Making Safety A Culture, Not Just an Initiative Sherry R. Perdue, Ph.D. Safety Performance Solutions 610 N. Main Street Suite 228 Blacksburg, VA 24060.

Making Safety A Culture,Making Safety A Culture,Not Just an InitiativeNot Just an Initiative

Sherry R. Perdue, Ph.D.Sherry R. Perdue, Ph.D.Safety Performance SolutionsSafety Performance Solutions

610 N. Main Street Suite 228 Blacksburg, VA 24060610 N. Main Street Suite 228 Blacksburg, VA 24060www.safetyperformance.comwww.safetyperformance.com

(540) 951-7233(540) 951-7233

©Safety Performance Solutions, Inc. (5.06) 2

A TSC Requires A Shift From A TSC Requires A Shift From Dependence to Interdependence.Dependence to Interdependence.

Dependence:• Top-Down• Condition of Employment• Safety for OSHA• Disincentives for Outcomes• Environment Focused• Fault Finding• Safety is Important• Quick Fix

Independence:• Bottom-Up• Personal Commitment• Safety for Self• Incentives for Outcomes• Behavior Focused• Fact Finding• Safety is Priority• Eventual Fix

Interdependence:• Empowerment• Team Commitment• Safety for Others• Recognition for Behavior• Env./Beh./Person• Systems Thinking• Safety is a Value• Continuous Improvement

DependenceDependence

IndependenceIndependence

InterdependenceInterdependence

Safe

ty A

chie

vem

ent

Safe

ty A

chie

vem

ent

BeginningBeginningImprovingImproving

SucceedingSucceedingLeadingLeading

1 2 3 4


A Total Safety Culture A Total Safety Culture Has Four Characteristics.Has Four Characteristics.

Safety is held as a Safety is held as a valuevalue by all employees. by all employees.

Each individual feelsEach individual feels responsibleresponsible for the safety of their coworkersfor the safety of their coworkers as well as themselves.as well as themselves.

Each individual is Each individual is willingwilling and and ableable to “go beyond the call of duty” to “go beyond the call of duty” on behalf of the safety of others. on behalf of the safety of others.

Each individual routinelyEach individual routinely performs actively caringperforms actively caring and/or safetyand/or safety behaviors for the benefit of others. behaviors for the benefit of others.


Values, Intentions, and Values, Intentions, and Behaviors Aren’t Always Consistent.Behaviors Aren’t Always Consistent.

0

20

40

60

80

100

Values(Should)

Intentions(Willing)

Behaviors(Do)

Per

cent

Agr

eem

ent

...caution coworkers when observing them perform at-risk behaviors.”...caution coworkers when observing them perform at-risk behaviors.”...caution coworkers when observing them perform at-risk behaviors.”

“I do ... “I am willing to ...“Employees should ...


SAFETYSAFETYCULTURECULTURE

A TSC Requires A TSC Requires Continual Attention to Three Areas.Continual Attention to Three Areas.

ENVIRONMENTENVIRONMENTEquipment, Tools, Machines,

Housekeeping, Climate, Management Systems

BEHAVIOR

Putting on PPE, Lifting properly, Following procedures,Locking out power, Cleaning up spills,

Sweeping floors, Coaching peers

PERSONPERSONKnowledge, Skills, Abilities,

Intelligence, Motives,Attitude, Personality


Actively Caring Is Actively Caring Is Influenced by Five Person States.Influenced by Five Person States.

Actively Caring

BelongingSelf-Esteem

OptimismPersonal Control

Self-Effectiveness

“I care about my team”“I care about myself”

“I expect the best”“I am in control”

“I can do it”


““The very things that got us here The very things that got us here may be the same things may be the same things

that hold us back from getting better.”that hold us back from getting better.”


Total

Safety

Culture

A ‘Call to Arms’

- Assess safety culture

-- Create a sense of urgency

Establish Expectations

- Make safety everyone’s

responsibility

Develop Safety

Leadership

- Improve the ability

of leaders to drive safety

Align SafetySystems

- Develop & improve systems using a

‘people-based’ focus


Total

Safety

Culture






responsibility

Develop Safety

Leadership



Align SafetySystems



A “Call to Arms”


A Safety Culture Survey Measures A Safety Culture Survey Measures Employee Perceptions.Employee Perceptions.

