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Improving Safety Culture in Public Transportation (2015)

Chapter: Chapter 1 - Literature Review Highlights

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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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Suggested Citation:"Chapter 1 - Literature Review Highlights." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Safety Culture in Public Transportation. Washington, DC: The National Academies Press. doi: 10.17226/22217.
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14 Literature Review Highlights Introduction Little has been written about the role of safety culture in public transportation. The research team, therefore, was limited to the literature on the theory of safety culture and its application to aviation, nuclear power operations, natu- ral resource extraction, and related fields. In deciding which material to include in the review, the researchers fell back on their experience in improving safety culture to assess the applicability of prior research to public transportation, the degree to which the material has stood the test of time or holds promise for the future, the rigor with which the material was produced, and the extent to which the conclusions reached appear to be reasonably supported. There is a great deal of literature in these areas, the most important of which is presented in the research team’s com- plete literature review, which may be found at Appendix A. In this chapter, the purpose is to present only the highlights of that review. The first step in the literature review was to examine the theoretical foundations of safety culture. Then the researchers: • Addressed the challenges of defining safety culture, one of which is to distinguish it from safety climate; • Examined various competing theories and models; • Detailed the various components of safety culture included in these theories individually and combined into sets that var- ied significantly in terms of individual components included in or excluded from different theories and models; and • Discussed the various methods of assessing the state of safety culture in a given organization. Theoretical Foundation In looking at the theoretical foundations that underlie the research, the researchers found a distinct and traceable path for safety climate; however, this was not the case for the theory of safety culture, which developed differently. Background Early accident investigations and discussions of safety sci- ence focused on technical failures and human error. There were some exceptions: A few studies focused on organizational and social factors. For example, Turner (1978) used accident case studies to produce a theory of socio-technical accidents. However, most of the earlier literature revolved around hard- ware or human failure. In searching for a theoretical foundation, the research team discovered two separate research streams that turned out to provide almost all of the theoretical foundation for the research. These are the fields of safety climate research and safety culture research. Origins of Safety Climate Research The concept of organizational climate is grounded in psychological research. It is a line of study that goes back to Lewin et al. (1939), who examined social relations and inter- actions in boys’ groups. The next significant step was a work by Argyris, Personality and Organization (1957). Argyris’s contention was that employees were infantilized by indus- try practices and reacted by behaving as children, as man- agement expected them to do. Shortly thereafter, McGregor (1960) developed his Theory X and Theory Y, a construct that posits that managerial behavior has a direct bearing on employee behavior. Likert (1961) introduced four systems by which organizations might function, ranging from com- pletely autocratic to completely participative. In a later book, Likert (1967) called these System 1 (exploitative autocratic), System 2 (benevolent authoritative), System 3 (consultative), and System 4 (participative). Argyris, McGregor, and Likert each focused on how people were treated by organizations and how they responded as a means of understanding orga- nizational effectiveness. Katz and Kahn published The Social Psychology of Organizations in 1966. It looked at a wide array of factors that determined behavior, emphasizing “the total C H A P T E R 1

15 social situation encountered by employees rather than a more focused leadership perspective” (Schneider et al., 2010). Schein’s Organizational Psychology (1965) summarized most of the conceptual work that had been accomplished up to that point. The essence of this work was its analysis of the human issues surrounding organizational effectiveness. Schein studied perception, motivation, and attitudes toward work, but “the focus was on the design of organizations that were effective through collective human attitudes and action and not on individual employees as the unit of theory or analysis” (Schneider et al., 2010). For many years, however, research bogged down over whether the climate in an organization could be adequately represented by the aggregate responses of individual employees. The impasse was mitigated when James and Jones (1974) coined the term “psychological climate”; it referred to stud- ies in which the individual, rather than the organization, was examined: “the unit of data collection as well as the unit of analysis was the individual” (Schneider et al., 2010). This gave rise to the study of organizational climate. As Kuenzi and Schminke (2009) noted, three times as many articles on organizational climate were published between 2000 and 2008 than were published in the 1990s. Safety climate research effectively