How To Develop Your Organisation’s Safety Culture
Last week we highlighted how mindless management actions can destroy an organisation’s safety culture and we explained that building a strong, positive safety culture takes deliberate, concerted and continual effort. But what sort of effort? This week the annual European helicopter expo and conference, Helitech, is being held in Amsterdam. Three years ago we presented on this very topic at the safety seminar at Helitech 2011 in Duxford, UK.
Safety Culture – the Key to Safety Performance
The term ‘safety culture’ was initially used in the report on the 1986 Chernobyl nuclear accident. While there are many definitions of ‘culture’ and an associated concept of ‘climate’, a safety culture can be conveniently considered to be the product of an organisation’s collective, safety related:
- social norms and ultimately…
- patterns of behaviour
We think that those patterns behaviours are the most important as they are observable and therefore the strongest manifestation to influence others.
As such an organisation’s culture can not evolve simply by management edict but in response to a whole range of factors including:
- local conditions,
- past events,
- the character of leadership and
- the mood of the workforce
Prof. James L. Heskett of Harvard Business School wrote in his 2011 book The Culture Cycle, that effective culture can account for 20-30% of the differential in corporate performance when compared with “culturally unremarkable” competitors.
A safety culture reflects the organisation’s actual collective, shared commitment to safety. It not simply what is said about safety but the commitment to safety that is demonstrated by normal behaviour, crucially when problems emerge or hazards are identified.
Weaknesses in safety culture are increasingly being identified in accident investigation reports as a critical precursor to accidents. This not because there is necessarily a widespread decline in organisational safety cultures, but because investigators are now looking more closely at organisations, how they function and how the shared culture is influencing individual and team behaviour. One example is the Columbia Accident Investigation Board (CAIB) report on the loss of a Space Shuttle in 2003.
It has been written that:
Safety Culture can have a direct impact on safe performance. If someone believes that safety is not really important, even temporarily, then workarounds, cutting corners, or making unsafe decisions or judgements will be the result, especially when there is a small perceived risk rather than an obvious danger.
Safety Leadership - the Key to Safety Culture
The term ‘leadership’ is sometimes misused. Sometimes as a trendy alternative for ‘senior management’ and occasionally in the Orwellian term ‘thought leadership’ (which was recently labelled “grossly indulgent” in the Forbes list of ‘most annoying business slang’).
Leadership is not the same as managing resources and schedules. Here we use leadership to represent an activity that involves:
- Being visible,
- Focusing on people,
- Building trust and ultimately…
- Influencing other people’s behaviour
It is this deliberate, concerted and continual activity that can influence culture, though as we have showed previously, that can be unravelled far more rapidly by poor leadership.
Excellent safety leaders realise that safety leadership is not an alternative to safety management but an essential complement. They also have a vision for safety in their organisation. It perhaps goes without saying that safety leaders therefore have a passion for safety.
Safety Leaders Don’t Buy-In To Safety
Its not uncommon to see safety practitioners bemoaning senior management for not ‘buying-in’ to safety proposals. The shocking truth is that excellent safety leaders don’t ‘buy-in’ to safety initiatives! That’s because their passion and motivation for safety means they are so actively involved in ‘leading’ safety (in many ways ‘selling safety’) rather than following and are actively developing their organisation’s approach to safety so they don’t need to ‘buy-in’. The term ‘buy-in’ is also distinguished by making the Forbes list of ‘most annoying business slang’.
Equally shockingly(!) is that excellent safety leaders aren’t that committed to their safety management systems! They see an SMS as a means to an end, and for that matter a means that needs to continuously improve and evolve. Excellent safety leaders are however deeply committed to safety and the protection of people from harm. Its for that reason, when it comes to their SMS, they are more interested in effective performance than mere compliance with any particular regulation (as they recognise these are just a minimum standard).
Leadership Development at All Levels
While an organisation’s CEO is influential, in all but the smallest organisations, they can only have a strong, direct and continual leadership influence on a relatively small number of employees. So when the planning started in 2006 for one award winning safety initiative, the development of safety leadership skills at all levels of this international organisation was a key part of the plan, along with a communication strategy and other initiatives to create a common dialogue on safety across the organisation.
Other Safety Culture Resources
We highly recommend this case study co-written by our founder, Andy Evans, 2008: ‘Beyond SMS’ by Andy Evans & John Parker, Flight Safety Foundation, AeroSafety World, May 2008 and this 2011 interview with Andy: How Organizational Culture Drives Safety and Quality
You may also be interested in these Aerossurance articles:
- How To Destroy Your Organisation’s Safety Culture a cautionary tale of how poor leadership and communications can undermine safety.
- The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa a real life example of safety leadership and how the stock markets reacted badly until O’Neill’s focus on safety, responding to employee suggestions and continuous improvement (not mere compliance) started to created exceptional business performance.
