Safety Culture Development: The Gap Between Industry Guidelines and Literature, and the Differences Amongst Industry Sectors.

Amsterdam University of Applied Sciences

Safety Culture Development

The Gap Between Industry Guidelines and Literature, and the Differences Amongst Industry Sectors.

Karanikas, Nektarios; Soltani, Pedram; de Boer, Robert J.; Roelen, Alfred L.C.

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10.1007/978-3-319-41929-9_7 Publication date

2016

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Advances in safety management and human factors

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Karanikas, N., Soltani, P., de Boer, R. J., & Roelen, A. L. C. (2016). Safety Culture Development: The Gap Between Industry Guidelines and Literature, and the Differences Amongst Industry Sectors. In P. Arezes (Ed.), Advances in safety management and human factors (pp. 53-63). Springer International Publishing. https://doi.org/10.1007/978-3-319- 41929-9_7

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Pre-print version. Post-print version: DOI 10.1007/978-3-319-41929-9_7

Safety Culture Development: the Gap Between Industry Guidelines and Literature, and the Differences Amongst

Industry Sectors

Nektarios Karanikas ¹ , Pedram Soltani ² , Robert J. de Boer ¹ , and Alfred L.C. Roelen ^1,3

1

Aviation Academy, Amsterdam University of Applied Sciences, Weesperzijde 190, Amsterdam, the Netherlands.

{N.Karanikas, RJ.de.Boer, A.L.C.Roelen}@ hva.nl

2 Department Technology, Policy and Management, Delft University of Technology, Jaffa- laan 5, Delft, the Netherlands

P.Soltani@student.tudelft.nl

3 Netherlands Aerospace Centre, Anthony Fokkerweg 2, Amsterdam, the Netherlands Alfred.Roelen@nlr-atsi.nl

Abstract. Reason’s typology of safety culture (i.e. Just, Informative, Learning, Flexible and Reporting cultures) is widely used in the industry and academia.

Through literature review we developed a framework including 36 markers that reflect the operationalization of Reason’s sub-cultures and general organiza- tional prerequisites. We used the framework to assess to what extent safety cul- ture development guidelines of seven industry sectors (i.e. aviation, railway, oil

& gas, nuclear, healthcare, defense and maritime) incorporate academic refer- ences, and are similar to each other. Gap analysis and statistics showed that the guidelines include 53% to 69% of the safety culture markers, with significant differences across subcultures and industry sectors. The results suggested that there is a gap between the industry guidelines and literature, as well as variant approaches to safety culture across the industry. The framework suggested in the study might be used as reference for completing existing safety culture de- velopment plans and constructing safety culture assessment instruments.

Keywords: safety culture; just culture; informative culture; learning culture;

flexible culture; reporting culture

1 Introduction

Over the last decades, different theories of organizational culture have been devel-

oped, various characteristics of organizational culture have been identified [1] and

several definitions have been suggested based on the way people think (e.g., values,

attitudes, beliefs) and/or behave [2]. Safety culture is an aspect of organizational cul-

ture, and was firstly introduced in the frame of the investigation of the Chernobyl

nuclear accident in 1986. Since then, numerous studies have attempted to define, and conceptualize safety culture, thus leading “… to different ideas about the best means of developing a safety culture and thus also about the means of developing safety.’’

[3]. Regardless the diversity of studies, it seems that there has not been a framework integrating the safety culture characteristics referred in the literature and providing a holistic approach to safety culture development.

Despite the lack of academic consensus on the precise definitions and conceptualiza- tions, safety culture is seen as part of a safety management system. Authorities and organizations have recognized the need to plan for initiatives in order to foster safety culture, with the goal of reducing accidents and incidents. This is achieved by ensur- ing that employees pay attention to risks, are committed to safety, and openly discuss their views. Regional and international bodies of various industry domains have gen- erated their own lists of safety culture dimensions - prerequisites, and regulators have included safety culture as a matter of concern when auditing organizations [3]. How- ever, no study has been conducted about the extent to which guidelines of industry bodies embrace the academic body of knowledge, and how similar those guidelines are to each other.

The purpose of this paper is to present the results of a research project conducted for a European Nuclear Power Plant (ENPP) [4]. One of the main project objectives was to suggest a complete set of safety culture development prerequisites, and compare the relevant ENPP documentation with the guidelines published by the aviation, railway, oil & gas, nuclear, healthcare, military aviation and maritime sectors. The selection of the sectors was made upon request of the ENPP. As part of the study, a comprehen- sive literature review led to the development of an inclusive theoretical framework, and a gap analysis revealed the distance between industry guidelines and literature as well the differences amongst the industry sectors considered. The analysis framework presented in this paper can be used to establish a common cross-industry approach to the development of safety culture, which is important since professionals might work in different industry sectors during their career and a harmonized approach to safety culture will make the respective transitions more effective and will enable the sharing of good practices between industries. The framework can also function as basis for developing an instrument to assess and benchmark safety culture.

