How To Destroy Your Organisation’s Safety Culture

How To Destroy Your Organisation’s Safety Culture

The term ‘safety culture’ was initially used in the report on the 1986 Chernobyl nuclear accident.  Building a strong, positive safety culture takes deliberate, concerted and continual effort.  Destroying a safety culture is a lot easier…

Bad Safety Leadership

The following is the text of a real e-mail, spotted pinned to the wall of the flight planning room of an onshore helicopter operator (but with expletives deleted!):

Gentlemen, I have been flying multiengine airplanes and helicopters for over 40 years and 20,000+ hours, and have yet to see two gauges match perfectly!!!!!!

Please don’t waste your time and my email space reporting this $&*@!!! It’s not even worth writing about!!!

The Captain of the aircraft makes the decision if he wants something looked at, at which time he will tell the crew chief and it will get fixed.

If the Co-pilot sees something that he is concerned about, he tells the captain. Only the Captain!!!

His job is to do what the Captain asks him to do. If the Captain has concerns, he is to ask me.

SIGNED – Director of Ops Dated: December 2008

As well as discouraging safety reporting and communication, there is an underlying tone of ‘you will be blamed if you don’t conform to previously undisclosed expectations’ and ‘I know best’ contrary to the principles of a just culture or that of a questioning/learning culture.  This was a powerful sign that this operator had a pathological safety culture.  Prof Patrick Hudson proposed the following model, developed from earlier work by Ron Westrum:

safety culture types

When discussing this model, Hudson wittily explains why brown was chosen as the colour for the pathological to whom bad things just happen…


Operational Control

However in this case, the situation is even worse as the very existence of the memo also subverted the management of the operator.  The context is that the Director of Operations worked for a North American operator who leased aircraft and support services (including captains), to a South American operator.  The aircraft were actually legally being flown under the AOC of the South American operators (who provided co-pilots). Just a few months earlier a Bell 412EP, operated under a similar basis, supporting a remote copper mine was, lost in a fatal accident. The Peruvian Comisión de Investigación de Accidentes de Aviación (CIAA) commented in that case on the effect on operational control of having a ‘Field Manager’ from a US organisation with a satellite link back to his US HQ, controlling operations at the forward operating base, rather than the actual operator.

UPDATE 14 October 2014: A legal action after this accident is still on-going and the case will be heard in the US.


Downeast Airlines

In another example of a pathological culture, the US National Transportation Safety Board (NTSB) reported on the 30 May 1979 Downeast Airlines DHC-6-200 Twin Otter N68DE  Controlled Flight Into Terrain (CFIT) accident in which 17 people died.  The NTSB report stated:

ntsb downeast 2

From NTSB report AAR-80-05 on Downeast Airlines, Inc., DeHavilland DHC-6-200, N68DE, Rockland, Maine, May 30, 1979

From NTSB report AAR-80-05 on Downeast Airlines, Inc., DeHavilland DHC-6-200, N68DE, Rockland, Maine, May 30, 1979


Safety Culture Resources

POSTSCRIPT: As a follow up to this article we have published: How To Develop Your Organisation’s Safety Culture

UPDATE 5 May 2015: Former NTSB Board Member John Goglia discusses other ways to compromise your safety culture as described in NASA ASRS reports: Torqued: NASA Data Reveals Intimidation of Airline Mechanics

UPDATE 26 April 2016: Chernobyl: 30 Years On – Lessons in Safety Culture

UPDATE 30 October 2016: For a more general discussion on culture see: New research and a new understanding about culture change in organisations.  This discusses the ‘Mosaic Theory’ explaining that:

In the last few years our understanding of culture and how we take on cultural attributes has shifted away from the idea that culture is a homogeneous solid entity to the understanding that:

    • Cultures are dynamic, ever changing entities
    • Cultures don’t exist nor can be defined on their own. All cultures are in fact made up of a mosaic of different sets of behaviours, thinking and beliefs from a wide range of sources.
    • Individuals navigate the range of cultures they encounter and learn to ‘fit in’. So for example our family will have a culture that most likely is very different from the culture at work or from a social group.
    • From an individual’s perspective cultures are made up of identifiable layers or tiles which are shared or not shared between the various cultures they encounter on a daily basis.