began when Zohar (1980) took the organizational/social factors derived from the theory of organizational climate and devised a safety climate questionnaire to examine how these factors were perceived by the workforce. When collecting safety data from various Israeli manufacturing organizations, Zohar found that scores developed from safety climate data significantly correlated with company accident rates and ratings by safety inspectors: higher safety climate scores were associated with lower com- pany accident rates and higher ratings by safety inspectors. Additional safety climate studies involving a formal quantita- tive approach (“quantitative” defined as measures of attitudes and empirical relationships to other variables, versus a quali- tative approach, which is characterized by conclusions derived from case studies) followed in different industries and cul- tural contexts. These studies generally support a relationship between safety climate scores and safety performance. Origins of Safety Culture Research The roots of organizational culture are found in anthro- pology and sociology. Pettigrew (1979) originally introduced the construct of culture to the study of organizational behav- ior so that organizational researchers would become familiar with the language and concepts of social anthropologists. By 1990, Pettigrew’s focus had become the study of processes of leadership, commitment building, and change and the nexus of culture, strategy, and change. “Practitioners and manage- ment consultants loved the concept of organizational cul- ture, and it caught on quickly as a key variable in trying to distinguish more effective from less effective organizations” (Schneider et al., 2010). Several popular management trade books, among them In Search of Excellence by Peters and Waterman (1982), used the study of culture and concepts such as myth and taboo to examine organizations. A signifi- cant problem in the study of organizational culture was that researchers were unable to establish a relationship between their qualitative case study results and organizational effec- tiveness. And, just as climate researchers bogged down in the morass of statistical levels of analysis, culture researchers became obsessed with the variety of ways in which culture might be conceptualized instead of studying how it related to organizational effectiveness (Smircich, 1983). It was not until culture researchers began to switch to quantitative methods (e.g., surveys) that relationships between culture and organizational effectiveness were demonstrated (Kotter and Heskett, 1992; Sorenson, 2002). A series of serious accidents—Three Mile Island (1979), Bhopal (1984), Chernobyl (1986), Zeebrugge Ferry (1987), King’s Cross Underground (1988), Clapham Junction (1989), and Piper Alpha (1990)—highlighted the significant role played by organizational and social factors (Zhang et al., 2002). The International Nuclear Safety Advisory Group (INSAG) first introduced the term “safety culture” in the aftermath of the nuclear disaster at Chernobyl. It was used in a number of subsequent accident inquiries as an umbrella term for a combination of managerial, organizational, and social factors that were seen as causally contributing to the accident. In this way, the concept of safety culture—unlike that of safety climate—initially sprang into existence with- out benefit of being theoretically derived. Instead it was practically derived from a series of detailed accident analyses. Clarke (2000) noted that some academics had attached the concept to the existing literature on safety climate. She called safety climate theory the “adoptive” parent of safety cul- ture. Organizational culture is the “natural” parent, but she asserted that the necessary theoretical framework had never been established. Clarke noted further that safety culture— while it was not derived from organizational culture—does share many of its features. For instance, it is of a social nature and is expressed in behavior. Researchers are divided over how difficult it is to trans- form a safety culture. The interpretive view is that culture cannot easily be altered because it is not a “simple thing that can be bolted onto an organization” (Turner et al., 1989). The functionalist view is that safety culture in fact can be “socially engineered” by “identifying and fabricating its essential com- ponents and then assembling them into a working whole” (Reason, 1997) and that it is a critical variable that can be manipulated so as to influence safety and reliability (Frost et al., 1991). In short, functionalist theory says that companies

16 can change their existing safety culture to one that will result in improved safety performance primarily by changing safety practices, while interpretive theory says that such changes are very difficult to achieve and cannot simply be imposed by fiat. It is therefore the functionalist perspective that provides a conceptual bridge between organizational behavior and strategic management interests (Wiegmann et al., 2004). In other words, functionalists believe that organizational behav- ior can be manipulated in the interests of achieving strategic business objectives. Unfortunately, the theoretical framework for safety culture, which should be based on organizational culture, remains immature in comparison with that for safety climate, and progress toward operationalizing safety culture has also been slow. There is also still no convergence toward a universal definition of safety culture or even agreement as to what major components are necessary to produce a positive safety culture. Theoretical Foundation Findings Theoretical foundation findings from the literature review are as follows: • There is a distinct and traceable theoretical