2 Theoretical background

The safety culture decomposition most widely mentioned in the literature and used by

the industry is the one suggested by Reason [5], who proposed that safety culture

consists of five subcultures that must be concurrently in place in order to foster such a

culture. Reason’s concept was complemented by various authors, who elaborated on

the scope of each subculture and provided more detailed guidance about their devel-

opment and maintenance (table 1).

Table 1. Reason’s safety subcultures (adapted from [5]) and further literature references.

Reason’s safety

subcultures Definition Literature references

Just culture A culture in which acceptable and unacceptable behavior is commu- nicated and understood.

[6]

Flexible culture A culture that allows flexibility and reconfiguration when the vari- ability of working conditions and goals cannot be captured by estab- lished procedures.

[7], [8], [9], [10]

Reporting culture A culture where staff from all or- ganizational levels voluntarily report safety hazards and own errors, violations, and deviations.

[6], [9], [11], [12], [13]

Informative cul-

ture A culture that enables sharing of a variety of safety information across the organisation.

[7], [11], [14], [15]

Learning culture A culture that draws valuable con- clusions from its safety infor- mation system, and drives changes in the organisation based on the lessons learned.

[7], [9], [12], [14], [15]

In addition to the elements per specific subculture, general prerequisites for safety culture development are described in the literature [7], [10], [12], [13], [15], [16], [17]. The combination of the safety subculture elements and general organizational prerequisites form a set of 36 markers, which comprises the analysis framework pre- sented in table 2 and used in this study.

Table 2. Analysis framework.

Marker Explanatory remarks

General prerequisites (G)

G1. Management commitment. Changes start from the top. There is both writ- ten and visible commitment.

G2. Leadership. Leadership is valued as a steering factor to- wards safety culture development. Leaders adapt and shift between target-oriented and transformational styles.

G3. Clear responsibilities and ac- countabilities of all management areas towards safety.

-

G4. Safety department visibly re- sponsible and accountable for safety

-

Marker Explanatory remarks planning.

G5. Employees’ involvement. The companies engage employees to planning, monitoring and improvement activities. A broad workforce representativeness minimizes power distance. A bottom-up approach in deci- sion making is preferred and planned.

G6. Non-reliance on past success. There is no ceiling for safety culture and resil- ience under a constantly changing environ- ment.

G7. Risk management policy. Decisions about changes and plans are based on a risk management framework, tailored to each level of decision-making.

G8. Planning for buffers. In addition to optimizing resources during planning, there is capacity to cope with the unexpected. This is not seen as resource waste.

G9. Rewarding safety initiatives. Rewarding active and exceptional contribution to safety such as new ideas, voluntary partici- pation in safety plans etc., but not daily per- formance.

G10. Internal communication. Open communication, questioning attitude and effective conflict management.

G11. External communication. Communication channels with the society, authorities and other sectors.

Just culture (J) J1. Documented definition of ‘’ac-

ceptable’’ and ‘’unacceptable’’

safety behavior, accompanied by assumptions, examples, indications, required evidence etc.

Workers and managers know what acceptable and unacceptable behavior is about, although a clear line cannot be drawn.

J2. The decision for attributing un- acceptable behavior is made and agreed by a team including peers.

-

J3. Practitioners know their rights and duties regarding occurrences.

A list of indicative measures and the cases that these might apply is communicated to employ- ees.

J4. Prevention of practitioners’

stigmatization. In cases of mistakes / errors (acceptable behav- ior) that caused adverse outcomes, support is provided to the actors regarding their reinte- gration.

J5. Organizational support in legal disputes.

In cases of “acceptable behavior” subject to police investigations, the organization provides legal, financial and psychological support.

Flexible culture (F) F1. Recognize the inevitable gap

between standard procedures and Rules and procedures assume ideal and con-

stant conditions.

Marker Explanatory remarks working practices.

F2. Control of variability. Policy for managing the efficiency – thor- oughness trade-off.

There is agreement on risk thresholds and boundary policies that delegate authority to employees for self-organizing. Emergency stop procedures are accessible when safety is compromised.

F3. Emergency response and crisis

management exercises. In addition to the planned exercises, the resili- ence of the system is assessed through un- planned diverse scenarios under different con- ditions and various actors.

Reporting culture (R)

R1. Clear policy about reporting. Definition of “who, what, when, where etc.”

regarding reporting; communication of poten- tial implications of reporting.

Characteristics for maximum poten- tial of a reporting system (note: 6 aspects in total as mentioned in the right column)

R2. Voluntary R3. Non-punitive

R4. Protected (confidential) R5. User-friendly

R6. Accessible (system close to work-station) R7. Timely feedback to reporter.