-Perceptions are “reality” - Although perceptions may be incorrect, they drive behaviors and establish the culture.


A Safety Culture Survey (SCS)A Safety Culture Survey (SCS)Serves Several Purposes.Serves Several Purposes.

Identifies strengths and weaknesses in current safety systems Identifies strengths and weaknesses in current safety systems to help identify and prioritize areas of focus.to help identify and prioritize areas of focus.

Provides a means to compare performance against a Provides a means to compare performance against a benchmark.benchmark. External (overall, industry)External (overall, industry) Internal (cross-department, cross-facilities, oneself over time)Internal (cross-department, cross-facilities, oneself over time)

Provides a performance metric of improvement initiatives Provides a performance metric of improvement initiatives (through repeated administration).(through repeated administration).


A SCS Provides Many Benefits.A SCS Provides Many Benefits. Provides a proactive measure (v. trailing indicators such as injury stats, Provides a proactive measure (v. trailing indicators such as injury stats,

workers’ comp costs and regulatory penalties)workers’ comp costs and regulatory penalties)

Provides a gap analysis, differentiating perceptions of management and Provides a gap analysis, differentiating perceptions of management and employees employees

Provides information to effectively set budget priorities and allocate limited Provides information to effectively set budget priorities and allocate limited funds (and avoid the shotgun approach)funds (and avoid the shotgun approach)

Opens lines of communicationOpens lines of communication

Enhances employee support for change (employees more likely to support Enhances employee support for change (employees more likely to support change that’s based on change that’s based on theirtheir input and recommendations) input and recommendations)

Address requirements for employee involvement and annual program Address requirements for employee involvement and annual program evaluations mandated by OSHA VPPevaluations mandated by OSHA VPP


A SCS Has Benefits Over Other A SCS Has Benefits Over Other Information Gathering Tools.Information Gathering Tools.

Gathers information from Gathers information from allall or a or a representativerepresentative sample. sample. Committees, suggestion systems, and even interviews favor the Committees, suggestion systems, and even interviews favor the vocal vocal

minorityminority Results in better information, as well as “empowered” workforce.Results in better information, as well as “empowered” workforce.

Gathers sensitive information from employees in a confidential Gathers sensitive information from employees in a confidential manner (thus encouraging more frank, candid comments).manner (thus encouraging more frank, candid comments).

RelativelyRelatively quick, easy, and cost-effective. quick, easy, and cost-effective.


A SCS Should MeasureA SCS Should MeasureA Wide Variety of Issues.A Wide Variety of Issues.

Management Support for SafetyManagement Support for Safety Genuine interest in reducing injuries (v. “keeping the numbers low”)Genuine interest in reducing injuries (v. “keeping the numbers low”) Willingness to invest resources (i.e., time and money)Willingness to invest resources (i.e., time and money) Ability to balance safety with other KPI’s (e.g., productivity, schedule)Ability to balance safety with other KPI’s (e.g., productivity, schedule)

Peer Support for Safety Peer Support for Safety (“Interdependence” or “Actively Caring”)(“Interdependence” or “Actively Caring”)

Personal Responsibility for SafetyPersonal Responsibility for Safety


A SCS Should Measure A SCS Should Measure A Wide Variety of Issues.A Wide Variety of Issues.

Safety Management Systems, including:Safety Management Systems, including: Incident Reporting & InvestigationIncident Reporting & Investigation DisciplineDiscipline Rewards & RecognitionRewards & Recognition CommunicationCommunication Safety AccountabilitySafety Accountability TrainingTraining Behavior-based Observation & Feedback processBehavior-based Observation & Feedback process Employee InvolvementEmployee Involvement Facilities Audits & InspectionsFacilities Audits & Inspections


When Interpreting the Data, Consider These When Interpreting the Data, Consider These Particularly Interesting Comparisons.Particularly Interesting Comparisons.

Organization vs. Timevs. Norm

Wage vs. Salary vs. Wage Normvs. Mgt. Norm

2003 Survey Results: "Supervisors sometimes encourage employees to

overlook hazards to get the job done."