foundation for safety climate; safety culture theory, however, has only pro- gressed from “atheoretical” to “immature.” • Safety climate and safety culture are two closely associated but distinct concepts. • Safety climate studies generally use formal quantitative methods, while safety culture studies historically have used mainly qualitative case study techniques. How- ever, the number of safety culture quantitative studies is increasing. • Safety climate studies generally support a relationship between safety climate scores and safety performance, and recent quantitative safety culture studies have demonstrated a similar relationship between safety culture scores and orga- nizational effectiveness. Safety Culture Versus Safety Climate Is there really a difference between safety culture and safety climate? There are two diametrically opposed views. Schein (1985) defined organizational culture as “a pattern of basic assumptions—invented, discovered, or developed by a group as it learns to cope with its problems of external adaptation and internal integration—that has worked well enough to be con- sidered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those prob- lems.” He said that climate is reflective of organizational culture but that the term “culture” has a deeper meaning that implies basic assumptions and beliefs that are shared by members of the organization. Ekvall (1983) described culture as beliefs and values about people, work, the organization, and the commu- nity that are shared by most members within the organization; organizational climate, he said, stems from common character- istics of behavior and expression of feelings by organizational members. Table 1 presents the differences between culture and climate in organizations as defined by Krause (2005). For purposes of this project, the research team treats safety climate as a snapshot in time of the organization’s safety culture (Krause, 2005). This view is consistent with that of Wiegmann et al. (2002), who concluded that safety climate is “a temporal indicator of a more enduring safety culture.” Definition of Safety Culture The literature contains scores of different definitions of safety culture. Many of these are cited in the full literature review (Appendix A). Dr. James Reason, whose model of safety culture is outlined later in this chapter, endorsed two in lieu of formulating a definition of his own. • The Uttal definition is: “shared values (‘what is impor- tant’) and beliefs (‘how things work’) that interact with an organization’s people, structures, and control systems to produce behavioral norms (‘the way we do things around here’)” (Uttal, 1983). The Uttal definition has been echoed in a number of fairly recent federal government definitions. CULTURE CLIMATE Common values that drive organizational performance Perceptions of what is expected, rewarded, and supported Applies to many areas of functioning Applies to specific areas of functioning “How we do things” “What we pay attention to” Unstated Stated Background Foreground Changes more slowly Changes more rapidly Table 1. Comparison of culture and climate concepts (Krause, 2005).

17 • The UK Health and Safety Commission definition is: “the product of individual and group values, attitudes, com- petencies, and patterns of behaviour that determine the commitment to, and the style and efficiency of, an orga- nization’s health and safety programs. Organizations with a positive safety culture are characterized by communica- tions founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy measures” (Health and Safety Commission, 1993). The Uttal definition has recently been echoed in a number of federal government definitions. • The Energy Facilities Contractor Group of the Department of Energy (EFCOG/DOE) definition says a safety culture is “an organization’s values and behaviors, modeled by its lead- ers and internalized by its members, which serve to make safe performance of work the overriding priority to protect the public, workers, and the environment” (EFCOG/DOE, 2009). • The Transit Rail Advisory Committee for Safety (TRACS) defines safety culture as “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that can determine the commitment to and the style and proficiency of an organization’s safety management system” (Transit Rail Advisory Committee for Safety, 2011). • The Federal Railroad Administration (FRA) defines organi- zational culture as “shared values, norms, and perceptions that are expressed as common expectations, assumptions, and views of rationality within an organization and play a critical role in safety.” It notes that organizations with a positive safety culture are characterized by “communica- tions founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures” (U.S. Federal Register, 2012). Models and Theories of Safety Culture Safety culture is complex and multidimensional, and there are numerous theoretical models of safety culture in the lit- erature. In the full literature review (Appendix A), the research team details the Westrum, Reason, Hudson, Guldenmund, and Cooper models. Also covered are the Fleming safety culture maturity model, the DuPont Bradley curve model, the systems view model, and the high-reliability organization model. Of these models, the most elaborate and sophisticated is the Reason model, which is grounded in Reason’s extensive practical experience. Reason Model (1997) Reason asserted that a safety culture can be engineered. Figure 1 provides a schematic of the Reason model. The various elements of Reason’s model are driven by underlying perceptions, attitudes, and behaviors. According to Reason, four of the elements (learning, reporting, flexible, and just) feed into and support the fifth element (informed). As Reason said, “The