Our thoughts on safety culture

Our last thought

A positive approach to safety is a powerful lever
issue 28 - september 2017 - Philippe Balzer,Damien Santa-Maria
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More thoughts on safety culture

Organizational silence: the best enemy of safety
issue 26 - january 2017 - François Daniellou
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Promoting safe behaviour is not the ultimate challenge when improving safety performance
issue 23 - september 2016 - Myriam Promé
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Professional misconduct does not explain the real cause of accidents
issue 16 - december 2015 - Mario Poy and Diego Turjanski
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Safety at work must be consistent with safety at home
issue 15 - september 2015 - Philippe Balzer
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Systematic sanctions are not the best approach to change the behaviour of a person who does not respect the rules
issue 14 - october 2015 - Amel Sedaoui
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Accidents are not due to good or bad luck
issue 13 - september 2015 - Philippe Balzer
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The most experienced people can be too sure of themselves
issue 12 - june 2015 - Denis Besnard
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More rules = fewer accidents or more violations?
issue 11 - May 2015 - Myriam Promé

While they cannot claim to be ultra-safe (Amalberti, 2008), large industrial facilities are governed by safety management systems that implement rules and operating procedures. In everyday language, ‘rules' refers to requirements regarding appropriate conduct in a particular situation. They extend beyond the scope of the company and lie at the heart of our society.

In many domains, rules do not express the wishes of those that are governed by them; they represent an order or an imposition. The domain of safety is no exception in this respect; on the contrary, here rules are particularly prescriptive. Non-compliance can lead to a dangerous situation, sometimes coupled with sanctions.

However, the increasing complexity of our organizations and the proliferation of rules can make compliance very expensive or even impossible. Furthermore, overly rigid (zero tolerance) enforcement can lead to non-compliance. The result is ‘automatic' actions that reflect short-term compliance rather than intelligent prevention behaviour (in the form of an integrated safety culture, for example).

The same questions keep coming up: Why do people break the rules? Why do they comply with them? How far should the rules go?

While there are many reasons why someone decides to break a rule, the fundamental element of compliance strategies is that it must make sense to the person who is expected to follow it. Without being exhaustive, here are some ideas to think about:

-1. Encourage feedback from operators about the conditions that lead to non-compliance. Operators know their job best and understand the circumstances in which compliance becomes impossible. Encouraging this feedback is the first stage in managing situations that lead to violations.

-2. Working upstream with operators in the development of rules before their implementation is a very effective way to reduce the number of accidents. It fosters compliance and reduces the number of violations.

-3. Establish a consensus on stop rules. These rules allow operators to immediately stop work when conditions require. This decision becomes easier when it is sanctioned by management.

-4. Encourage a questioning attitude to managed safety. If an action must be carried out in an at-risk environment or difficult working conditions, what is the safest way to proceed? What do experienced colleagues recommend? HSE standards? Supervisors?

-5. What are the company’s strategic objectives? What resources are allocated to these goals? What are the working conditions that they create for operators? Many violations are simply attempts to carry out work in degraded conditions.

Myriam Promé-Visinoni

May 2015

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Is local culture a major influence on safety culture?
issue 10 - April 2015 - Dounia Tazi

It is often the case that when we work with companies we hear statements such as "Oh, but here it's different, you can't compare us to somewhere else or expect to find the same practices here, it's our culture", in order to justify some safety practice or other. The ‘somewhere else' can include: the next valley, another region, another country or another continent.

Studies carried out on a global scale, such as the ‘Global Leadership and Organizational Behaviour Effectiveness' project support this idea, grouping countries according to their cultural similarity. This criterion is identified as a determining factor in the effectiveness of organizational and behavioural leadership. One conclusion that is given can be summarized as, ‘When in Rome, do what the Romans do; if you're somewhere else, do what they do'.

ICSI has been asked to work with companies in many parts of the planet with different local cultures, and in turn can ask the question: to what extent is safety culture influenced by the country's culture?

Between 2008 and 2013, the Institute carried out a large-scale study of the factors that influence perceptions of beliefs and practices related to safety. We collected more than 21,000 questionnaires about perceptions of safety (21 entities in 4 continents in the oil, services, and gas transport and storage sectors). Three potential influential factors were tested: the sector of activity, the geographical area and the hierarchical level of respondents.