60%

46%

51%

60%

21%

15%

17%

15%

19%

38%

33%

25%

Unknown

Shift 3

Shift 2

Shift 1

Unknown

Wage

Line Mgt

Senior Mgt

Unknown

HR & Accounting

Materials Mgt

Loading

Repair Shop

Engineer Svcs

Mining Prod

Mining Maint

Plant Prod

Plant Maint

Norm

Site S-SA 2000

Site S-SA 2001

Site S-SA 2003

57%

69%

71%50%

15%

18%

11%17%

29%

13%

17%33%

Unknown

Shift 3

Shift 2

Shift 1

Unknown

Wage

Line Mgt

Senior Mgt

Unknown

HR & Accounting

Materials Mgt

Loading

Repair Shop

Engineer Svcs

Mining Prod

Mining Maint

Plant Prod

Plant Maint

Norm

Site S-SA 2000

Site S-SA 2001

Site S-SA 2003

Wage

Mgt.

Mgt Norm

Wage Norm



Look at the patterns shown by ‘sets’ of items:Look at the patterns shown by ‘sets’ of items: Employees should give feedback to peers for at-risk behavior…Employees should give feedback to peers for at-risk behavior… I’m willing to give feedback to peers…I’m willing to give feedback to peers… I do give feedback to peers…I do give feedback to peers…

66%

78%

80%

24%

16%

14%

10%

6%

6%

Do

Willing

Should

Favorable Neutral Unfavorable



Look at the patterns shown by ‘sets’ of items:Look at the patterns shown by ‘sets’ of items: Production demands don’t override Production demands don’t override ManagersManagers’ concern for safety.’ concern for safety.

Production demands don’t override Production demands don’t override SupervisorsSupervisors’ concern for safety.’ concern for safety.

Organization

Organization


Following the Analysis, Leadership Must Following the Analysis, Leadership Must Set a Clear Agenda for Change. Set a Clear Agenda for Change.

A clear vision (what the desired culture will be like) and A clear vision (what the desired culture will be like) and objectivesobjectives

Agreement of the steps that must be takenAgreement of the steps that must be taken

A leadership team that is unified, energized, and prepared to A leadership team that is unified, energized, and prepared to lead the changelead the change

A communication strategy to ensure that the message is A communication strategy to ensure that the message is consistent across the organizationconsistent across the organization


Total

Safety

Culture






responsibility

Develop Safety

Leadership



Align SafetySystems





Poorly Defined ExpectationsPoorly Defined ExpectationsResult In Two Problems.Result In Two Problems.

Leaders don’t always understand what they Leaders don’t always understand what they cancan and and shouldshould do to support safety.do to support safety.

The organization doesn’t The organization doesn’t recognizerecognize or or rewardreward those who perform well or help those who perform well or help developdevelop those who those who do not.do not.

““What Gets Measured Gets Done”.What Gets Measured Gets Done”.


SCS Results Often RevealSCS Results Often RevealLow Supervisor Support for Safety.Low Supervisor Support for Safety.

““Supervisors sometimes encourage employees to overlook hazards to get Supervisors sometimes encourage employees to overlook hazards to get the job donethe job done.”.”

““Employees are given feedback by supervisors if they are observed working Employees are given feedback by supervisors if they are observed working unsafely.”unsafely.”

““I am encouraged to stop a job is a safety hazard is identified.”I am encouraged to stop a job is a safety hazard is identified.”

““Work productivity and quality usually have a higher priority than work Work productivity and quality usually have a higher priority than work safety.”safety.”


Further Study Often Reveals Supervisors Have Further Study Often Reveals Supervisors Have Poorly-Defined Safety Responsibilities.Poorly-Defined Safety Responsibilities.

““Give monthly safety meeting talk”.Give monthly safety meeting talk”.

““Make sure everybody’s wearing their PPE”.Make sure everybody’s wearing their PPE”.

““Stop an employee if you see them breaking a safety rule”.Stop an employee if you see them breaking a safety rule”.

““Send people to training when required”.Send people to training when required”.

““Help new employees or transfers learn the safety rules”.Help new employees or transfers learn the safety rules”.

““Keep the injury rate in your group as low as Keep the injury rate in your group as low as possible.”possible.”


Use Three Steps to Develop Use Three Steps to Develop Supervisor Accountabilities.Supervisor Accountabilities.

