1 Steven R. Ash, Ph.D. The University of Akron [email protected]The Safety Climate Steven R. Ash, Ph.D. The University of Akron
2 Disasters “With each disaster that occurs our knowledge of the factors which make organizations vulnerable to failures has grown. It has become clear that such vulnerability does not originate from just ‘human error,’ chance environmental factors or technological failures alone. Rather, it is the ingrained organizational policies and standards which have repeatedly been shown to predate the catastrophe.” (Gadd, S; Collins, A.M., 2002)
3 Safety Culture The attitudes, beliefs, perceptions and values that employees share in relation to safety (Cox, S. & Cox, T., 1991) 1986 Chernobyl Incident
4 “The way we typically do things around here.”
5 Organizational CultureWhere does an organization’s culture come from? Founders Leaders How is a culture sustained? Reinforced by demonstrations of acceptable and unacceptable behaviors and decisions
6 Safety Climate “A summary of… perceptions that employees share about their work environment” (Zohar, 1980) 1980 Factories in Israel
7 Why Safety Climate? Results of questionnaires can serve as leading indicators as opposed to lagging indicators
8 Lagging Indicators Statistics related to accidents Injury frequencyInjury severity OSHA recordable injuries Lost workdays Worker’s compensation costs
9 Leading Indicators Measures that predict behavioral outcomesSafety training Ergonomic opportunities identified and corrected Reduction of risk factors Employee perception surveys Safety audits
10 Crisis Agent CategoriesMan-made Deliberate Terrorism 9/11 attacks Internal Sabotage Disgruntled employee Unintentional Human Error Design Maintenance Operations Natural Disaster Acts-of-God Meteor Probability Events Tornado Hurricane Earthquake Flood Tsunami
11 Some General Sources of Human ErrorPoor Information (Overload or Lack of) Poor Data, or incomprehensible information Inadequate Ability or Training Knowledge or understanding is lacking Improper Tools/Equipment Right tools not available/used Poor System Design Improper Human Factors (man-machine interfaces) Individual Cognition Biases, perceptual errors, emotional override Social Environment (Culture) Leadership, communication, time pressures, personality, etc.
12 Cognitive Biases and Decision MakingHeuristics = Rules of thumb (humans live by these) E.g., In a building with several floors, restrooms on one floor are often located in roughly the same place as on other floors.
13 Example A bat and ball cost $1.10 The bat costs $1.00 more than the ball. How much does the ball cost?
14 Answer The number that came to your mind is, of course, 10 cents.It is intuitive. It is appealing. It is wrong!
15 Answer Cost: Ball = .10 Bat = $1.10 (one dollar more than ball)Total = $1.20 WRONG!
16 Answer The correct answer is the ball costs 5 cents. Ball = .05Bat = $1.05 (one dollar more than ball) Total = $1.10 CORRECT!
17 Types of Cognitive Biases in Individual Decision MakingAvailability Bias Representativeness Confirmation Bias Anchoring and Adjustment Overconfidence Bias Hindsight Bias Framing Bias Escalating Commitment Randomness Error Barnum Effect
18 Stroop Effect On the following slide, as quickly as possible, loudly say the color of each word, do not read the words.
19 Unlearning It is very difficult to change the way we think.Unlearning something that we have spent a lot of time learning is quite challenging.
20 Confirmation Bias We find what we are looking for!“There’s the proof! I knew it all along.”
21 Seeing Patterns Where None Exist (Pareidolia)Pre-existing expectations (Confirmation Bias) Sexual references are often seen References to strong beliefs Faces in particular seem to be innate Our brains can distinguish between faces and other objects in less that .20 seconds (Hadjikhani, 2009)
22 Seeing Divinity Remarkable sightings have been identified by the faithful of all walks
23 Pattern Recognition “When it works well, we can find our lost child in the middle of a huge crowd at the mall. When it works too well, we spot deities in pastries, trends in stock prices, and other relationships that aren’t really there.” Chabris & Simons, 2010
24 We tend to seek out and attend to information that supports earlier decisions, and ignore information that is contradictory. We are generally blind to things we are not expecting.
25 Responses to Human ErrorYou want to encourage information flow, but also recognize that some discipline may be necessary You want to do something about the employee who is truly dangerous, while still encouraging reporting from conscientious employees
26 Types of Errors Considers the employees’ motivation in acting when deciding on punishment so as to create a feeling of trust among all involved
27 Example Nurses in the state of Texas who made 3 medication errors in 1 year would lose their license What type of reporting would you expect? Rather than improving safety, punishment made reducing errors much more difficult by providing strong incentives for nurses to hide their mistakes, thus preventing recognition, analysis, and correction of underlying causes (Leape, L.L., 1994)
28 Types of Safety CulturesPathologic “We don't make errors, and we don't tolerate people who do.” This organization is likely to “shoot the messenger.” Bureaucratic “If something occurs, we will write a new rule.” Learning Seeks to understand the broader implications of error. (Westrum, R. 1993)
29 Wrong Door In 1990, Martin Marietta deployed a satellite into the wrong orbit when engineers told the computer programmers to, “open the bay door to the hatch containing the satellite.” The programmers complied, however they opened the wrong door. Today, the $150 million dollar satellite sits dead in orbit around the earth. The total cost of the single miscommunication is estimated to be $500 million dollars (AP,1990).