The study showed that the factor that has the most influence on perceptions in terms of safety culture is the sector of activity, which is well ahead of the geographical factor. In fact, the geographical factor takes third place after the hierarchical level. In other words, the ‘local' culture does impact safety culture but is not a major determinant in the sectors that were studied. The factor that has the most influence on perceptions of safety culture and practices is the sector of activity.

Yes, organizations that want to move to safer practices must take into account the local culture if they want to have a better understanding of the perceptions and practices of actors. However, they have other levers that can influence perceptions and practices at the entity itself, notably the organization that they put in place and the ‘culture' of the sector they are part of.

Dounia Tazi
April 2015
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Safety leadership provided by managers is essential to improve the organization's safety culture
issue 9 - March 2015 - Camille Brunel

Managers are at the heart of forging safety culture and developing leadership is a key objective. Several observations confirm this fact:

- Getting individuals to think in terms of safety does not happen spontaneously, even if their health and safety are at stake. Employees are influenced by the concerns of their manager and the priorities that they establish. If managers show no interest in safety, it is unlikely that their workforce will!

- Managers have access to resources that can encourage the development of safe behaviour. They can influence this behaviour by acting on both human and organizational factors; in particular good working conditions and a high-performance organization.

- The manager has a pivotal role in linking safety to the company’s other challenges: production performance, quality, costs and deadlines. They make trade-offs that ensure safety has its rightful place.

In short, individual and collective mobilization must go hand-in-hand with the safety leadership provided by managers, understood as the ability to influence behaviour so that it becomes safer.

But the influence of managers does not stop there. Organizational safety culture is directly dependent on the level of managerial commitment to safety issues. This commitment is an essential component of an integrated safety culture. Several levers are available to managers: i) their own attitudes and behaviour, ii) direct action on individual or group behaviour, iii) indirect action through factors that promote safe behaviour, such as work situations or the organization.

Based on these arguments, seven general principles of safety leadership management have been identified by members of ICSI:

- Principle 1 : Create a vision of safety that is consistent with the values and principles of the organization

- Principle 2 : Make safety a priority – both for the organization and for managers – and monitor it on a daily basis

- Principle 3 : Share the safety vision: influence, persuade and promote the feedback of information

- Principle 4 : Be credible: provide a coherent example

- Principle 5 : Promote team spirit and cooperation between teams

- Principle 6 : Spend time in the field, observe, listen and communicate effectively

- Principle 7 : Acknowledge good practice and make sure any sanctions are fair

In conclusion, the commitment of managers and the leadership they provide helps to improve safety culture. They create the conditions for employees to contribute. They also translate and make trade-offs between the strategic priorities of their business on a daily basis. They have at their disposal a number of levers from the world of human and organizational factors, which are based on a few fundamental principles.

Camille Brunel
March 2015
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Most accidents happen to people with the least experience - or do they?
issue 8 - February 2015 - Jesús Villena-López

During field visits, a comment that our team frequently hears is, "it's the least experienced ones who have the most accidents".

This assertion is a belief; an ideological expression. In other words, something believed to be true, even if the facts or empirical evidence do not support it. Beliefs, commonly found in the fields of politics or religion, can also affect safety. Consequently, work in the domains of anthropology and sociology argues that in a business, the expression of beliefs is a defensive ideology used to counteract risks that arise when work is done ("good doctors don't make mistakes").

Scientific evidence shows that newly-hired workers, who are still learning the skills of their trade, have accidents. But beware! More experienced employees can also have accidents - some of them dramatic. In fact, very experienced operators are often involved in major catastrophes.

There are various reasons for these phenomena. The psychological "SRK" (skills, rules, knowledge) model developed by Jens Rasmussen provides a better understanding of the reason for this paradox. According to the model, experience gradually builds direct associations between problems and solutions that help in the efficient completion of tasks. Over time, an experienced worker builds up a kind of repertoire consisting of a large number of solutions in response to a wide variety of problems. How, then, can experts be wrong? Surprisingly, too much experience can lead to an accident. This happens, for example when experts automatically trigger a solution to a problem they have (wrongly) identified. As for inexperienced workers, errors and accidents are most often due to incomplete or incorrect knowledge. Errors can also arise from new or complicated situations that overwhelm their ability to respond, and where their lack of experience means that they do not have immediate solutions.