preceding . . . have identified four criti- cal subcomponents of a safety culture: a reporting culture, a just culture, a flexible culture, and a learning culture. Together they interact to create an informed culture which, for our purposes, equates with the term safety culture as it applies to the limitation of organizational accidents” (Reason, 1997). Note that many depictions of the Reason model incorrectly portray informed culture as being separate and distinct from the learning, reporting, flexible, and just cultures. Reason said clearly that both the Westrum and Reason models have the processing of information as their primary focus. In an informed culture, the organization collects and ana- lyzes relevant data and actively disseminates safety informa- tion. Individuals who manage and operate the organization’s safety system know the human, technical, organizational, and environmental factors that determine the safety of the sys- tem. All members of the organization understand and respect the hazards of operations and are alert to the system’s poten- tial vulnerabilities. In a reporting culture, an environment is cultivated that encourages employees to report safety issues without fear of punishment. Employees know that confiden- tiality will be maintained and that, when they disclose safety information, management will act to improve the situation. Reason’s model particularly communicates the importance of maintaining a reporting culture within an organization. This reporting culture, which must be initiated and sup- ported wholeheartedly by management, is necessary in order for management to get an accurate picture of the status of an organization’s safety culture. For example, Wiegmann et al. (2004) similarly supported a claim by Eiff (1999) that “one of the foundations of a true safety culture is that it is a reporting culture” by identifying an effective and systematic reporting Figure 1. Reason’s safety culture model (research team modified version).

18 system as the keystone to identifying breaches before acci- dents happen. In a just culture, unintentional errors or unsafe acts are not punished. Deliberate, reckless, and indefensible acts that are considered unjustifiable and that place the organization and individuals at risk are subject to disciplinary action. A just culture in turn promotes mutual trust. In a flexible culture, the organization and employees are able to adapt effectively to changing needs and demands. For example, the organiza- tion may shift from a hierarchical structure to a flatter, or more horizontal than vertical, structure for more decentral- ized problem-solving capability. A learning culture encourages use of safety information to draw conclusions about necessary changes and incorporate a willingness to implement major reform when change is required (Civil Air Navigation Services Organisation, 2008). Management is able to take direct action in the areas pertaining to each subculture to move the organi- zation from its present practices toward the ideal and thereby engineer a positive safety culture. The success of the new prac- tices affects underlying employee perceptions, attitudes, and behaviors. For example, the changing of practices having to do with reporting and just treatment of employees can create a state of mutual trust in an organization, which in turn results in a much greater flow of useful information throughout the organization. It is important to note that Reason’s primary focus was on what he termed “organizational accidents” as opposed to “individual accidents.” He defined “organizational accidents” as the “comparatively rare, but often catastrophic events that occur within complex modern technologies such as [those in] nuclear power plants, commercial aviation, the petro- chemical industry, chemical process plants, marine and rail transport.” Individual accidents, on the other hand, are “ones in which a specific person or group is often both the agent and the victim” (Reason, 1997). DuPont Bradley Curve Model (1999) The DuPont Bradley curve model is impressive because of the extensive amount of empirical data that was employed to verify the inverse relationship between the degree of strength of safety culture and the Occupational Safety and Health Administration (OSHA) recordable injury rate. The DuPont Bradley model places companies and organi- zations in the following four sequential categories: 1. Reactive: These companies handle safety issues by natural instinct, focusing on compliance instead of a solid safety culture. Responsibility is delegated to the safety manager, and there is generally a lack of management involvement in safety issues. 2. Dependent: While there is some management commit- ment, supervisors are generally responsible for safety control, emphasis, and goals. Attention to safety is made a condition of employment but with an emphasis on fear and discipline, rules, and procedures. Such companies do value all their people and will provide safety training. 3. Independent: These companies stress personal knowledge of safety issues and methods as well as commitment and standards. Safety management is internalized and stresses personal value and care of the individual. These companies engage in active safety practices and habits and recognize individual safety achievements. 