30 Looking but Not Seeing Homeland Security Screeners failed to spot weapons of any kind one third of the time J. McClarey, Elements of Human Performance in Baggage X-ray Screening, 4th Annual Aviation Secruity Technology Symposium, Washington D.C., 2006
31 Organizational ErrorsIt takes a village to really screw things up!
32 Disasters When multiple errors combine together in complex systems, large scale disasters become possible
33 Error Chains Swiss Cheese effect (after Reason, 1990)Tragedies are seldom the result of a single error Serious errors are compounded, multiplying the impact There are often many opportunities to stop disasters
34 Swiss Cheese Effect
35 Nuclear Power Plant EmergenciesOyster Creek (1979) Three Mile Island (1979) Ginna (1982) Davis-Besse (1985) Chernobyl (1986) Fukushima (2011)
36 Fukushima Nuclear PlantOn March 11, 2011, a massive 9.0 earthquake hit Japan. Terrible loss of life One of the scariest parts was nuclear Japanese Commission Report: “We believe that the underlying causes of the accident are to be found in the organizational and control systems that supported wrong decisions and actions.”
37 Three Mile Island 1979: The operators did not recognize that the relief valve on the pressurizer was stuck open. The panel display indicated that the relief valve switch was selected closed. They took this to indicate that the valve was shut, even though this switch only activated the opening and shutting mechanisms. They did not consider the possibility that this mechanism could have (and actually had) failed independently and that a stuck-open valve could not be revealed by the selector display on the control panel. Worst nuclear incident on American soil.
38 Error Chain ConstructionOn Sunday April 14th, 1912, RMS Titanic sank, claiming the lives of 1513 of the 2224 people on board. Only about 1/3 lived (711). Why did so many people die?
39 Error Chain Examples Case - Jose Eric Martinez Iatrogenic injuryAn injury causing harm to a patient resulting from medical management rather than from the patient's underlying or antecedent condition
40 Group Errors When groups work well, synergy is the result (2+2=5)When they don’t, outcomes can be catastrophic Potential Group Problems Conformity Obedience Groupthink
41 1) Group Conformity Asch experiments Line length Multiple confederatesMany unquestioningly went along with majority
42 Group Conformity Which line is longer? A B C
43 2) Obedience to AuthorityMilgram experiments Questions: How could the Nazis commit such atrocities? White coated researcher, “you must continue” Increasing amounts of voltage were administered Why blind obedience?
44 Challenge NTSB study found that 25% of all accidents could have been prevented if the pilot had been challenged when making an error. E. Tarnow, Self Destructive Obedience, in Obedience to Authority, Blass (Ed.) 2000
45 Obedience In an experiment, twenty-one of twenty-two nurses were prepared to administer an obviously deadly dose of medicine to a patient. No resistance, no internal conflict, no conscious awareness of a problem. C. Hofling, 1966
46 3) Groupthink When groups override a realistic appraisal of the situation in order to maintain unanimity and cohesiveness
47 Examples of GroupthinkBay of Pigs Pearl Harbor Space Shuttle Challenger
48 Symptoms of GroupthinkInvulnerability Rationalization Morality Stereotypes Pressure Self-censorship Unanimity Mindguards
49 Avoiding Groupthink 1 Leader encourages open expression of doubtLeader creates climate where dissenting opinions are OK High-status members offer opinions last Receive recommendations from duplicate group Periodically divide into subgroups
50 Avoiding Groupthink 2 Get reactions from trusted outsidersPeriodically invite outsiders to join discussions Assign role of devil’s advocate Develop possible outcome scenarios
51 Devil’s Advocate Historically, the Catholic Church made use of a devil’s advocate in canonization decisions. He was the promotor fidei – the promoter of faith. His role was to build a case against sainthood. John Paul II eliminated the office in 1983. Since then, saints are canonized 20 times faster than the old system.
52 Murder Board The Pentagon uses a “murder board.”This group is staffed with highly skilled and experienced officers. Their job is to try to kill ill-conceived missions.
53 Safety Culture Traits The U.S. Nuclear Regulatory Commission (NRC) has developed a list of 9 traits associated with a positive safety culture, along with examples of each.