This model is supported by the risk management theory developed by René Amalberti. The author argues that the relationship between competence and undesired events takes the form of an inverted U: lack of knowledge can lead to accidents and too much knowledge can turn into the normalization of deviance, which can exceed system limits and lead to an accident.

Finally, beliefs have historical roots. Marcel Simard demonstrated that at one time in the history of industrialization, the only protection workers had against accidents was their own professionalism and experience. Although the socio-technical context has changed (notably with the development of safety management systems and close attention from mangers) this belief, called the "shop-floor" culture by ICSI is still, more-or-less present in organizations. A very strong shop-floor culture indicates that workers believe first and foremost in their own experience and expertise in order to manage risk.

Jesús Villena-López
February 2015
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Individual decisions are influenced by group opinion
issue 7 - January 2015 - Philippe Balzer

Why was it a bad idea for Robinson Crusoe to play rugby ?
We all know the story of Robinson Crusoe. Now imagine he'd been on his desert island with his five best friends, partners in crime from his youth and fellow rugby players. Would he have behaved in the same way and adopted the same safety strategies as those described in the novel?

Rationality would suggest, "As long as Robinson is aware of the risks he'll always be cautious. He might only do stupid or dangerous things if he doesn't know about the risks or if he's foolish..."

However, behavioural sciences and the sociology of organizations tell us that it is not as straightforward and systematic as the advocates of "safety values" would like it to be.

Unfortunately, Robinson, because he wants to fit in with his friends who just want to have fun, goes diving beyond the reef to see the sharks. He joins in and throws himself off the top mountain as if it was a ski slope.

Heavily influenced by pressure from the group, he adopts risky behaviours that are inconsistent with what he would otherwise have done given his experience.

How to save the brave soldier Crusoe?
Fortunately for all of those who are HSE advocates, this influence can also work in everyone's favour! Rowdy revellers can become devout practitioners of risk-free leisure activities. In the interest of survival, they are able to become a member of an organisation and adopt behaviours that help to manage, as far as possible, risks that cannot be avoided.

We can save the "risk takers" in our companies by working to create groups whose practices, rituals and beliefs have a positive influence on each of its members at all times. Our efforts to create groups where there is a strong safety culture will also influence any newcomers.

Over time, this "organisational socialisation" will create a virtuous and constructive circle.

Philippe Balzer
January 2015
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To change safety culture, we need the personal involvement of all of the organisation's stakeholders
issue 6 - December 2014 - Amel Sedaoui

Safety culture is built through social relations between actors in an entity. The dynamics of these relationships allows "ways of thinking and acting" to become collective, in other words shared and accepted by a majority of the management and employees. However, if this change is measured at the organisational scale, it is a "personal and collective experience" and implies a profound transformation of values, norms and practices.

For this transition to be successful, management involvement is paramount. It should drive and sustain changes as they progress, through visible leadership and participatory practices. Managers are also expected to provide guidance on the anticipated changes or, at a minimum, provide a vision of safety culture.

This does not mean that employees and groups, including supervisors and local managers are simply the targets or recipients of the anticipated changes. Although there are many contradictory examples in the industry, it is impossible to imagine that a profound transformation at the level of grass-roots workers can simply be managed by a director or the HSE department. A programme to change safety culture is a company-wide project that requires the active involvement of all of the organisation's stakeholders, who must take ownership and execute it.

In this context, the involvement of grass-roots workers has three benefits:

- In the inital justification of the need for change: workets are given a voice, and any concerns that they may have about the implications of the changes for their job are listened to. It is at this stage that the psychological mechanisms that lead to individual and collective resistance to the new safety culture project are generated.

- When the main areas for the changes in safety culture are developed: this will boost their commitment and encourage them to take ownership of the anticipated changes.

- When action is taken to implement changes: this makes them actors in making changes, rather than simply the recipients of them.

It is clear that the extent of the involvement of grass-roots workers varies as the project advances, and must be organised and led. It takes the form of consultation, the co-construction of the action plan, or even the delegation of actions and responsibilities for the programme's development.

Finally, knowing when and how to calibrate the right degree of involvement (supervisors and grass-roots workers) that is appropriate to the context, the phase of the programme and those concerned, itself calls for an evolution or change in management practices. These include listening, two-way communication, consultation, delegation and especially, positive feedback. These practices suggest a directive-participative leadership style (see the conviction from April 2014). This change in supervisory practices has to be managed and supported as new habits must be learned and cannot be decreed.

