Which of the following is one of the three major categories that make up a culture of safety?

2.9 Safety Culture

A safety culture has been described as the product of the individual and group values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety programs. James Reason has taken this description one step further by breaking down the individual parts necessary to create a safety culture. Dr Reason says there are four parts to an effective safety culture, an informed culture, a reporting culture, a just culture and finally a learning culture (Reason, 1993). Let's discuss each one of these individually.

An informed culture is one in which an organization collects and analyzes the right kind of data to keep it informed of the safety health of the organization. This collection can be done in a number of ways. One of the easiest ways is to analyze data from the training department in the form of satisfactory and unsatisfactory performance during check rides. Depending on an organization's grading system, there may be invaluable data from proficiency checks, recurrent training and LOFT performances that identify the need to develop focused training. For instance, items that are graded poor or unsatisfactory more often than other items in the check rides may indicate the need for emphasis on those particular items.

Another excellent source of data for an organization is the FAA Flight Operations Quality Assurance (FOQA) program, which flags data from the digital flight recorder in flight that exceed certain parameters. If collected and analyzed correctly, the data will show trends such as flap speed exceedences, excessive speed below 10,000 feet, unstabilized approaches, etc. If a trend is detected, the organization now has options on how to reverse the trend. This may not always be a flight crew problem, which can be addressed with bulletins and training. Experience has shown us that at times, a particular destination with a rash of flap speed exceedences may indicate a poor arrival profile. This is where union committees and ATA committees can be of great value. Sharing the data and working with other organizations experiencing the same problem in the industry have been very successful in resolving such problems.

An organization with a robust informed culture can create a safety information system that collects, analyzes and disseminates information on incidents and near misses, as well as proactive safety checks. The key word here is disseminating. Information of this type is of no value unless it is sent through the proper channels and to the right people so that action is assured.

A reporting culture is one where employees are encouraged to report safety problems. The most important ingredient of this culture is trust. They must feel confident they will not be punished or ridiculed for reporting. This trust can best be achieved if a written non-reprisal policy exists, signed by the most senior management as mentioned earlier in this discussion. This assumes confidentiality will be maintained or the data are de-identified. Lastly, they must have confidence the information will be acted upon if found to be meaningful.

A just culture exists if the employees realize they will be treated fairly. Recognizing the ubiquity of error, organizations will not punish those who error commit unsafe acts so long as the error was unintentional. However, it must be perfectly clear that those who act recklessly or take deliberate and unjustifiable risks will be punished. Willful violations and reckless operation will not be tolerated and will be acted upon swiftly and painfully if necessary.

The final part of an effective safety culture is a learning culture. In short, the organization is able to learn and change from its prior mistakes. This may seem an oversimplification but those who study management know how difficult change can be. Human beings are inherently resistant to change. The enemy of any organization is “business as usual.” Even after a problem has been identified and corrective action initiated, it is not unusual for the day-to-day operation to slip slowly back to the old routine. One of the definitions of insanity is doing the same thing over and over again and expecting a different outcome. Yet this is something we see organizations doing constantly. The ability to correct operations that are going wrong is truly a skill fraught with apprehension and angst. It takes a strong leader with a clear vision of what he or she wants and, even better, an understanding of how to get there and what it looks like to achieve true and lasting change.

My experience has shown that although an organization can have an overall healthy safety culture it is possible for departments within the company to differ greatly. For instance, when a new aircraft type is introduced into an organization, the new fleet manager(s) usually incorporate the latest concepts in training for technical proficiency and human factors skills. This is a positive step forward because all aspects of the training and operation tend to be scrutinized and optimized. Using lessons learned by others already flying the aircraft type may also benefit the new fleet in creating the best possible procedures.

However, the older fleet types don't necessarily benefit from this optimization or may resist changing from the way they have historically done things. This is one of the easiest ways for cultures within an organization to drift apart. As more modern aircraft are brought into the fleet, the older aircraft fall further and further behind in the way they operate. This change is so slow and insidious that it is hard to detect. Sometimes this problem does not come to light until an incident or accident highlights the problem and the fix is a reactive one.

One of the most successful ways of overcoming this problem is through a robust trend analysis and auditing system. Line Operational Safety Audit (LOSA) is undoubtedly one of the most effective ways to accomplish this task proactively. LOSA will be covered in depth by Bruce Tesmer in Chapter 10 so I won't say much more except it is an excellent way to get a unique and insightful view of an operation.