- UPDATE 27 January 2016: Challenger Launch Decision – 30 Years On
- UPDATE 26 April 2016: Chernobyl: 30 Years On – Lessons in Safety Culture
Prof James Reason published this paper in 1998: Achieving a safe culture: theory and practice
When discussing this model, Hudson wittily explains why brown was chosen as the colour for the pathological to whom bad things just happen…
The question above is important: If you only implement an SMS because there is a regulatory requirement you are at best reactive and if your implementation is half-hearted you may well be in the pathological category.
However, the authors caution “the model is provided to illustrate the concept and it is not intended to be used as a diagnostic instrument”.
In June 2013, The Hon. Mr Justice Haddon-Cave addressed delegates at Piper 25 (a conference to mark the 25th anniversary of Piper Alpha offshore disaster in the North Sea, in which 167 workers died). His paper was entitled “Leadership and Culture, Principles and Professionalism, Simplicity and Safety – Lessons from the Nimrod Review”, a report issued in October 2009, following the loss of Royal Air Force (RAF) Nimrod XV230:
A paper by the Health and Safety Laboratory is worth attention: High Reliability Organisations [HROs] and Mindful Leadership. Mindfulness is developed further in a paper by the Future Sky Safe EU research project and by Andrew Hopkins at the ANU.
Malcolm Brinded also discusses leadership and how good safety performance and good business performance go hand in hand:
Amy Edmonson discusses psychological safety and openness, another function of good leadership:
If leaders really want people to show up, speak out, take chances and innovate, we have to create cultures where people feel safe—where their belonging is not threatened by speaking out and they are supported when they make decisions to brave the wilderness, stand-alone, and speak truth to bullshit.
Further Safety Culture Updates
1. Overlooking context
Too many training initiatives we come across rest on the assumption that one size fits all and that the same group of skills or style of leadership is appropriate regardless of strategy, organizational culture, or CEO mandate.
In the earliest stages of planning…companies should ask themselves a simple question: what, precisely, is this program for?
Context is as important for groups and individuals as it is for organizations as a whole: the best programs explicitly tailor a “from–to” path for each participant.
2. Decoupling reflection from real work [i.e. the 70%]
The answer sounds straightforward: tie leadership development to real on-the-job projects that have a business impact and improve learning. But it’s not easy to create opportunities that simultaneously address high-priority needs…
…one large international engineering and construction player [successfully] built a multiyear leadership program that not only accelerated the personal-development paths of 300 midlevel leaders but also ensured that projects were delivered on time and on budget. Each participant chose a separate project…. These projects were linked to specified changes in individual behavior…
3. Underestimating mind-sets
Becoming a more effective leader often requires changing behavior. But..most companies…are reluctant to address the root causes of why leaders act the way they do. Doing so can be uncomfortable…leaders who are stretching themselves should feel some discomfort as they struggle to reach new levels of leadership performance.
4. Failing to measure results
When businesses fail to track and measure changes in leadership performance over time, they increase the odds that improvement initiatives won’t be taken seriously.
Too often, any evaluation of leadership development begins and ends with participant feedback; the danger here is that trainers learn to game the system and deliver a syllabus that is more pleasing than challenging to participants.
We think these points are relevant to learning and development and culture development more generally.
UPDATE 30 April 2015: Another McKinsey survey finds that :
…executives who move effectively into the C-suite are communicating priorities, valuing their teams, spending time on culture, and understanding their unique leadership role.
Indeed, executives reporting the most successful transitions stand out from the rest in how they built buy-in and communicated a vision to their teams and their organizations.
While they wanted more time to build their teams, the executives who transitioned successfully are more likely than others to say they devoted the right amount of time to understanding the organizational culture.
UPDATE 6 November 2015: Ed Shein gave a presentation: So You Want to Create a Culture? which emphasised understanding the change you want to achieve.
UPDATE 26 April 2016: We look at the origins of the safety culture concept: Chernobyl: 30 Years On – Lessons in Safety Culture. We also look at the International Atomic Energy Agency (IAEA) framework for ‘strong’ safety culture consisting of five characteristics: Each of these five characteristics have a series of subsidiary attributes.
UPDATE 11 January 2016: You may like this Forbes article Do You Know What’s Really Driving Your Organizational Culture? This make 4 key points:
- Culture is a collective concept.
- You may need some outside perspective to get an unbiased view.
- Don’t jump to conclusions. What you see isn’t always what you get and may result addressing symptoms rather what is creating them.
- Understand the why behind the what.
UPDATE 1 March 2016: A Deloitte research report, that surveyed over 7000 executives in more than 130 countries showed, 86% and 89% of executives rate culture and leadership respectively as important priorities.