Informative culture (I) I1. A user-friendly safety infor-

mation system in place with free access for all employees.

-

I2. Content of safety information. Proactive and reactive type of information;

internal and external topics.

I3. Time for access to safety infor- mation is planned in working schedules.

I4. Information sharing across

teams, units and departments. Dedicated meetings, workshops, safety days etc., tailored to local needs as means to stimu- late discussions.

Learning culture (L)

L1. Learning from failures. Occurrence and voluntary reports; safety in- vestigation reports and audits results.

L2. Learning from success. Part of safety investigations; promotion of success by managers and leaders.

L3. Safety training. Incudes general training about safety manage- ment in the organization and specific training about the job role.

L4. Internal benchmarking. Lessons from internal comparisons across departments, units etc.

L5. External benchmarking. Lessons from external comparisons (e.g., simi- lar companies, industry sectors, regions).

L6. Safety information used to initi- Knowledge is transformed to learning. This is

Marker Explanatory remarks

ate changes. evident if lessons learned from all sources drive policy and attitude changes.

3. Methodology

The framework of table 2 was used to analyze the safety culture development guide- lines of seven industry sectors: nuclear, aviation, healthcare, maritime, oil & gas, railway and defense. The researchers consulted the documentation published by inter- national agencies and organizations per industry sector. In cases that such documents or agencies were not identified, we considered the ones available for the European region, and in case of inadequate resources in Europe, the North American region references were utilized; this decision was made on the grounds that the whole re- search project regarded a European firm.

If more than one document dedicated to safety culture was available per industry sec- tor, it was decided to assess the one(s) most recently published. Also, wherever there were various documents referring to safety culture development and including refer- ences to each other, the researchers analyzed the whole set of such published guidance per sector. Table 3 for provides an overview of the documents consulted per industry sector.

Table 3. Safety culture guidelines per industry sector.

Industry sector Documents consulted

Nuclear  [18], [19]

Aviation  [20], [21]

Healthcare  [22], [23], [24]

Maritime  [25], [26], [27]

Oil and gas  [28]

Railway  [29], [30]

Defense  [31], [32]

For each set of documents per sector, the researchers assessed which safety culture markers of table 2 were present (i.e. conducted a gap analysis). Only the guidance clearly and distinctly linked to safety culture was considered in the analysis; under this approach, general references to safety management were not considered if in the documentation these were not explicitly connected with safety culture. Following the gap analysis, percentages of markers’ reference in the guidance per sector were calcu- lated in overall and per safety culture area (i.e. safety subcultures and general prereq- uisites).

In order to provide a more concrete indication of the extent of alignment amongst

industry sectors in overall and per safety culture area, we used the Cochran’s Kappa

for evaluating the differences amongst all sectors and the Cohen’s Kappa for as-

sessing the degree of pair agreements. The former test shows if there is a significance

difference amongst binary data sets (i.e. safety culture is referred in the guidance or not). The Cohen’s Kappa takes values from 0.00 (complete disagreement) to 1.00 (complete agreement) and takes into account the effects of agreement by chance. The SPSS 22 software package was used, and the significance level was set to α=0.05.

4. Results

Due to space constraints, this paper only reports the percentages per safety culture area and industry sector, as well the results of the statistical tests in overall for the 36 markers. The statistical results for the differences amongst industry sectors per safety culture area are available to the reader upon request to the corresponding author. The industry sectors referred in the following Tables were coded (alphabetical order) as follows: A for Aviation, D for Defense, H for Healthcare, M for Maritime, N for Nu- clear, O for Oil & Gas and R for Railway.

Table 4 presents the percentages of markers indicated in the guidance per sector and safety culture area.

Table 4. Percentages of safety culture markers across industry sectors.

Sector All

markers Safety culture areas

General Just Flexible Reporting Informative Learning

A 69% 64% 40% 67% 86% 75% 83%

D 53% 73% 0% 67% 14% 75% 83%

H 58% 73% 0% 0% 71% 75% 83%

M 33% 55% 0% 33% 14% 25% 50%

N 64% 91% 40% 67% 29% 75% 67%

O 67% 82% 40% 67% 57% 50% 83%

R 67% 91% 40% 33% 43% 75% 83%

All 59% 76% 23% 48% 45% 64% 76%

The Cochran’s test showed significant differences amongst the industry sectors when considering all 36 markers (p=0.000); the same test indicated that the highest non- alignment amongst sectors concerned the general prerequisites (p=0.046) and report- ing culture (p=0.038). The pair agreements for sectors (i.e. Cohen’s Kappa values) for all markers combined are shown in Table 5.

Table 5: Cohen’s Kappa values for all safety culture markers Table 5. Cohen’s Kappa values for all safety culture markers.