4.4 Safety culture

Organizational safety culture has been defined in a variety of ways, but is often summarized as “how people in the company behave when no one is looking”. There are several “subcultures” that contribute to the overall safety culture of an organization and these are related to the cornerstones of resilience as mentioned in Section 4.32:

Flexible culture – Like the ability to anticipate system requirements, having a flexible culture means being able to reconfigure the system to deal with the pressures that are acting on it at the time.

Reporting culture – Like the ability to monitor, people working in the organization feel completely comfortable to report threats, errors or undesirable conditions as well as any near-misses. These potential warning signals (or algedonic signals, in the language of cybernetics) can provide managers with vital information about the levels of resilience in the system and where resilience may be eroded.

Informed culture – Like the ability to respond, the components of the system know what they need to do and what is expected of them as part of the larger system.

Learning culture – Like the ability to learn, the system can reconfigure itself based on what it has learned from past experience.

Just culture – People working in the system trust that they will be treated fairly in the event of unsafe acts occurring. The key to a successful just culture is the acceptance of the New View of error. This is such an important contributor to the overall safety culture that it will be covered in more detail in Section 4.4.1, below.

Patrick Hudson identifies five levels of safety culture that an organization could have11:

Pathological – It does not matter what we do, as long as we do not get caught.

Reactive – We do a big safety drive after things go wrong, and then we stop.

Calculative – We have systems that can manage all hazards.

Proactive – We continue to work on problems that we identify.

Generative – We are constantly looking for new areas of risk and we do not take past success as a guarantee against future failure.

An organization can evolve up through these stages (or, indeed, devolve back down through them), and one of the key determinants of the safety culture is the extent to which a just culture exists.

4.4.1 Just culture

Having a just culture means having a systematic way of investigating unsafe acts, incidents and accidents that is open, consistent and fair. It is worth pointing out that this is not the same as having a no-blame culture. It is possible that someone might be blamed after an incident if culpability can be clearly demonstrated. This involves following a series of investigative steps, the most crucial of which is the substitution test (i.e. given the same set of circumstances, is it possible that another person would have done the same thing?). The difference between having a robust just culture in an organization and having a poor just culture is like the difference between living in a modern country with a fair and independent judicial system and living in a country where the judicial system is inconsistent, corrupt and controlled by the government. In the former case, you can be sure that your treatment will be fair and sensible. In the latter case, not even your basic rights are guaranteed and you could find yourself being made a scapegoat to draw attention away from a more severe and significant problem higher up in the organization. Developing a just culture in your organization can be the springboard that improves safety culture as people will be more likely to report problems if they know they are not going to be criticized in a prejudicial manner for the role they played. Figure 4.1 illustrates one procedure for determining culpability during an investigation. There are several versions of this type of decision tree but this one demonstrates the framework on which the others are built.2

Figure 4.1. Culpability flowchart.

You will notice that the flowchart differentiates errors and various types of violation, and is based on the error/violation theory we covered in Chapter 3. Whatever system you use, the challenge is to make it as consistent and fair as possible. Consider your just culture procedures to be similar to those of a courtroom. In order for the people working in your organization to have faith that the system works, investigations and deliberations should not be prejudiced by facts beyond those relevant to the matter at hand. Ideally, events should be judged by trained individuals who do not know the identities of the people involved. In a small organization, this can prevent prejudices clouding the investigation. The main risks in accident/incident investigations are that the investigator succumbs to hindsight bias and fundamental attribution error as described in Chapter 2 (Information Processing), specifically Section 2.6.3.4 on social heuristics. It is the challenge for the investigator to put himself in the place of the people involved and try to imagine the situation as it would have been unfolding around them at the time, with no knowledge of the final outcome. If this is done successfully, it may become apparent that the crew had no way of knowing that their actions were going to result in a negative outcome and that other crews would probably behave in the same way.

Conclusion: Synthesis of Safety Culture Methods and Outcomes

Looking back at the safety culture pyramid and the definition of safety culture, three key aspects come to light:

An organization, as a dynamically balanced system, may exist in any of the four states of safety culture—secretive, blame, reporting, or just.

If an organization seeks to change its cultural state toward a just culture, there needs to be a purposeful alignment across all four components of the safety culture—values, leadership strategies, attitudes, and behaviors.

The time taken to change the culture depends on (a) effective articulation of the safety values and communication of the need (intensity and urgency) to change the culture and (b) the collective engagement at all levels of the organization to make the necessary changes in strategies, processes, and policies in order to align with the safety values.

