The roots of Safety Culture are spread across several industries (oil and gas, nuclear power, space, air transport, rail, medical and maritime), being first mentioned officially in a report of the Chernobyl nuclear power accident in 1986. The International Atomic Energy Agency (IAEA) used safety culture to explain the organizational conditions that led to the violations of the front-line operators that created the path to disaster. A weak safety culture is seen as a strong contributory factor in various important accidents such as the King’s Cross underground station fire (Fennell, 1998), the Herald of Free Enterprise passenger ferry sinking (Sheen, 1987), the Clapham Junction passenger train crash (Hidden, 1989), the Dryden air crash (Maurino et al. 1995), the Uberlingen mid-air collision (2002), and – more controversially – the two recent Boeing 737-Max air crashes where poor safety culture appeared to apply more to the design, development, validation and oversight phases.
Even though there is no single definition of safety culture, various authors such as the International Nuclear Safety Agency Group (INSAG-4, 1991), Cox and Cox (1991), the UK Health and Safety Commission (HSC 1993) and Guldenmund (2000) agree on what safety culture represents. In broad terms, they all endorse the idea that safety culture embodies the practices, attitudes, beliefs, norms, perceptions and/or values that employees or groups of employees in a company share in relation to managing risks and overall safety. In addition, EUROCONTROL (2008) specified that safety culture can be described as “the way safety is done around here”, suggesting that it needs a practical approach.
Traditionally, safety culture is applied to operational organizations such as air traffic organizations (most in Europe undertake periodic safety culture surveys, certain airlines, and more recently, airports. However, the approach has been applied to one research and development centre where the focus was on designing new operational concepts for air traffic management (Gordon et al, 2007). While it is difficult to directly link equipment design and safety culture, and it is perhaps impossible for a designer to predict the safety culture that may evolve in the future when their design goes into operation, there are some salient points that designers need to consider:
• Safety culture surveys sometimes do raise issues concerning design and the need for design improvement.
• Design of equipment, workplace or interfaces that are cumbersome, difficult to use or complex/confusing may lead human operators to perform ‘workarounds’ that are easier in practice, but may possibly be less safe in certain circumstances.
• Whenever design choices are being made, and there is a safety element, and especially when there is a potential safety-efficiency trade-off, the designer should favour safety. As one senior project manager put it, safety at any cost doesn’t make sense, but safety as a starting point does.
• In stressful or emergency scenarios, where the operators have to make judgement calls between safety and productivity, if indications in the interface are not clear and integrated to help rapid decision-making that errs on the side of safety and caution, then a different outcome is likely to arise. Designers must ensure that, in the heat of the moment, the required safe action will be as clear as it can be.
• Designers must be clear as to which equipment and interface elements are safety critical.Moreover, the chief designer must have a holistic (rather than piecemeal or fragmented) view of the system and the safety critical role of the human operators, as well as a clear idea of the competence of those intended operators.
• The designer cannot ‘leave safety to the safety assessor’, or assume that oversight authorities can pick things up later. This is poor design culture, and, frankly, no one understands design intent better than the designer. The safety role of the human operator must be con sidered from the outset by the designer and be ‘built-in’.
• The designer cannot assume something is fit for purpose based on a few prototyping sessions with a few operational experts. Proper validation with a range of typical end users and abnormal as well as normal scenarios needs to occur.
• Designers should not underestimate the positive impact of design on safety culture, particularly where new and better equipment – user-friendly, making use of human aptitudes – enters a workplace which has hitherto been dogged by equipment problems.
• Designers should read accident and incident reports. This is the only way to look ahead, and to see how well-intended designs can end up in accidents.
• Designers should stay close to real operations and operators as much as possible, and their design organizations should encourage and enable such contact. This is the best way for designers to see around the corner, and to understand the user and their working context and culture as it evolves.
More generally, safety culture (or lack of it) can of course be felt by those working in design organizations. If for example, as a designer or engineer you think you are being pressurized to produce or accept a poorer design because of commercial pressures, who are you going to tell, and will they take you seriously and support your safety concern, or will they bow to the commercial pressure?
Safety culture has a number of dimensions, such as the following (Kirwan et al, 2016):
• Management commitment to safety (extent to which management prioritize safety);
• Communication (extent to which safety-related issues are communicated to staff, and people ‘speak up for safety’);
• Collaboration and involvement (group involvement and attitudes for safety management);
• Learning culture (extent to which staff are able to learn about safety-related incidents);
• Just culture and reporting (extent to which respondents feel they are treated in a just and fair manner when reporting incidents);
• Risk handling (how risk is handled in the organisation);
• Colleague commitment to safety (beliefs about the reliability of colleagues’ safety behaviour);
• Staff and equipment (extent to which the available staff and equipment are sufficient for the safe development of work);
• Procedures and training (extent to which the available procedures and training are sufficient for the safe development of work).