Step 1:Step 1: Skill Set Development and EndorsementSkill Set Development and Endorsement A representative team develops a list of items describing how A representative team develops a list of items describing how

supervisors can be “TSC Change Agents”. supervisors can be “TSC Change Agents”. The list is reviewed, modified, and endorsed by the SeniorThe list is reviewed, modified, and endorsed by the Senior

Management Team as expectations for job performance. Management Team as expectations for job performance.

Step 2:Step 2: Skill Set Communication and TrainingSkill Set Communication and Training

Step 3:Step 3: Performance Support and EvaluationPerformance Support and Evaluation


The Skill Set Typically Contains The Skill Set Typically Contains Many Categories.Many Categories.

1.1. Support and reward employee participation in safety activities.Support and reward employee participation in safety activities.2.2. Set safety goals and expectations with employees.Set safety goals and expectations with employees.3.3. Provide regular formal and informal safety performance feedback.Provide regular formal and informal safety performance feedback.4.4. Model appropriate safety-related behaviors.Model appropriate safety-related behaviors.5.5. Solicit and encourage employee input on safety-related matters.Solicit and encourage employee input on safety-related matters.6.6. Demonstrate fact-finding rather than fault-finding for safety concerns.Demonstrate fact-finding rather than fault-finding for safety concerns.7.7. Communicate safety-related information, focusing on process measures, to Communicate safety-related information, focusing on process measures, to

employees regularly.employees regularly.8.8. Show visible support for safety policies, rules, procedures, and regulations Show visible support for safety policies, rules, procedures, and regulations

(regardless of personal opinion).(regardless of personal opinion).9.9. Demonstrate appropriate balance between safety and other performance Demonstrate appropriate balance between safety and other performance

measures.measures.10.10. Focus on safety processes rather than outcomes.Focus on safety processes rather than outcomes.11.11. Foster teamwork within the group.Foster teamwork within the group.


Each Category Should be Defined in Each Category Should be Defined in Objective, Observable, Behaviors.Objective, Observable, Behaviors.

A. Support and reward employee participation in safety activitiesA. Support and reward employee participation in safety activities

Behavioral Observation and Feedback Process (BOFP)Behavioral Observation and Feedback Process (BOFP) Work with BOFP committee member(s) to establish goals for your group.Work with BOFP committee member(s) to establish goals for your group. Schedule time for observations every week.Schedule time for observations every week. Allow/encourage BOFP meetings.Allow/encourage BOFP meetings. Participate in (or lead) ABC analyses.Participate in (or lead) ABC analyses. Request BOFP observations for specific operations or jobs and during Request BOFP observations for specific operations or jobs and during

outages or turnarounds.outages or turnarounds. Request BOFP observations be performed on you.Request BOFP observations be performed on you. Review (or ask BOFP participant to review) BOFP progress reports atReview (or ask BOFP participant to review) BOFP progress reports at

monthly safety meetings.monthly safety meetings. Recognize individual contributions toward BOFP (privately and publicly).Recognize individual contributions toward BOFP (privately and publicly). Recognize overall BOFP process accomplishments.Recognize overall BOFP process accomplishments. Keep up-to-date on pertinent BOFP data, including:Keep up-to-date on pertinent BOFP data, including:

Group members who are trained observers. Group members who are trained observers.


Use Three Steps to Develop Supervisor Use Three Steps to Develop Supervisor Accountabilities.Accountabilities.

Step 1:Step 1: Skill Set Development and EndorsementSkill Set Development and Endorsement A diagonal cross-sectional team developed a list of items (skill set) A diagonal cross-sectional team developed a list of items (skill set)

describing the ways FLSs can be “TSC Change Agents”. describing the ways FLSs can be “TSC Change Agents”. The list was reviewed, modified, and endorsed by the Senior The list was reviewed, modified, and endorsed by the Senior

Management Team as expectations for job performance.Management Team as expectations for job performance.

Step 2:Step 2: Skill Set Communication and TrainingSkill Set Communication and Training

Step 3:Step 3: Performance Support and EvaluationPerformance Support and Evaluation


Employee Engagement is Critical to Employee Engagement is Critical to Achieve a TSC.Achieve a TSC.

Employees know about unsafe conditions.Employees know about unsafe conditions.

Employees know when and where the at-risk behaviors occur.Employees know when and where the at-risk behaviors occur.

Employees know more about peers’ feelings, attitudes, and Employees know more about peers’ feelings, attitudes, and emotions which may impact safety.emotions which may impact safety.