Figure 4.4 presents a synthesis of safety culture components, methods and outcomes. Safety culture is presented here as a pyramid with four components: safety values, safety leadership strategies, safety attitudes, and safety performance. In order to truly and fully characterize safety culture, the state of each component, the interconnection across the four components, the dynamic balance between the four components, and the cumulative influence of values, safety leadership strategies, and safety attitudes on safety performance must be examined.

Surveys

Another way of measuring safety culture is simply to ask people through the use of structured surveys. Such surveys typically ask participants to answer a series of questions on a 5-point Likert scale:

Strongly agree

Agree

Neutral

Disagree

Strongly disagree.

The following is a list of questions that can be asked (it is derived from O’Toole (2005)):

Senior Management Commitment to Safety and Safety Communication

Line Management Commitment to Safety

First Line Supervisor Commitment to Safety

Self-Perception of Safety

Influence of Peer Groups on Safety

Safety Competence

Risk Taking Behaviors by Self and Others

Roadblocks to Safe Behavior

Accident Investigations and Near Miss Reporting.

It should go without saying that, once a survey is complete and the results are in, management must act on those results. To ignore the opinions of those surveyed with throwaway phrases such as, “Our employees don’t understand the big picture” destroys management’s credibility.

About 65 companies shared to shape the earlier definition of “Safety Culture” in 2003

The Conference Board defined safety culture with a very realistic spin when their report stated:

Safety and health are (or have become) part of the company culture - and frequently the management system. “Culture” is traditionally defined as “a shared set of beliefs, norms, and practices, documented and communicated through a common language.” The key word is shared. Companies have found that if safety and health values are not consistently (and constantly) shared at all levels of management and among all employees, any gain that result from declaring safety and health excellence a “priority” are likely to be short-lived.

For example, if employees believe that management values productivity over safety and health, they may try to “work around” a hazard and knowingly risk accident. But if they believe that management values their safety and health, they will often report or repair hazardous conditions - often at some loss of productivity that is acceptable to management-to avoid the potentially greater loss that an accident or illness might cause later. If a bit simplistic, this illustration demonstrates the power of a successful safety and health culture. (See Fig. 16.2) [5].

11.12 SFRM: Safety Culture

A recurring theme in the literature is that organizations with effective safety cultures share a constant commitment to safety as a top-level priority; and this commitment permeates the entire organization. Some of the common components are the following: acknowledgment of the high-risk, error-prone nature of an organization's activities, a blame-free environment where individuals are able to report errors or close calls without punishment, the expectation of collaboration across ranks to seek solutions to vulnerabilities, and a willingness on the part of the organization to direct resources to address safety concerns (Taylor and Rycraft, 2005).

5 Using Public Health and Traffic Psychology to Improve Traffic Safety

Human behavior remains an important factor in traffic injury prevention (Evans, 2004; Lonero, Clinton, & Sleet, 2006). A long line of human factors research and engineering has demonstrated an inextricable link between human behavior, the environment, and technology to enhance human health and safety (Fuller, 2002; Summala, 2005). However, the uses of this information in public health are under-recognized, underappreciated, and underfunded. Whereas traffic psychologists have been major contributors to our understanding of the behavioral and social causes of traffic crashes and injuries (Evans, 2004; Frank, 1997), health psychologists have not. Leading journals in health psychology, such as Health Psychology, the Journal of Health Psychology, the British Journal of Health Psychology, and Applied Psychology: Health and Well-Being, rarely publish articles related to traffic injury prevention and behavior. One of the leading textbooks in health psychology for more than 20 years (Brannon & Feist, 2009) allots 26 pages to discussing the behavioral dimensions of exercise, but not even a page appears on the behavioral dimensions of traffic injury—the leading cause of death for Americans in the first four decades of life. The cover of a popular British health psychology text (Morrison & Bennett, 2009) shows a rock climber wedged between two boulders hundreds of feet above the ground without a harness, yet the book does not even include “unintentional injury” or “accidents” in its index of topics covered.

Road safety needs transportation and traffic psychology, health psychology, environmental psychology, and public health. Improving road safety will require a shift in how these professions think about traffic hazards, personal and public health behavior, risk control, and the value of prevention. Both behavioral and environmental changes are necessary to reduce traffic injuries, but this will take time, professional collaborations, and resources from many fronts.