Amel Sedaoui
December 2014
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People's actions, reactions and resistance are consistent with their perceptions
issue 5 - October 2014 - Denis Bernard

Humans have a very partial access to reality. We are limited by what our senses, our knowledge and experience allow us to grasp. A useful analogy for understanding the concept is the perception of the temperature of a room. If you ask the occupants to decide on the temperature, the answers will be different to the temperature indicated by a thermometer. Transposed to the field of risk, the concept of perception reflects the fact that the level of perceived risk varies from one person to another. Perceptions vary according to whether he or she has already experienced a similar event or not, the extent of their knowledge of risk factors, etc. Thus, risk taking has little to do with logical analysis but rather what individuals or groups perceive as the risks they face.

Perceptions are intrinsically valid: they express a form of reality that people hold to be true. However, a fundamental question is that of the homogeneity of perceptions within a group of people. For example, a typical question in the field of safety is the following: "On our site, do operators have the same ideas about following rules as managers?" Surveys  of perceptions therefore make sense, particularly before a company-wide programme is launched. They measure the convergence or divergence in the views of group members. The more divergent the views, the more work is needed to explain the differences and how to reduce them before commiting to the programme.

According to the principle of consistency, individuals spontaneously act in accordance with their perceptions. Therefore asking individuals about behaviours that are consistent with these perceptions is a route to success. Conversely, asking individuals to behave in ways that are inconsistent with their perceptions creates resistance. From this point of view, every programme that a company attempts to put in place and, in particular, any programme aimed at the development of a safety culture is a change that will engender both support and resistance to varying degrees. We can imagine a program that aims to eradicate the macho culture found on building sites. Such a programme may run into opposition from teams on the ground that have established initiation rites for young recruits. Conversely, the same program would meet less resistance from operators who are unfamiliar with the practice, or do not understand its social usefulness.

A programme to develop safety culture that begins without this knowledge of perceptions is exposed to unknown difficulties. It could be compared to a hiker who sets out blindly for a long walk, without knowing the summits they may need to climb in the following days.

In management terms, taking account of perceptions when providing support for a programme that aims to develop safety culture implies:

- recognising the weight of perceptions in the decisions of individuals and groups;
- assessing the degree of convergence and divergence of individual and group perceptions of actors who influence safety culture;
- anticipating the effect of group perceptions on support from, or resistance to, a programme that aims to change safety culture.

Denis Besnard
October 2014
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Safety indicators tell us nothing about the management of major risks
issue 4 - September 2014 - Dounia Tazi

In many sectors accident rates and seriousness are the main indicators of safety performance.

Moreover, they are one, if not the point of reference used by companies in a sector to compare their safety performance and set more ambitious targets.

However, a lingering belief persists.

It is usually assumed that the probability of a major industrial accident is low when the accident rate is low.

The illusory correlation between a low rate of workplace accidents and a low probability of a major accident is all the more common in companies and sectors where occupational safety is managed by the same entity that is responsible for safety related to major risks, or when safety management systems give priority to occupational safety indicators. This is regularly seen in the hijacking of a widely-known model: Bird's pyramid.

Figure 2: Bird's pyramid applied to occupational safety

Although the model and the numbers that compose it give an impression of clarity, it must be used with great care. Here we note two significant limitations in its use when applied to major accidents:

- it is a model of work-related accidentology: it cannot therefore be used to predict an event from another domain;
- it does not establish a causal link between incidents and fatal accidents (statistics from industry show that these two types of events can change independently).

One final point makes it possible to reject the idea of a link between work-related accidentology and major accidents. There are companies that, despite a very low or zero accident rate, have nevertheless experienced major accidents. A well-documented case is that of BP, in particular the explosion at the Texas City refinery in 2005 and the Deepwater Horizon oil platform in 2010.

Drawing parallels between occupational accidents and major accidents must therefore be done very cautiously. Some causes are shared by both types of events. However, significant differences in their nature and aetiology means that performance indicators of occupational accidents do not tell us anything about the possible occurrence of a major industrial accident. To think otherwise is a major error in risk management.