UPDATE 5 May 2016: The UK Confidential Incident Reporting and Analysis System (CIRAS) has released the presentations from their ‘Safety Culture Under Strain’ conferences held in London and Edinburgh in April 2016. Aerossurance attended the excellent Edinburgh event.
UPDATE 1 August 2016: We also recommend this article: Leicester’s lesson in leadership, published in The Psychologist.
UPDATE: 28 August 2016: We look at an EU research project that recently investigated the concepts of organisational safety intelligence (the safety information available) and executive safety wisdom (in using that to make safety decisions) by interviewing 16 senior industry executives: Safety Intelligence & Safety Wisdom. They defined these as:
Safety Intelligence the various sources of quantitative information an organisation may use to identify and assess various threats.
Safety Wisdom the judgement and decision-making of those in senior positions who must decide what to do to remain safe, and how they also use quantitative and qualitative information to support those decisions.
The topic of weak or ambiguous signals was discussed in this 2006 article: Facing Ambiguous Threats
UPDATE 14 September 2016: An article on leadership learning and development in the Harvard Business Review commented that:
…we’ve learned that education and training gain the most traction within highly visible organizational change and development efforts championed by senior leaders. That’s because such efforts motivate people to learn and change; create the conditions for them to apply what they’ve studied; foster immediate improvements in individual and organizational effectiveness; and put in place systems that help sustain the learning.
UPDATE 19 September 2016: It’s worth listening to Todd Conklin’s podcast interview with Prof Ed Schein.
UPDATE 22 September 2016: NTSB Board Member Robert L. Sumwalt presented Lessons from the Ashes:
The Critical Role of Safety Leadership to an audience in Houston, TX. Its worth noting the emphasis made of safety as a ‘value’ and of alignment across an organisation. He illustrates that presentation with two charts that show the differences in perception of safety at Metro-North:
UPDATE 26 September 2016: John Bersin writes: Data Proves that Culture, Values, and Career are Biggest Drivers of Employment Brand. When it comes to recommending your organisation to others:
An employee’s rating of “culture and values” is 4.9 times more predictive of a company recommendation than salary and benefits. The second most important factor is “career opportunities,” which is 4.5 more important than salary and benefits. The third factor is “confidence in senior leadership,” which is approximately 4 times more predictive than salary and benefits.
UPDATE 29 September 2016: Culture Change is Not About Navel Gazing
…addressing culture is extremely important for business success however organizations need to be informed about whether they will actually get measurable performance results from the approach that is being suggested. Don’t be fooled…an approach that sounds like an interesting behavioral experiment or a snazzy tech solution is not usually a good one.
UPDATE 30 September 2016: Talking leadership: Julia Fernando on understanding culture to enable compassionate care in the NHS.
The difficulty is that once a culture is set and norms are established, it can be hard to change the status quo. Changing a culture of fear and blame can therefore be difficult. Leadership plays a vital role in driving forward such changes…
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:
- The culture of the organisation
- The culture of their profession
- Experience (Age)
- Their family values
- Their nationality and ethnicity equally
- Whether they come from an urban or rural area, so rural or urban cultural values
UPDATE 16 February 2017: See also our article Consultants & Culture: The Good, the Bad and the Ugly
UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017
Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning.
The result was a self-reflective approach to find ways to stimulate improvement.
- easyJet’s experience of our first safety culture survey by Siân Blanchard and David Cross of easyJet. It particular this discussed a collaborative approach to safety across organisations, in what easyJet has termed ‘the Luton Stack’.
- Safety intelligence and middle managers – the undiscovered country? by Corinne Bieder, Airbus/ENAC
UPDATE 21 March 2017: How Middle Managers Provide Leadership Everyday
Providing leadership as a middle manager requires an expanded understanding of your role and a willingness to take the risk to think and act more broadly.
Perhaps the most powerful way you provide leadership is by developing leadership capability in others. You don’t need to have all the answers. Look for opportunities to support other’s leadership efforts. And as your team develops into a high performance team, you will need to step out of their way so they can fly.
UPDATE 22 March 2017: Which difference do you want to make through leadership? (a presentation based on the work of Jim Kouzes and Barry Posner). Note slide 6 in particular:
UPDATE 25 March 2017: In a commentary on the NHS annual staff survey, trust is emphasised again:
Developing a culture where quality and improvement are central to an organisation’s strategy requires high levels of trust, and trust that issues can be raised and dealt with as an opportunity for improvement. There is no doubt that without this learning culture, with trust as a central behaviour, errors and incidents will only increase.