4. Interdependent: These companies actively help others conform to safety initiatives—they become others’ keep- ers, in a sense. They contribute to a safety network and have a strong sense of organizational pride in their safety endeavors. In the DuPont Bradley curve model, the three elements of safety management are (1) leadership, (2) structure, and (3) processes and actions. DuPont has administered its safety perception survey since 1999 and has a database available for benchmarking. The data- base contains more than 632,000 responses from 96 industries, 41 countries, and over 3,383 locations. It is used to rate com- panies on the basis of their relative cultural strength (RCS). These ratings are “weak” (RCS less than 40), “average” (40–60), “good” (60–80), and “world-class” (greater than 80). RCS is then plotted on the x-axis of the DuPont Bradley curve against each company’s 3-year average OSHA total recordable injury rate (TRIR) on the y-axis. The results are as follows: 19 organizations with a “weak” RCS had a mean TRIR of 4.6, 57 companies with an “av er- age” RCS had a mean TRIR of 2.7, 164 companies with a “good” RCS had a mean TRIR of 1.1, and 106 companies with a “world-class” RCS had a mean TRIR of 0.61. This compari- son shows a very strong correlation between relative culture strength and safety performance. No proof of causality, how- ever, is offered (Hewitt, 2011). While DuPont’s behavior-based safety work in the public transportation industry has some detractors (Lessin, 2000), the DuPont Bradley curve model (in Figure 2) has no obvi- ous weaknesses or internal contradictions, is based in part on credible empirical data, and demonstrates a strong relationship between safety culture and safety performance. What is lacking in most theories and models is a systems view. These theories and models do not consider influences outside of the affected organization. As shown in the Roberts (2010) schematic of David Gaba’s “Arrow” in Figure 3, regu- lators and government frequently have a significant effect on outcomes. The Arrow might be further expanded to include

19 the individual involved in the accident, peers, management, board, stockholders, regulators, legislatures, and the public. Research has shown that the general public is reactive regard- ing safety—that is, willing through its legislators to provide resources after a dramatic accident rather than before, even though the best predictors and risk assessments indicate that proactive interventions are far more effective at reducing risk. This comports with the observations made by Reason (1997) about the role that regulation plays: “if regulators are to be other than convenient scapegoats, they will have to be provided with the legislation, the resources, and the tools to do their jobs effectively. As we have seen, safety legislation is enacted in the aftermath of disasters, not before them.” He went on to note that, while there is no obvious political gain to be had from preventing accidents, in the long run that effort is more rewarding. This applies throughout the “system chain” of prevention responsibility. High-Reliability Organization Model The research team believes that, given the potentially cata- strophic consequences of an unanticipated event and the sub- sequent loss of critical transportation functions, larger transit authorities might consider adoption of the high-reliability organization (HRO) model. Two subway trains operating under communications-based train control (CBTC) at rush hour in the tunnels of New York carry up to 5,000 passengers. The results of a head-on collision due to a CBTC failure and a subsequent fire at rush hour would lead to total casualties that exceed most aviation crashes, offshore platform accidents, and other high-profile accidents and incidents and could cripple all transportation within New York City for days, if not weeks. This model is therefore described in great detail because the research team believes its adoption by large, heavy-rail opera- tions could be a prudent step as the technology and complex- ity of these operations are rapidly advancing. An HRO is generally defined as an organization that repeat- edly accomplishes its mission while avoiding catastrophic events, despite significant hazards, dynamic tasks, time con- straints, and complex technologies (Hartley, 2010). B&W Pantex has published several books on HRO implementation in the nuclear weapons industry, including Hartley et al., High Reliability Operations: A Practical Guide to Avoid the System Accident (2008), and Hartley et al., Causal Factors Analysis: An Approach for Organizational Learning (2008). The HRO model places a special premium on positive safety culture and possesses special attributes that help those who use it identify potentially dangerous safety behaviors. HROs are recognized as having extraordinary technical competence, flexible decision-making processes, sustained high technical performance systems, and processes that reward the discovery and open reporting of errors or potential errors. These organi- zations value safety as much as they prize production demands and organizational commitment to sustaining institutional cul- ture. They place a substantial value on organizational learning, expertise, and the promotion of a questioning environment in which the revelation of potential safety issues can be recognized and appreciated. HROs tend to be preoccupied with failure and share a collective mindfulness that leads to learning from mis- takes and the continual analysis of information gained from near misses and other leading indicators that have proven to be predictive of potential safety issues. They believe that compla- cency leads to vulnerability and puts the organization at risk. HROs are generally regarded as ranking high in the safety hierarchy. The Columbia Accident Investigation Board was critical of NASA’s safety culture and, as a result, adopted the high-reliability organization as a standard. Its conclusion was that, had the principles of HRO organizations been fol- lowed, the Columbia would not have disintegrated (Boin and Schulman, 2008). Figure 2. DuPont Bradley curve. Figure 3. David Gaba’s Arrow systems view model (Roberts, 2010).