Sector A D H M N O R

A

D 0.43

H 0.64 0.55

M 0.36 0.51 0.42

N 0.38 0.55 0.42 0.34

O 0.55 0.49 0.35 0.30 0.45

R 0.55 0.60 0.59 0.40 0.57 0.50

5. Discussion

5.1 Planning for safety culture development

Taking into account the definition and scope of each safety culture area and marker, it can be claimed that the set of general prerequisites is the ground on which the organi- zations can build their safety culture. Furthermore, when considering the five subcul- tures suggested by Reason, it seems that their operationalization must follow a specif- ic order: Just, Flexible, Reporting, Informative and Learning. More specifically:

1. Just culture corresponds to an operational environment in which workers are dealt with fairness, and unwanted events are judged against predefined and agreed boundaries and not merely against the severity of their outcomes.

2. Given the establishment of a just culture, a flexible culture might be established and the inevitable variability of working conditions and human performance will be recognized. Procedures will be revisited when design assumptions are invalid and/or conflicting goals emerge repeatedly.

3. Flexible and just cultures not only might result to an increase of the amount of the voluntary reports, but they might boost the quality and traceability of such re- ports. In addition to hazards, staff will share their own errors and experiences sourcing from confrontation with competing objectives and inadequate working conditions.

4. When reporting becomes systematic, a broad range of local safety information will be obtained, that can be shared across the organisation in addition to the in- formation collected through other sources (e.g., audits, safety reviews, safety in- vestigations).

5. A consistent and effective sharing of safety related information will increase the possibility for the organisation to learn and proceed to targeted and substantiated changes.  

5.2 Alignment between industry and literature and within industry

The percentages of markers in overall suggest that, in average, the industry guidelines

in overall refer to 59% of the safety culture development elements suggested by the

literature. In this context, aviation is the sector that includes most of the markers in its

guidelines, while the maritime sector includes only one third of those and ranks last

amongst the seven industry sectors examined. When considering the individual safety

culture areas, in average, just culture is the area least discussed in industry guidelines,

whereas the general prerequisites and learning culture are the areas mostly represent- ed. It is interesting that the percentages of markers’ presence vary from 0% to 91%

across the sectors and safety culture areas, indicating remarkable variances of align- ment to the academic references.

The results of the gap analysis suggested that there has been a distance between the academia and the industry regarding safety culture markers, such a distance varying from moderate to large. The fact that this study identified in literature various tangible ways to realize safety culture denotes that academia might generate practical solutions for the industry but those might not be appropriately communicated.

The statistical tests regarding the agreement amongst the industry sectors, revealed that the guidelines of the industry differ highly in the safety culture markers consid- ered. The highest disagreement regards the reporting culture and general prerequi- sites; it is noticeable that although the latter area is one of the most frequently repre- sented in terms of average percentage of safety culture markers, the industry sectors differ significantly in the sets of general prerequisite markers included in their respec- tive documentation. The pair comparisons revealed low to moderate agreement with Cohen’s Kappa values varying from 0.30 to 0.64, where the lowest agreement was indicated between the oil & gas and maritime sectors and the highest agreement re- garded the aviation and the healthcare industry sectors.

6. Conclusions and Recommendations

The framework used in this study was based on a comprehensive literature review and incorporates specific and tangible characteristics that organizations can use to opera- tionalize their safety culture development. Although the researchers sought to build a collectively exhaustive and mutually exclusive list of safety culture markers, the framework might be adjusted based on new research and concepts, and will be re- evaluated in the frame of an on-going study about safety culture assessment.

Since organizations might already have a set of safety culture markers in place, and need to prioritize their additional efforts under limited resources, it is suggested that they ensure maintenance and valid assessment of the existing safety culture markers and proceed to developing the complete set of markets with a specific order as pro- posed in the discussion section: General prerequisites, Just, Flexible, Reporting, In- formative and Learning cultures.

The gap between literature and industry signifies the need for initiatives in order to bridge theory and practice. This will ensure that the concepts and models developed by the academia serve the needs of the industry, and that research results are retrofit- ted with practical experience and enable scientists to refine their theories and models.

Apart from the distance between professional practice and academia, this research

also showed a distance amongst industry sectors. It seems that although safety is a top

priority for all industries considered, the way safety culture development is guided

differs much across these. Relevant initiatives, efforts, ideas, concepts, solutions and

challenges must be shared amongst the various sectors, to establish a common lan- guage about safety and facilitate the sharing of practices and experiences across the industry. This becomes increasingly important as professionals work in various indus- try sectors during their career.

Lastly, in the frame of this study, it is noted that an absence of a safety culture marker in the guidance documentation in an industry does not provide evidence that the re- spective industry sector does not exploit this marker. There is always some distance between work-as-designed and work-as-done and the practice in individual companies will differ from the guidelines published by industry bodies.

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