Organizational Culture and Safety

“..only a fool perseveres in error.” Cicero. Humans will break the most advanced technological devices and override safety and security systems if they are given the latitude. Within the workplace, the operator may be just one of several factors in causing accidents or making risky decisions. Other variables considered for their involvement in the negative and often catastrophic outcomes include the organizational context and culture. Many organizations have constructed and implemented safety programs to be assimilated into their culture to assure employee commitment and understanding of the importance of everyday safety. The purpose of this paper is to examine literature on organizational safety cultures and programs that attempt to combat vulnerability, risk taking behavior and decisions and identify the role of training in attempting to mitigate unsafe acts. Much attention has been paid to the contributions of various factors in accidents that have occurred in industries that share the common characteristics of low probability, high risk socio-technical systems characterized by strict legislation, potentially hazardous situations, many employees, intricate technology, and rigid timescales. Socio-technical systems are dependent upon the interaction of technical, human, social, organizational, managerial and environmental elements that may be singular or collective co-contributors to incidents. In response to this, organizations have initiated programs to discover and mitigate failures along a continuum rather than just at the end point. Organizations have sought to formalize these efforts into cultures that are aligned with their organizational culture. These safety cultures represent the amalgamation of individual and group values, attitudes, perceptions, and behavioral patterns that formulate the style and effectiveness of a safety program. • High standards are often established to eliminate or reduce risks so that they are measurable and observable. However, on a day-to-day basis, the adherence to safety management practices may be obscured by appearances. • Different levels of risk influence how involved society or an organization will become in its mitigation and • often reflect the organization’s attitude toward risk and/or it’s role in its prevention or inadvertent promotion. • An individual’s acceptance of risk depends on whether or not s/he can control the outcome. • If there is a discrepancy between how the environment is perceived and how it exists, employees may knowingly take chances that they believe are important to the achievement of a task (Turner, 1978). People take risks: out of choice by evaluating the payoff, because they have no alternatives, because they are uninformed, because they are encouraged to do so, or because they might loose self esteem in the eyes of their family, friends or peers. They might miscalculate the level of risk because they have: a high commitment to the job, have been involved in a similar event, have not been penalized in the past and can probably get away with it again, or there is sense of remoteness where there is a low probability they will encounter the event (Adams and Adams, 1998, O’Hare, 1990, Tuler, Machlis and Kasperson, 1996). Risk based decisions are typically made when the benefits outweigh the perceived risks. Models applied to risk based culture and safety. Literature and research on the relationship of organizational culture and safety has been increasing over the last 20 years with the emphasis on risk management and investigations into risk acceptance primarily on a retroactive basis. One of the earliest attempts to develop a safety culture was the Helicopter Safety Advisory Conference (HSAC) formed in 1978 after an accident in which 19 people lost their lives when a helicopter came in contact with a platform crane. Realizing there was a lack of communication between oil companies, service organizations, helicopter operations, and the helicopter industry, representatives of these companies agreed to work toward improved safety offshore. The HSAC effort is proactive in resolving issues of interest to the industry. Australia has done extensive research on driving with some interest in cultural influences of accidents in their trucking industry. The airline industry has been at the forefront of developing safety cultures and evolving programs, targeting human error through Crew Resource Management (CRM) training programs designed to foster and maintain teamwork. England, in light of the Piper Alpha offshore oil rig explosion in 1988, has had to examine it’s approach to safety and change the way organizations in high risk environments, train and acculturate their employees (Back and Woolfson, 1999). Medicine, until recently, has all but ignored the errors that have serious and often life threatening results. Researchers look to several models of risk taking to explain why people take risks. These include the risk perception model, the social amplification of risk, resident latent pathogen model and variations on utility theory (Wahlberg, 2001, Louberge, and Outreville, 2001, Maurino, et. al, 1995). Utility theory is most often cited as the rationale underlying risky decisions because it is felt that neither social amplification nor the basic risk perception model provide statements of causal mechanisms (Farthing, 1996). Utility theory facilitates questions regarding pleasure-displeasure and perceived risk. Extensions of utility theory include subjective probability as well as distortions of probability. The latent pathogen model is one of the more current attempts to look beyond linear causal explanations of error. Only one research paper identified a model to examine the relationship between culture and risk based decisions, the Subjective Expected Utility Theory (Farthing, 1996). Farthing started with this theory to provide a normative model for risky decisions influenced by culture but cited its limitations in being able to describe likeliness of engagement, and group differentiation between sensation seekers and cautious decision makers. Reason (1991) focuses on the fallible decisions that are associated with processes common to all technical organizations (i.e. setting goals, organizing, regulating, managing, communicating, designing, building, operating and maintaining). These “seeds” represent conditions, that by themselves, are not dangerous. However, as these latent failures proceed along the path to the work environment, they fuel unsafe acts, few of which become actual errors because of the strength of a system’s defenses. It is the weaknesses that let the pathogens (virus-like dormant system deficiencies) slip by when they combine with local triggering events such as weather, location, communications, etc and the active failures at the proximate end – the pilot, the air traffic controller or the mechanic to cause accidents. The Air New Zealand flight into Mt. Erebus on Antarctica underscores the notion that organizational culture and communication patterns influenced the actions of pilots, who, unwittingly flew directly into its base at 1500 feet (Casey, 1993). In order to make sightseeing more exciting, upper management changed the routing from circling the mountain to flying over the mountain prior to circumnavigating at lower altitudes. The aircraft’s flight management systems was reprogrammed by avionics personnel but no one told the crew. Flight briefers advised new altitudes but not in the context of new routing. Air New Zealand pilots, therefore, assumed the altitudes were guidelines rather than requirements. None of the pilots had flown the tour a policy requirement that was not enforced. As a result, they were unfamiliar with the whiteout conditions, so prevalent in Anarctica, that prevented them from seeing the mountain once they ducked under the clouds. Aviation has not been the only industry where these accidents have occurred. Some of the risks might be calculated risks driven by economics and/or resource availability. For example, the Union Carbide explosion in Bhopal, India (Casey, 1993) resulted from cutbacks in staff, failure to provide chemical sensors and environmental or worker safety regulatory policies while continuing to operate a plant that was deteriorating from poor maintenance. Being marginally profitable, most of the deficiencies were driven by economics. A pressure buildup within the chemical silos could not be abated because broken pipes and frozen valves propelled a geyser of toxic fumes into the air. The neutralizer, water, could not be ported to the heights of the plumes because of a lack of pressure and late decisions over methods to counteract the chemical. Over 2500 lives were lost. As a result, an entire industry sought to reevaluate its approach to dealing with low-probability, highconsequence risks (Kunreuther and Meszaros, 1997). These crises illustrate how cultural problems can permeate industrial society and point to the need for more aggressive attention to be placed on the collective role of the organization’s elements in risk taking. The culture of an organization often produces conditions and mechanisms that undermine safe practices by influencing the task environment (Maurino, Johnston, Reason and Lee (1995). Organizational Culture Culture is defined as a complex pattern of beliefs, expectations, ideas, values, attitudes and behaviors in an organization that binds members together and influences what they think about themselves and what they do (Hellriegel, Slocum, and Woodman, 1998; Wagner and Hollenbeck, 2000). It evolves over time as a product of assumptions and values transmitted through artifacts (objects and visible features of an organization) history, myths and mentors (Argyris and Schon, 1978). Culture is built on long term experiences but it must convey, on a daily basis a climate of tangible as well as qualitative outputs of it’s emphasis on