Employees are in the best position to use the behavior-change Employees are in the best position to use the behavior-change strategies on a daily basis.strategies on a daily basis.

Peer support (“peer pressure”) is an extremely powerful motivator.Peer support (“peer pressure”) is an extremely powerful motivator.

Participation fosters ownership.Participation fosters ownership.


Involvement Increases the GeneralizationInvolvement Increases the Generalizationof Safe Behavior.of Safe Behavior.

IncreaseIncrease

IncreaseIncrease

No No Change*Change*

IncreaseIncreaseInvolvedInvolved

UninvolvedUninvolvedTw

o G

rou

ps

Tw

o G

rou

ps

TargetTarget OtherOtherBehaviorBehavior


Employees Should Contribute In Ways that Employees Should Contribute In Ways that Match Their Skills and Interests.Match Their Skills and Interests.

Conducting a VHS AuditAn individual achieving a “positive score” on a VHS auditA department achieving an average “positive score” on a VHS auditAchieving a positive grade on “Company Safety Directives” Attending a optional safety meeting or safety trainingServing on a safety committeePassing a “knowledge check” after trainingAnswering a series of questions correctly during a “Knowledge Check Audit”Leading a group safety meetingConducting or reviewing a JSA, JHA, or SOPParticipating in an incident investigationReporting a “qualifying” near miss or safety suggestionAverage time to safety work order closureConducting a safety/housekeeping audit or vehicle inspection“Score” on a housekeeping auditSharing injury/near miss at safety meetingCompleting ‘Defensive Driving” course or EMT/First responder certificationConducting an Ergonomic job evaluation/modification


Total

Safety

Culture






responsibility

Develop Safety

Leadership



Align SafetySystems



Develop Safety Leadership


Total

Safety

Culture






responsibility

Develop Safety

Leadership



Align SafetySystems



Align Safety Systems


Align Safety Systems

All systems should accomplish their primary objectives

in a way that fosters a TSC.

• Safety-Related Discipline • Safety Committees• Audits and Inspections • Safety Communication• Incident Reporting and Analysis • Safety Policies & Procedures• Observation and Feedback • Safety Accountability Systems• Reward and Recognition Systems • S&H Measurement Systems

Case Study 1Case Study 1

Safety and HealthSafety and HealthMeasurement SystemMeasurement System


““Visibility Boards” Are Used to Manage Visibility Boards” Are Used to Manage Key Performance Indicators.Key Performance Indicators.

Fabrication Department

Schedule

Quality

Efficiency

BudgetSafety


Monthly Safety Topic: Fall Protection

Days Since Last Lost Time Injury

41

The “Visibility Board” for Safety Contained The “Visibility Board” for Safety Contained Little Useful Information.Little Useful Information.

SafetySafety

TRIR

0

5

10

15

20

J F M A M J J A S O N D


Incident Statistics Are Not Sufficient Incident Statistics Are Not Sufficient Indicators of Safety Performance.Indicators of Safety Performance.

Polluted (influenced by):Polluted (influenced by): At-risk Behaviors and ConditionsAt-risk Behaviors and Conditions Uncontrollable EventsUncontrollable Events Reporting PracticesReporting Practices Record-Keeping Practices Record-Keeping Practices Medical Management and Return-to-Work PracticesMedical Management and Return-to-Work Practices

Trailing vs. LeadingTrailing vs. Leading

Non-diagnostic: tell us how things are going, but do notNon-diagnostic: tell us how things are going, but do not indicate how to improve. indicate how to improve.


Emphasis on Outcome Measures Emphasis on Outcome Measures Damages the Safety Culture.Damages the Safety Culture.

Encourages (and rewards) underreporting. Encourages (and rewards) underreporting.

Fosters a lack of confidence in management’s Fosters a lack of confidence in management’s commitment to employee safety.commitment to employee safety.

Stifles employee involvement and personal Stifles employee involvement and personal accountability.accountability.

Failure oriented: breeds “learned helplessness”. Failure oriented: breeds “learned helplessness”.

Precludes system improvementsPrecludes system improvements FFosters a “fix the symptom”, not “fix the system” mentalityosters a “fix the symptom”, not “fix the system” mentality Encourages knee-jerk reactions (i.e., tampering) Encourages knee-jerk reactions (i.e., tampering)


Over-Emphasis on Outcome Measures Over-Emphasis on Outcome Measures Damages Employee Perceptions.Damages Employee Perceptions.

