# Presentation: 476001

## Evaluation of Safety Culture as a Measure of a High Reliability Organization Effectiveness

***ISM Workshop – Developing Effective Safety Culture ***
***Session D-7***
***Richard S. Hartley, Ph.D., P.E.***
***November 28, 2007***

## Let’s Think for a Moment...

**Pantex builds nuclear weapons**
**Pantex will use lethal force to protect assets**
**Pantex’s daily job is to wrap large amounts of high explosives around plutonium**

**All at the crossroads of America’s Heartland!**

## If You are Going to be an HRO

**You had better know what  an HRO is**

## HRO vs. Non-HRO ATTRIBUTES

***HRO****** vs. ******Non-HRO****** ******ATTRIBUTES***

**HRO Attributes**
_***Accidents can be avoided***_
**Leadership safety objectives**
**Safety held high as priority**
**Provide clear operational goals**
**Willing to pay for barriers and training**
**Redundancy**
**Independent barriers reduce the fatal error by one person**
**Decentralized, culture, continuity**
**Worker calls the shots**
**Worker calls the shots like management wants him to**
**Worker stays proficient through training and work**
**Organizational learning**
**Adjust through trial and error**
**Learn from past mistakes**
**Simulate if practice not feasible**

**Non-HRO Attributes**
_***Accidents are inevitable***_
**Conflicting safety objectives**
**Pressure to maintain production**
**Difference between customer and organization**
**Mgt. misinformed of real status of operations**
**Perils of redundancy**
**Redundant backups not independent**
**Redundancy hides problems**
**Redundancy provides false security**
**No decentralization, culture, continuity**
**Leaders don’t know enough about ops to know whether workers responding correctly**
**Can’t keep militaristic state gong**
**Can’t practice for every contingency**
**Restrictions on organizational learning**
**Cause of accidents unclear so can’t learn**
**Investigation of accidents politicized**
**Incentives to cover up errors **
**Learning impeded by stovepipes**

*Scott Sagan, The Limits of Safety*

## How Does Safety Culture Fit In?

_**Safety Culture Provides**_
** **
**1. Sustainability for the HRO **
**or **
**2. Inhibitors to being**** an HRO**

## Safety Culture is that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear organizational safety issues receive the attention warranted by their significance.  - IAEA

***Definition of Safety Culture***

## Impact of Culture on Safety

***Impact of Culture on Safety***

**Culture**

**Ignored**
**Requirements **
****** ****Makings of an HLO**

- Modified from W. R. Corcoran, NSRC Corporation, firebird.one@alum.MIT.edu

**Safety Requirements to be **
**an HRO**

- Safety
- Requirements
- Followed

## Components of Safety Culture

_**REPORTING CULTURE**_
- A climate in which people are prepared to _**report**_ their errors and near-misses.

_**JUST CULTURE**_
- An atmosphere of _**trust**_ where people are encouraged, even rewarded, for providing essential safety-related information – but in which clear lines are drawn between acceptable and unacceptable behavior.

_**LEARNING  CULTURE**_
- Able to draw the _**right**_ conclusions from safety information systems and _**willing**_ to implement major reforms if the information is negative.

_**FLEXIBLE  CULTURE**_
- Able to shift from hierarchical mode to a flatter mode in the face of high tempo operations or danger.

- Managing the Risks of Organizational Accidents, James Reason

## Culture

***What Do We Do About Safety Culture?***

**Ignored**
**Requirements**

**Unwritten**
**Rules**

- Modified from W. R. Corcoran, NSRC Corporation, firebird.one@alum.MIT.edu

**Safety Requirements to be **
**an HRO**

- Safety
- Requirements
- Followed

**Implement Corrective Actions and Learn our Lessons to expand culture to cover safety requirements.**

**Use Causal Factors Analysis to evaluate the safety requirements being followed**
** ****(i.e. degree of overlap).**

**Use Causal Factors Analysis to understand  culture and Latent Organizational Weaknesses to understand the unwritten rules that preclude safety requirements from being followed.**

## Characterization of Safety Culture

- © 2007 W. R. Corcoran, NSRC Corporation

***Characterization of Safety Culture***

-  _**NORMS – **__**WHAT WE DO**_
- Question assigned work
- Recognize & report events
- Consider HP Error Precursors
- Recognize Barriers to Protect Worker
- Perform Pre-job Walk-down & Brief
- Follow Procedures

_**MENTAL CONTENT – **__**THE WAY WE THINK**_
- Attitudes
- Goals
- Visions of Excellence
- Skills
- Abilities
- Professional Principals

_**PHYSICAL ITEMS – **__**WHAT YOU RUN INTO**_
- Signs
- Procedures
- Controls (administrative & engineering)
- Corrective Action Tracking (PER/ESTARS)
- Safety Analysis Reports
- PPE

_**INSTITUTIONS – **__**HOW THINGS GET DONE**_
- Training
- Work Planning & Control
- Safety Management
- Operating Experience Program
- Assessments (self, mgt, independent)
- Process Ownership, Corrective Actions

## Characterization of Safety Cultureby Category and Component

**Problem Identification & Resolution**
- Corrective Action Program
- Operating Experience
- Self and Independent Assessments

**Safety Conscious Work Environment**
- Willingness to Raise Concerns
- Preventing and Detecting Retaliation

- Nuclear Regulatory Commission Issue Summary 2006-13

**Organizational Issues**
- Accountability
- Continuous Learning Environment
- Organizational Change Management
- Safety Policies

**Human Performance**
- Decision Making
- Resources
- Work control
- Work Practices

## Culture Attribute Matrix

| Conflicts between Observed/Inferred Cultural Attributes 
and Functional Safety Culture |  |  |  |  |
| --- | --- | --- | --- | --- |
| Observed/ Inferred
(Not so good) | Functional
(Better) | Direct Result of Observed/ Inferred | Downstream Result of Observed/ Inferred | Significance of Observed/ Inferred
(Mental Content, Norm, Institution, /Physical Item) and (Problem Identification and Resolution, Human Performance, Safety Conscious Work Environment, Organizational Issues) |
| What were the behaviors observed or inferred that gave an indication of not being good? | What would be the more appropriate behavior that should have been exhibited? | What resulted in this event as a result of the behavior observed? | What was the result of the behavior exhibited?  | Which culture characteristic (Corcoran) or culture component (NRC) was affected by the observed behavior and what can be said about the culture that permitted it? |

## What Does it Take to be an HRO?

- You must evaluate the safety culture to determine how well your HRO programs are working and evaluate the attitude of the workers

***What Does it Take to be an HRO?***

- To be an HRO
- You have to really want to be an HRO
- You must know what being an HRO means
- You must select your HRO attributes
- You must have programs that push those HRO attributes
- You must know your organizational inhibitors
- You have to listen to your system  safety culture = sustainability
- You must be willing and able to learn and adapt

## What are your characteristics and attitudes to ensure that, as an overriding priority, nuclear organizational safety issues receive the attention warranted by their significance?  

***If You Claim to be an HRO***
***How is Your Safety Culture?***

## Have you ever got frustrated at work, said the heck with it, just checked the box and went home?

- People do what they see others do
- People don’t do what they can’t
- Behavior is a function of structure
- Behavior is elicited by antecedents
- Experience makes an antecedent out of an item
- Reinforcement increases frequency
- Punishment elicits only its avoidance
- Null consequences are reinforcement for dysfunctional behavior

***Safety Culture Easier Said Than Done***

- © 2007 W. R. Corcoran, NSRC Corporation

- Do you think maybe your workers react the same way?

- Got Culture?