Safety culture is typically evaluated using an online questionnaire of validated questions that is distributed across the organisation and filled in anonymously (usually taking about 10 minutes). Based on the responses, analysts then identify the safety culture ‘hotspots’, which are then discussed in confidential workshops, leading to recommendations for the organisation to improve its safety culture. At a macro level, typically a ‘spider diagram’ is produced based on the results, highlighting which safety culture dimensions need most attention. In the example figure to the right, ‘Colleague commitment to safety’ is doing well in safety culture terms, whereas ‘Staffing and Equipment’ requires attention.
Safety culture surveys, particularly when anonymous and carried out by an independent organisation, are often seen as one of the only ways to find out all your risks and what people really think about the state of safety and safety culture in an organisation. They can pinpoint both current issues that can be corrected (so-called ‘quick wins’) without too much trouble, as well as deeper problems that may be entrenched in the organisational culture. Most safety culture surveys do identify the safety culture strengths of an organisation as well as vulnerabilities, so there is always some ‘good news’ as well as areas for improvement. Because the approach uses workshops of operational personnel, usually the recommendations that arise from surveys are useful and practicable, since they come from the organisation itself. The survey process is long, however, often taking 9 months from the first decision to have a survey, to having a report with recommendations. The management need to be committed to doing the process and realise that it is not a quick fix, and there will be work to do afterwards. If management are doing the survey just to gain ‘a tick in the box’, then it may be better not to do one at all.
How It Works
There are two main phases used to evaluate the safety culture in a safety culture survey:
Phase 1: Questionnaire – The safety culture survey uses an electronic version of the Safety Culture Questionnaire, over a period of typically 3 weeks. The confidential data are anonymised by The London School of Economics and then independently analysed by EUROCONTROL
Phase 2: (Optional) Workshops – After an initial analysis of the questionnaire results, there is a visit to the organisation’s premises to hold a number of confidential workshops with front-line staff (without managers present) to clarify and explore further certain aspects emerging from the questionnaires. An example of what might be discussed in such a workshop is indicated by the figure below, which shows results for an organisation in the safety culture dimension ‘Staff and Equipment’. With respect to the questionnaire statement ‘We have the equipment needed to do our work safely’, whilst more than 70% were in agreement (the green bar), the rest were either unsure or in disagreement. The workshop would explore equipment issues or concerns people have, which are underlying this response.
Illustrative Case Study – Airbus Design
It should be noted that this was seen as an exploratory survey and were focused on a single particular segment of the organization – design [Airbus ‘EY’]– rather than being company-wide (see Kirwan et al, 2019).
For the Airbus survey, the focus was on the Design part of the organization, which involves around 2,000 of the 70,000 employees. This survey required considerable tailoring of the questionnaire, as the job of design and systems engineering is somewhat different from airline operations, even if most underlying issues, except fatigue, and dimensions remain relevant. But the tailoring worked, with the same issues raised during workshops as via the questionnaires. Participation in the workshops by designers from all three of Airbus’ main design locations (France, UK, and Germany) was intense. The general principle espoused in each workshop was that a safety defect in a design of an aircraft could simply not be allowed to happen; therefore, any safety issues had to be resolved carefully and thoroughly before continuing, even if resolution efforts delayed progress toward production. One observation from the study team was that the managers in the management workshop were connected with safety and detailed safety concerns, more so than is often the case for middle managers. This is because many of the managers had held operational positions or positions ‘close to operations,’, so that they understood the operational pressures that could affect airlines and pilots. Another had been to an accident site after an air crash, and noted that after such an experience ‘safety never leaves you.’
The workshops focused a lot on internal communications between the different design departments, as well as the resolution of safety issues that could delay production, and the importance of middle manager support during such resolution periods. A number of constructive recommendations were made to Airbus in the final survey report.
Illustrative Case Study – Safety Culture Assessment
A safety culture assessment and an implementation framework were developed by the University of Strathclyde to enhance maritime safety. The focus was on the development of a safety culture assessment tool which covers all of the safety related aspects in a shipping company and measures will be taken proactively and reactively in order to enhance safety of the shipping industry.
Questionnaires were developed with an interdisciplinary group to ensure that they capture the fight information to conduct a comprehensive analysis. Each safety factor has specific questions which try to address the employee’s attitudes and perceptions amongst crew members and shore staff. There are a total of 85 questions which are asked to the employees, under the headings of communication, employer-employee trust, feedback, involvement, problem identification, promotion of safety, responsiveness, safety awareness and training and competence. The aim of the surveys is to analyse strengths and weaknesses in the company and perform benchmarking between crew and shore staff’s attitudes towards safety. Participants of the surveys were asked questions about demography, safety factors and open-ended questions about company policies. The safety culture assessment framework requires commitment from all of the bodies in a shipping company for successful implementation. Based on the findings from the questionnaires a set of recommendations were provided to the shipping company to improve communication, employer-employee trust, feedback, involvement, mutual trust, problem identification, responsiveness, safety awareness, training and competence, and the promotion of safety.