UPDATE 12 April 2017: See our article: Leadership and Trust
UPDATE 1 May 2017: What makes a great leader?:
- Vulnerability (see the video below of Brené Brown and Emma Sepala in the Harvard Business Review)
- Tight/loose control (which again relates to trust)
- Near/far thinking (Patience + Resilience)
UPDATE 22 May 2017: Getting to the Critical Few Behaviors That Can Drive Cultural Change
UPDATE 25 May 2017: What makes change harder or easier:
Before you adopt any popular new management approach, it pays to analyze the implicit values embedded in it. Then ask yourself: How well will those values fit our existing organizational culture?
UPDATE 30 May 2017: This slightly cynical piece discusses corporate values: How Corporate Values Get Hijacked and Misused. The message is not that values are unimportant but that only defining values, or defining faux-values is worthless or worse.
People want their company’s values to be sacrosanct. And when they aren’t, the logical conclusion they draw is that the organization doesn’t mean what it says, and that behaving in ways that contradict the values is perfectly acceptable. The painful result of widespread misuse of company values, according to one major study, is that only 23% of U.S. employees strongly agree that they can apply their organization’s values to their work every day, and only 27% “believe in” their organization’s values.
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 25 June 2017: During an air ambulance positioning flight in Iceland an Impromptu Flypast Leads to Disaster, begging more questions on organisational culture.
UPDATE 27 November 2017: “The importance of having a strong corporate culture has been well documented”. But according to a research report by INSEAD, Board Agenda and Mazars:
…a worryingly small number of board directors are actually clear about what they desire from their corporate cultures. Even more alarmingly, the very discussion of corporate culture isn’t getting the attention it deserves at board level.
UPDATE 24 December 2017: The Leader’s Guide to Corporate Culture
UPDATE 8 February 2018: The UK Rail Safety and Standards Board (RSSB) say: Future safety requires new approaches to people development They say that in the future rail system “there will be more complexity with more interlinked systems working together”:
…the role of many of our staff will change dramatically. The railway system of the future will require different skills from our workforce. There are likely to be fewer roles that require repetitive procedure following and more that require dynamic decision making, collaborating, working with data or providing a personalised service to customers. A seminal white paper on safety in air traffic control acknowledges the increasing difficulty of managing safety with rule compliance as the system complexity grows: ‘The consequences are that predictability is limited during both design and operation, and that it is impossible precisely to prescribe or even describe how work should be done.’
Since human performance cannot be completely prescribed, some degree of variability, flexibility or adaptivity is required for these future systems to work.
- Invest in manager skills to build a trusting relationship at all levels.
- Explore ‘work as done’ with an open mind.
- Shift focus of development activities onto ‘how to make things go right’ not just ‘how to avoid things going wrong’.
- Harness the power of ‘experts’ to help develop newly competent people within the context of normal work.
- Recognise that workers may know more about what it takes for the system to work safety and efficiently than your trainers, and managers.
UPDATE 9 February 2018: A Historic Shift in Expecting Leaders to Understand and Evolve Culture
UPDATE 12 February 2018: Leadership is not just about senior management: Leading by Example – NCOs are the Vital Ground. After an example to show why cultural values and standards must not be situational the author goes on:
We must be under no illusion that our Junior NCOs are the vital ground, the cohort critical to the future success of the British Army as it continues a period of painful re-adjustment, against the well-publicised fiscal constraints that will endure well into the next decade.
The steps to ensure our Junior NCOs rise to the challenge are not, you will be relieved to read, anything unachievable or impractical. They simply acknowledge the requirement to go back to ‘first principles’, starting with the inculcation of a values based approach to leadership amongst our young leaders.
UPDATE 16 February 2018: How to Increase Your Influence at Work
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.
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 11 April 2018: The Two Traits of the Best Problem-Solving Teams (emphasis added):
…groups that performed well treated mistakes with curiosity and shared responsibility for the outcomes. As a result people could express themselves, their thoughts and ideas without fear of social retribution. The environment they created through their interaction was one of psychological safety.
Without behaviors that create and maintain a level of psychological safety in a group, people do not fully contribute — and when they don’t, the power of cognitive diversity is left unrealized. Furthermore, anxiety rises and defensive behavior prevails.
We choose our behavior. We need to be more curious, inquiring, experimental and nurturing. We need to stop being hierarchical, directive, controlling, and conforming.
We believe this applies to all teams not just those solving problems. Retrospective management application of culpability decisions aids have no more a place when trying to solve problems than they do in other work activities.
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 17 July 2018: Make Your Company’s Culture Go Viral
When faced with a challenge like spreading their critical few behaviors, most organizations will default to familiar ways of trying to encourage change — using a top-down communication cascade to deliver information. They may hang HR-produced posters where employees congregate, or send company-wide emails to introduce an initiative. But these methods are rarely sufficient in driving real behavior change.
- Engage “Authentic informal leaders”
- Ensure leaders signal the behaviours
- Ensure formal systems are aligned
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.