Dounia Tazi
September 2014

- Human and organizational factors of safety : state of the art. François Daniellou, Marcel Simard, Ivan Boissières, March 2010
- The baker panel report, Baker et al., 2007
- Mortureux, Y. (2013). Heinrich et Bird. La malédiction des pyramides. Tribunes de la sécurité industrielle.
- CSB reports on the Texas City explosion (2007)

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Human error is a consequence and not a cause ...
issue 3 - June 2014 - Myriam Promé-Visinoni

This does not mean that there is no human error involved in major disasters or simply in our daily lives! Rather, it means that operators are more often the victims of system defects rather than the main instigators of accidents. The error in question here refers to cases where a planned sequence of activities does not reach the desired ends, in the absence of chance or unexpected occurences. [3]
If we consider that errors are the result or a symptom of a malfunction [2] opens up opportunities to:

- improve prevention, develop the capacity to identify errors and recover from them; and
- search for the root causes of events.

If we view human error as a result, it is another way to improve the reliability of socio-technical systems, and their design throughout their lifespan. It improves human reliability by controlling the operational conditions of operators. It also makes it possible to focus on facilities and equipment, the organisation and whether resources are consistent with any safety objectives that have been set.

When human error is seen as a consequence, event analyses see the identification of errors as the beginning of the investigation! It becomes a search for the constraints that led to the occurrence of inappropriate actions or deviations from good practice. This in-depth appraoch requires an iterative understanding, turning the question over many times. In deciding to learn from the root causes of an event rather than its consequences, corrective actions can more effectively prevent the occurrence or recurrence of similar events [1].

This belief encourages us to examine in greater depth our working environment in order to create the conditions for risk management.

Myriam Promé-Visinoni
June 2014

[1] ICSI Working group  "Events analysis" (2014). FHOS, L'analyse approfondie d'évènement. N° 2014-04 of the Industrial safety reports, Institute for an industrial safety culture, Toulouse, France (ISSN 2100-3874).
[2] Dekker S. (2006). The Field Guide to Understanding Human Error. Ashgate, London.
[3] Reason J. (1993). L'erreur humaine, PUF, Paris.

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Departing from procedure does not necessarily increase the risk of an accident
issue 2 - May 2014 - Denis Besnard

The belief that departing from procedure leads to accidents is widespread in all sectors of industrial activity. This belief is based on the idea that procedures are exhaustive and all that need to be done is to follow them to carry out a task.

However, this comprehensiveness is not a given. Work is often made up of complex tasks that are carried out in a changing environment under time constraints. In these conditions, the number of parameters at play in the workplace and the combinations makes it impossible to identify all aspects of an activity in a useful document.

The reality of work is that procedures are almost always adapted in situ by operators. These are the people who find inconsistencies, lack of detail and problems in application. These invisible and silent adjustments make it possible for all at-risk socio-technical systems to function.

Consquently, these daily adjustments, that we call 'departures' make it possible to carry out the expected work. In practice, very few of them lead to safety breaches.

Denis Besnard
May 2014

Human and organizational factors of safety : state of the art. François Daniellou, Marcel Simard, Ivan Boissières, March 2010

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Promoting proactive safety behavious is key to developing safety culture
issue 1 - April 2014 - Camille Brunel

Industrial safety assumes a ongoing relationship between prescriptive "directives" set down by management (regulated safety) and "participation", i.e. taking into account the knowledge of workers in the field about local realitites (managed safety). The participatory aspect is absolutely essential. The involvement of the workforce is the condition by which they perceive that their daily contribution is acknowledged, and what they use to maintain a high level of vigilance and safe behaviour.

Thus promoting proactive behaviour encourages staff to participate in safety policy. It aims not only to promote the applicability of policy, but also helps to increase ownership by the workforce with the aim of improving the management of activities.

Camille Brunel
April 2014

- Human and organizational factors of safety : state of the art. François Daniellou, Marcel Simard, Ivan Boissières, March 2010
- Facteurs humains et organisationnels de la sécurité industrielle : des questions pour progresser. François Daniellou, April 2012
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Conviction équipe accompagnement - Icsi

Our thoughts on safety culture

"Icsi's consultancy team outline their philosophy about safety culture and the contribution of human and organisational factors. These beliefs underpin our commitment and guide our work on a daily basis"

Dounia Tazi

Director of the consultancy team

Conviction: Borrowed from the latin word convictio "convincing demonstration, decisive" = a principle or fundamental idea of an individual