With crippled limbs and mangled feet,With crippled limbs and mangled feet,

a million man-hours we did meet;a million man-hours we did meet;

With records kept such as these, With records kept such as these,

we’ll reach a zillion it’ll be a breeze;we’ll reach a zillion it’ll be a breeze;

Rewards are for achievements met, Rewards are for achievements met,

but we ain’t reached a million yet;but we ain’t reached a million yet;

Their safety program is a sham,Their safety program is a sham,

As for you and me? They don’t give a damn.As for you and me? They don’t give a damn.- Hourly employee, Chemical processing plant- Hourly employee, Chemical processing plant


Safety Process Safety Process Measures Provide Many Benefits.Measures Provide Many Benefits. Provide early identification of system problems. Provide early identification of system problems.

Track genuine change, improvement. Track genuine change, improvement.

Identify opportunities for injury prevention.Identify opportunities for injury prevention.

Encourage active involvement (engagement).Encourage active involvement (engagement).

Foster sense of personal control.Foster sense of personal control.

Builds self-esteem and group cohesion.Builds self-esteem and group cohesion.


Safety Metrics Were Chosen To Reflect Safety Metrics Were Chosen To Reflect Performance of Key Safety Processes.Performance of Key Safety Processes.

Ergonomic job Ergonomic job evaluation/modification evaluation/modification

Behavioral observation andBehavioral observation and feedback feedback

Safety inspections Safety inspections

Incident reporting andIncident reporting and analysis analysis

Safety suggestions / nearSafety suggestions / near miss reporting miss reporting

Safety trainingSafety training

Safety meetings Safety meetings

Safety work ordersSafety work orders

Safety committeesSafety committees


Process Measures Should IncludeProcess Measures Should IncludeQuantitative and Qualitative Measures.Quantitative and Qualitative Measures.

Safety Audit ProcessSafety Audit Process Quantitative Measures:Quantitative Measures:

Number of safety audits completedNumber of safety audits completed Percentage of audits involving managers; hourly employeesPercentage of audits involving managers; hourly employees Number of action items identified; completedNumber of action items identified; completed Average time-to-closure on action itemsAverage time-to-closure on action items

Qualitative Measures:Qualitative Measures: Accuracy of audits (via second observer reliability)Accuracy of audits (via second observer reliability) Significance of issues identifiedSignificance of issues identified Effectiveness of solutions implementedEffectiveness of solutions implemented Employee perceptions (survey)Employee perceptions (survey)


The New “Visibility The New “Visibility Boards” Are Information Rich.Boards” Are Information Rich.

Safety

Other Activities vs. GoalMonthly training 74%Safety audit 100%AI Close-out 68%JSA Review 23%

Processes ERGONOMICSEvaluated Total Processes # Concerns # AIs in # AIs # AIs# % OK Not OK Identified Progress Completed Open185 100 72% 28% 42 3 32 3

0

10

20

30

40

50

60

70

80

90

100

J F M A M J J A S O N D

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7

Safety Suggestions# Received: 18# Addressable: 16# Complete: 11# in Progress: 1# Open: 4

Near Miss/Incident AnalysesTotal # : 4Closed out: 3 (75%)Resulting AIs: 11Closed out: 6 (55%)Avg Time 17 days

BBS

Highlighted Activities ________________________________________________________________________________________


The “Board” Is Reviewed Weekly With The “Board” Is Reviewed Weekly With Management and Employees.Management and Employees.

Case Study 2Case Study 2

Incident Investigation SystemIncident Investigation System

RedesignRedesign


Management Questioned the Management Questioned the Effectiveness of their Process Where Effectiveness of their Process Where

Human Behavior was Involved.Human Behavior was Involved.

RootCauses

? ?

???


The Current Process Revealed Several The Current Process Revealed Several Weaknesses.Weaknesses.

Little Little employee involvementemployee involvement during analysis or follow-up during analysis or follow-up

No expertise or training provided in No expertise or training provided in PsychologyPsychology or or Human FactorsHuman Factors

No No behavior analysis toolsbehavior analysis tools used (e.g., ABC Analysis, Task Analysis) used (e.g., ABC Analysis, Task Analysis)

Root causes identified often included “Root causes identified often included “Employee ActionEmployee Action”. Therefore“”. Therefore“Counsel Counsel EmployeeEmployee” or “” or “Discipline EmployeeDiscipline Employee” were common.” were common.

