplace health and safety has undergone a big transformation as a result, and views of safety culture will need to adapt accordingly.
Mindful Safety Culture
The world changed significantly in 2020, and our ideas about safety culture must follow suit. It makes sense to shift the emphasis to what it takes to create and sustain a âmindful safety cultureâ. Mindful safety culture can be defined as follows:
the degree to which an organisationâs people â individually, relationally, organisationally, and societally â consciously direct their everyday attention to improving safety.
In this approach, assumptions, values and beliefs do not represent the destination, but are viewed as reference points along the route to an improved safety culture. It is important to acknowledge their influence and bring them into conscious awareness wherever possible. There will of course be a shared understanding of how âthings are done around hereâ in relation to safety. This is important for establishing a suitable frame of reference. But ultimately, we are more interested in...