The history of public health reveals that successful changes in behavior to improve health are possible, and that health risks can be reduced through the actions of individuals and communities. For example, smoking was once considered a harmless habit and part of a healthy, active lifestyle. Tobacco was heavily advertised and frequently endorsed by physicians and athletes. With mounting scientific evidence on the hazards of tobacco use, the public began viewing smoking negatively, tobacco control became a major health goal, and smoking declined dramatically. Similar shifts are required to affect a change in traffic injuries.

Public health, together with traffic psychology, can contribute to this shift by

incorporating traffic safety culture into health education activities for the young so that children associate safety with all aspects of life;

using behavioral data to identify the most significant risks to traffic injury;

conducting research on behavioral determinants of traffic crashes and their associated psychological sequelae;

using public health tools to assist the transportation sector in conducting safety audits to identify hazardous and unsafe road environments;

adding road safety to health promotion and disease prevention activities;

reducing health disparities by ensuring equal access to community preventive services such as child safety seats, bicycle helmets, and neighborhood sidewalks among poor and underserved populations;

incorporating safety and mobility into healthy aging by focusing on the mobility needs of older adults, especially as they relinquish their driving activities;

applying modern evaluation techniques to measure the impact of road safety programs and interventions;

measuring health care costs and public health consequences of traffic injuries;

identifying cost savings by applying known and effective interventions;

assisting states and communities with local injury data collection and traffic injury surveillance systems;

strengthening prehospital and hospital care for trauma victims by supporting comprehensive trauma care systems nationwide;

applying behavioral theory to design interventions that influence policy makers to protect road users from traffic injury; and

disseminating critical behavioral research in traffic safety to public health practitioners and in key public health journals and books.

Success will require participation from other sectors in society, such as education, transportation, business, economics, justice, human factors, and social services. Using a multidisciplinary perspective, traffic safety and health can move into urban planning, the built environment, social ecology, road administration, injury surveillance, and social marketing as necessary extensions of their work to preserve health and safety.

Healthy Unease

Professor James Reason (1997) uses the term ‘chronic unease’ to describe a positive feature of an effective safety culture. We could suggest that an ‘uncomfortable’ airline culture will have the greatest integral safety. Such a culture, which is both outward and inward-looking, seeks to continuously learn and improve in critical training and operational (rather than just commercial and marketing) areas, and is more likely to trap serious problems before they occur. In Dr. Westrum’s language, this is a ‘generative’ (positive) safety culture.

2.1 Traffic Safety Culture

The conceptualization of traffic culture seems to be broad and sometimes equivalent to the traffic system as a whole. Traffic culture and traffic system are, in fact, mutually inclusive and the main contributors to the differences in traffic safety between countries. However, they are based on different principles. Traffic (or “hardware”) is mainly based on tangible things such as roads, traffic signs, infrastructure, vehicles, tools, and equipment. On the other hand, traffic culture is defined as the sum of all external factors and practices for mainly the goals of mobility and safety to cope with internal factors of traffic. In addition, basic assumptions, formal and informal rules, values, norms, perceptions, and attitudes are the center of the mechanism of traffic culture; in other words, the “software” of the traffic culture is traffic safety culture and/or climate.

The safety culture concept emerged after the Chernobyl accident and several reports prepared by the International Atomic Energy Agency. The concept of safety culture was defined for the first time by the Advisory Committee on the Safety of Nuclear Installations (International Nuclear Safety Advisory Group, 1991) as follows: “Safety culture is the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs.” Zohar (1980) defined the safety climate as “a summary of molar perceptions that employees share about their work environments (safety climate).” The development of these concepts seems to be successive rather than parallel: “The minor substantive differences between culture and climate may prove to be more apparent than real” (Glick, 1985). As presented in Table 14.1, however, it might be difficult to replace them with each other, and it might be difficult to separate these concepts in practice—even the concepts are very novel in the traffic literature (Antonsen, 2009; Guldenmund, 2000; Wiegmann et al., 2007).

TABLE 14.1. Features and Differences between Culture and Climate

“Traffic culture and/or climate” and “traffic safety culture and/or climate” have remained mostly a notion in the literature without attempts to measure it empirically. One special problem related to measuring traffic culture can be seen in studies measuring “safety culture”: The “traffic culture” seems to largely overlap with the concept of “traffic climate,” and sometimes these concepts are used interchangeably. However, they are different concepts while being mutually inclusive (Antonsen, 2009; Guldenmund, 2000). Wiegmann and colleagues (2007), for example, gave 13 and 12 example definitions for safety culture and safety climate, respectively. However, the definition of traffic safety culture/climate remained unexplored.