Communication was less than adequateCommunication was less than adequate Of the incidentOf the incident Of the analysis resultsOf the analysis results Of recommended follow-up actionsOf recommended follow-up actions Of the completion of follow-up actionsOf the completion of follow-up actions

Generalization of follow-up actions was infrequent.Generalization of follow-up actions was infrequent.


Incomplete Analysis Leads toIncomplete Analysis Leads toa Feeling of Blame.a Feeling of Blame.

“Human Error” Implies…

IncompetentCareless

LazyUnmotivatedInattentive

Clumsy


Survey Results Highlighted A Survey Results Highlighted A Revealing Pattern.Revealing Pattern.

Salaried who have been involved in incident investigations

Hourly who have been involved in incident investigations

Hourly who have NOT been involved

in incident investigations

4540353025201510

5Very Somewhat Neither Somewhat Very

4540353025201510


4540353025201510


Blame... Problem Solving...


Incomplete Analysis &Wrong Conclusions

Incomplete Information Disclosure

Feelings ofBlame

Ineffective Countermeasures


Negative Perceptions Leads to Negative Perceptions Leads to Under-Reporting.Under-Reporting.

60% of employees think they would be blamed. 60% of employees think they would be blamed.

47% believe they or a coworker will be disciplined.47% believe they or a coworker will be disciplined.

52% believe the incident would effect them in the 52% believe the incident would effect them in the future.future.

60% would not report an incident if they could avoid 60% would not report an incident if they could avoid doing so.doing so.


The Incident Analysis Process Was The Incident Analysis Process Was Redesigned to Meet Two Goals.Redesigned to Meet Two Goals.

Better determine the immediate causes and Better determine the immediate causes and root causesroot causes (especially those (especially those influencing influencing human behaviorhuman behavior) which allowed the incident to ) which allowed the incident to occur so effective counter-measures can be occur so effective counter-measures can be taken to reduce future injury risk.taken to reduce future injury risk.

Encourage the Encourage the full and open participationfull and open participation of all of all employees by eliminating any fault-finding, employees by eliminating any fault-finding, adversarial atmosphere.adversarial atmosphere.


Incident Analysis Team Training Incident Analysis Team Training Focused on Human Elements.Focused on Human Elements.

Interviewing strategies and techniquesInterviewing strategies and techniques

Factors influencing human performance Factors influencing human performance Human error Human error Risky behaviorRisky behavior

Analytical investigation techniques Analytical investigation techniques (including behavior analysis tools)(including behavior analysis tools)


Unsafe Behavior is Often the Result of Unsafe Behavior is Often the Result of System Influences.System Influences.

No

At-Risk Behavior

Yes

Did operator purposefully perform

a behavior whichs/he knew to be unsafe?

Human Error Risky Behavior

IndividualVariance

System-InducedHuman Error

System-EncouragedBehavior

Willful NegligenceAct of sabotage


A TSC Requires A Shift From A TSC Requires A Shift From Dependence to Interdependence.Dependence to Interdependence.

Dependence:• Top-Down• Condition of Employment• Safety for OSHA• Disincentives for Outcomes• Environment Focused• Fault Finding• Safety is Important• Quick Fix

Independence:• Bottom-Up• Personal Commitment• Safety for Self• Incentives for Outcomes• Behavior Focused• Fact Finding• Safety is Priority• Eventual Fix

Interdependence:• Empowerment• Team Commitment• Safety for Others• Recognition for Behavior• Env./Beh./Person• Systems Thinking• Safety is a Value• Continuous Improvement

DependenceDependence

IndependenceIndependence

InterdependenceInterdependence

Safe

ty A

chie

vem

ent

Safe

ty A

chie

vem

ent

BeginningBeginningImprovingImproving

SucceedingSucceedingLeadingLeading

1 2 3 4


Questions ??Questions ??

Making Safety A Culture, Not Just an Initiative Sherry R. Perdue, Ph.D. Safety Performance Solutions 610 N. Main Street Suite 228 Blacksburg, VA 24060.

Documents

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total safety culture

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condition of employment

safety culture survey

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