54 1. Leadership Leadership Safety Values and Actions in which leaders demonstrate a commitment to safety in their decisions and behaviors
55 2. Problem IdentificationProblem Identification and Resolution in which issues potentially affecting safety are promptly identified, fully evaluated, and promptly addressed and correct
56 3. Personal AccountabilityPersonal Accountability in which all individuals take personal responsibility for safety
57 4. Work Processes Work Processes in which the process of planning and controlling work activities is implemented to maintain safety
58 5. Continuous Learning Continuous Learning in which opportunities to learn about ways to ensure safety are sought out and implemented
59 6. Environment for Raising ConcernsEnvironment for Raising Concerns in which a safety-conscious work environment is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination
60 7. Effective CommunicationEffective Safety Communication in which communications maintain a focus on safety
61 8. Respectful EnvironmentRespectful Work Environment in which trust and respect permeate the organization
62 9. Questioning Attitude Questioning Attitude in which individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action
63 Example Application: Upper Big Branch Mine ExplosionInformation derived from: Mine Safety and Health Administration (MSHA), Coal Mine Safety and Health, “Report of Investigation—Fatal Underground Mine Explosion, April 5, 2010,” December 6, 2011
64 Upper Big Branch Mine On April 5, 2010, a series of explosions occurred inside the Upper Big Branch (UBB) mine in southern West Virginia. Twenty nine coal miners working for Performance Coal Company (a subsidiary of Massey Energy Company) lost their lives in the “largest coal mine disaster in the United States in 40 years.”
65 1. Leadership One specific work process that the Massey leadership had in place was to illegally provide advance notice to miners of MSHA inspections. This was a flagrant violation of Section 103(a) of the Federal Mine Safety and Health Act of 1977
66 2. Problem Identification“…when a worker told [the] foreman about the air reversal, [air moving the opposite direction of where it should have been in order to properly vent the mine] ‘He didn’t say nothing, he just walked away.’” The preshift, onshift examination system—devised to identify problems and address them before they became disasters—was a “failure.”
67 3. Personal AccountabilityIn the weeks preceding the disaster, investigators found that one foreman’s hand-held methane detector had not been turned on, even though he filled in the examiner’s books as if he had taken gas readings. “This data [integrity issue] raises doubt about the daily and weekly air readings and other data recorded by the crew foreman in the weeks leading up to the disaster.”
68 4. Work Processes “In instances in which a section boss did halt production because of a dangerous condition, such as wholly inadequate ventilation, he was instructed to write only ‘downtime.’ He was not to create a record acknowledging a potentially deadly situation.”
69 5. Continuous Learning “Testimony indicates that Massey inadequately trained their examiners, foreman and miners in health and safety…especially in hazard recognition, performing new job tasks and required annual refresher training. This left miners unequipped to identify and correct hazards.”
70 6. Environment for Raising Concerns“Witness testimony revealed that miners were intimidated by management and were told that raising safety concerns would jeopardize their jobs. As a result, no whistleblower disclosures were made in the 4 years preceding the explosion, despite an extensive record of Massey safety and health violations at the UBB mine during this period.”
71 7. Effective Communication“Workers were treated in a ‘need to know’ manner. They were not apprised of conditions in parts of the mine where they did not work. Only a privileged few knew what was really going on throughout the mine.”
72 8. Respectful Environment“Miners also mentioned disrespectful written messages they received” from [a senior manager]. Others, were intimidated by [a manager’s] “nasty notes” and didn’t say anything because they were “job-scared.”
73 9. Questioning Attitude “Testimony revealed that miners were intimidated to prevent them from exercising their whistleblower rights. Production delays to resolve safety-related issues often were met by officials with threats of retaliation and disciplinary actions.”
74 Summary “While violations of particular safety standards led to the conditions that caused the explosion, the unlawful policies and practices implemented by Massey were the root cause of this tragedy.”
75 Donald L. Blankenship The CEO of Massey Energy, was sentenced on April 5, 2016 to a year in prison for conspiring to violate federal mine safety standards (a misdemeanor). The prison term, the maximum allowed by law, came six years and one day after an explosion ripped through Massey’s Upper Big Branch mine, killing 29 men. Federal officials have said the guilty verdict was the first time such a high-ranking executive had been convicted of a workplace safety violation.
76 Measuring Climate to Assess CultureWashington Metro Area Transit Authority Survey question categories: 1. Tone at the Top 2. Supervisor Leadership 3. Reporting Tendency 4. Responsiveness to Incidents 5. Comfort Speaking Up 6. Openness of Communications 7. Awareness and Training 8 Fairness
77 Conclusion 1 Culture is complicated and includes the behaviors, communication, and decision making styles of the employees Climate is something you can assess. It includes the perceptions and attitudes of employees.
78 Conclusion 2 Researchers have found a significant association between the safety climate scores and injury data for many industries. Even among lone workers, safety climate is a valid predictor of safety outcomes.
79 Conclusion 3 Get Everyone on Board! Hands and backs can be bought, but hearts and minds must be won. If the leadership has not bought in, neither will the employees. Leadership is the biggest determinant of culture!
80 Thank you for your attention