As in the literature on safety culture and climate, traffic safety culture can thus be defined as the product of exposure and interaction of road users and the set of formal and informal rules, norms, basic assumptions, attitudes, values, habits, and perceptions in relation to safety and/or to conditions considered risky, dangerous, or injuries. As presented in Table 14.1, safety climate will then be the surface features of the safety culture (Mearns, Flin, Gordon, & Fleming, 1998) or the temporal state measure of culture (Cheyne, Cox, Oliver, & Thomas, 1998). In addition, climate exists at a lower level of abstraction than culture (Guldenmund, 2000) and provides a limited set of variables that can be operationalized and measured (Cox & Flin, 1998). Thus, climate research is conducted mostly using quantitative methods (e.g., questionnaires) dealing with the members’ perceptions and practices and how these practices and perceptions are categorized into the analytical dimensions defined by the researchers (Guldenmund, 2000).

Özkan and Lajunen (under review) used and defined “traffic climate” as preferred metric and the manifestation of traffic culture discerned from the road users’ attitudes and perceptions at a given point in time (Cox & Flin, 1998). Traffic climate is therefore defined as the road users’ (e.g., drivers’) attitudes and perceptions of the traffic in a context (e.g., country) at a given point in time (Özkan & Lajunen, under review). Özkan, Lajunen, Wallén Warner, and Tzamalouka (2006) found that compared to Swedish and Finnish drivers, Turks and Greeks perceived their traffic climate to be more dangerous, dynamic, fast, dense, unpredictable, chaotic, and free flowing, thus requiring more patience. In contrast, compared to Turks and Greeks, Swedes and Finns perceived their traffic climate to be more harmonious, safe, functional, enforced (including the use of preventive measures), dependent on mutual consideration, planned, and mobile. It can be claimed that the vast differences among countries (i.e., Greece, Finland, Sweden, and Turkey) in traffic safety also reflect their drivers’ perceptions of the traffic climate.

The set of formal and informal rules, norms, basic assumptions, attitudes, values, habits, and perceptions can operate in different layers of traffic safety culture and climate. For example, there are some basic assumptions, core values and norms, and goals that are underlying factors of traffic safety culture at each level of the traffic culture. In addition, there are some espoused values and artifacts (e.g., attitudes, habits, and perceptions) at the upper layers of traffic safety climate for each level of the traffic culture (for a multilevel model of culture including basic assumptions, espoused values, and artifacts, see Schein, 1992).

It is desirable in relation to safety that these layers operate consistently and harmoniously to minimize the exposure of road users and, sometimes, members of the public to conditions considered dangerous or to injuries at each level of traffic culture. In addition, levels of traffic culture should operate consistently and harmoniously as well. It can be assumed that any simultaneous latent or active failures either within layers and/or levels or between layers and/or levels could result in risky or dangerous acts or injuries in due course. Like the “Swiss cheese” model (Figure 14.3), traffic culture and traffic safety culture/climate focus on the interaction between latent and active conditions/failures within and between layers (i.e., traffic culture and traffic climate) and/or levels (i.e., ecocultural, sociopolitical, national, group, organizational, and individual) and unsafe acts and their contribution to accidents. Safety is therefore the responsibility of actors at all layers and/or levels of the system, especially in the absence of “defense barriers” (e.g., enforcement). In addition to the integrative perspective, differentiation and fragmentation perspectives can also be applied in the open system (i.e., traffic; Antonsen, 2009).

Salmon and colleagues (2010) stated that The Netherlands’ Sustainable Safety approach (Wegman, Aarts, & Bax, 2008), for example, highlights the fact that the fallibility of human operators is underpinned by the assumption that the responsibility for safety is shared among actors across all levels of the complex sociotechnical system (e.g., regulators, policy makers, designers, line managers, manufacturers, supervisors, and front-line operators). It is not just the responsibility of front-line operators (i.e., road users) alone. In contrast to a closed system (e.g., factories), the levels of traffic and traffic culture influence and are influenced by each other and are underpinned by traffic safety culture/climate (e.g., basic assumptions, espoused values, and artifacts). Then, they are reflected in individual road user behavior, which in turn influences the likelihood of being in a traffic accident and thereby affecting the content and development of the other levels (Figure 14.4).