In a follow up article, The 3 Main Conclusions and Findings from New Research about Culture Change in Organisations, it was noted that research has shown that at work “most people take their cultural cues for behaviour and beliefs from the following areas of their life” in descending order:

    1. The culture of the organisation
    2. The culture of their profession
    3. Experience (Age)
    4. Their family values
    5. Their nationality and ethnicity equally
    6. Whether they come from an urban or rural area, so rural or urban cultural values
    7. Hobbies
    8. Religion

UPDATE 8 December 2016: Aerossurance founder, Andy Evans, presented on the topic of safety leadership at a UK CAA helicopter safety culture seminar today.

UPDATE 16 February 2017: See also our article Consultants & Culture: The Good, the Bad and the Ugly

UPDATE 31 May 2017: The US National Transportation Safety Board (NTSB) commented on the poor organisational culture and leadership after the loss of de Havilland DHC-3 Otter floatplane, N270PA in a CFIT in Alaska and the loss of 9 lives: All Aboard CFIT: Alaskan Sightseeing Fatal Flight

UPDATE 12 February 2018: Leading by Example – NCOs are the Vital Ground has an example to show why cultural values and standards must not be situational.

UPDATE 7 April 2018: Investigators Criticise Cargo Carrier’s Culture & FAA Regulation After Fatal Somatogravic LOC-I.  A Shorts 360 N380MQ, operated by SkyWay Enterprises as a Part 135 flight on contract to FedEx crashed in the Caribbean after the crew likely suffered a Somatogravic Illusion raising the flaps on a dark night in 2014. The lack of an FAA SMS regulation for Part 135, the operator’s poor safety culture and implications for the wider industry culture stand out in a thoughtful accident report.

UPDATE 9 April 2018: Professor Dennis Tourish (Professor of Leadership and Organisation Studies at the University of Sussex) discussed The Dangers of Hubristic Leadership: Lessons from the Finance Sector at a British Army  Centre for Army leadership annual conference in 2017.  This included many horrific examples of hubris. He joked:

The banking sector has had a very bad press in the last number of years….That well-known Marxist magazine The Economist had a cover a couple of years ago called ‘Banksters’, published immediately after the LIBOR scandal, drawing attention to the dysfunctional leadership behaviours and the greed and avarice that was common within that sector.

When people in positions of authority acquire hubris it really does have a very serious, immediate organisational effect.

In the banking and finance sector people described to me the enormous institutional pressure for success. Huge rewards if you achieve success but success defined pretty much by narrow financial terms. ‘If we carry out this merger, this acquisition, or do these acts we will all get terribly rich’.

So you can see the incentive there to go in that particular direction: high levels of reward, which is always associated with the acquisition of power.

He concluded:

Ultimately leadership is 90 percent example and unless we, and people in authority, role model that acceptance of dissent other people will not take it seriously.

We need to lead with questions and not answers. We don’t have to pretend to have all the answers when we are in positions of authority. We need to use that magic phrase ‘I do not know.’ There are many historical examples that show the value of that kind of approach. I think we have drifted away from it. We need to go back to it.

UPDATE 29 April 2018: Counting the Costs of Winning: Doing the Right Thing, on a Difficult Day… When the Whole World is Watching

In today’s world of social media and smartphones the world is constantly watching. It is ready to make instant judgements, whether they be on military operations or a sports team’s judgement. Perhaps now we should tell the Officer Cadets something different. Today the challenge of leadership is ‘doing the right thing, on a difficult day, when you think no one will see… but the whole world is watching.’

“Leaders under pressure must keep themselves absolutely clean morally. The relativism of the social sciences will never do. They must lead by example, must be able to implant high-mindedness to their followers, and must have earned their followers’ respect by demonstrating integrity.” Vice Admiral James B. Stockdale, 1987

UPDATE 17 June 2018:  The Psychologist Guide to… Leadership  Ten tips including 10. Be aware of your own power

Our every word, action, even a stern glance – incidental or otherwise – has greater consequence. Giant’s whispers are shouts, their outbursts are explosions. Being a leader means never forgetting this.

UPDATE 13 November 2018: Inadequate Maintenance, An Engine Failure and Mishandling: Crash of a USAF WC-130H: investigators discuss a strong cultural overtone in this accident that killed 9.

For experienced support and advice you can trust on safety leadership and safety culture development, contact Aerossurance: enquiries@aerossurance.com

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