20 HROs create processes and systems that reduce the pos- sibility of unexpected events, allowing for containment and speedy recovery if one occurs. In the HRO infrastructure, small failures are tracked meticulously. Personnel are engaged in collective problem solving through inquiry, which allows HROs to maintain a high level of proficiency at identifying gaps in system continuity and understanding warnings of potential catastrophes. Operations personnel are trained to react to even weak signals and to address the cause of failure prior to initiation of a series of events that can lead to disaster. The interactions of HRO processes are illustrated in Figure 4. Components of Safety Culture In the course of conducting its literature review, the research team found no convergence in the literature on a single set of components of safety culture. The number of components in a set and the identity of those components varied significantly from one investigation to another. The sets differ significantly in terms of which components are included and which are excluded. See the numerous sets of components proposed by various researchers in Appendix A for examples. One source of confusion in dealing with the components of safety culture is the fact that, in the literature, components are also variously referred to as attributes, dimensions, elements, and indicators. Generating perhaps even greater confusion, however, is the considerable overlap that exists in the com- position of sets of components in the literature. For example, organizational commitment is sometimes understood to be made up of management commitment, company policies and procedures, and the provision of adequate resources. At other times, management commitment and organizational commitment are considered separate and equal components. The most common threads in the literature review are: • Maintaining safety as a core value; • Requiring strong leadership and management commitment; • Enforcing high performance standards; • Providing adequate resources for safety; • Empowering individuals at each organizational level to be responsible for safety; • Involving unions continuously in the safety process (where employees are unionized); • Emphasizing learning, education, and training; • Ensuring open, honest, and effective communication within the organization and encouraging a questioning environment; • Maintaining an effective reporting system, with visible action taken on issues reported, and ensuring timely responses to concerns and issues; • Using leading and lagging safety indicators to gauge the effectiveness of safety programs on employee behavior; • Demonstrating leadership behaviors that encourage mutual trust between management and employees; • Monitoring performance continuously; and • Treating employees fairly. Assessment Methods Numerous methods are available for assessing an organiza- tion’s safety culture. The most common include direct obser- vation and audits, surveys, interviews and focus groups, and performance indicator tracking. Direct Observation and Audits Direct observations of workplace behavior may provide objective information regarding the aspects of safety culture, including effectiveness of training, management, accountabil- ity, and behavior expectations. Direct observation of employ- ees at work can provide valuable information on employee involvement, attitude, and willingness to confront perceived unsafe behavior. The observer can watch the culture at work and can confirm results obtained from interviews and sur- veys. Observations can provide new information on cultural phenomena. However, observations—even if scored on a checklist—cannot be precisely quantified, and there is always the risk of overgeneralization from too few observations Figure 4. A mindful infrastructure for high reliability (Muhren et al., 2008).

21 (EFCOG/DOE, 2009). Conducting sufficient observations to produce an accurate assessment of the state of safety culture in an organization of any size is necessarily time-consuming and expensive. Safety audits are a form of direct observation and can pro- vide the basis for improving performance. Blair and O’Toole (2010) noted that several large organizations with which they were familiar “report anecdotally that . . . audit results correlate strongly with reductions in injury rates.” They rec- ommended Manuele’s risk score formula as a suitable tool to estimate risk levels and establish measurement priorities. The three-dimensional matrix assesses risk on the basis of probability, frequency of exposure, and severity of acci- dents or incidents. “Measuring safety performance is about developing the safety management systems and the related safety culture” (Blair and O’Toole, 2010). Petersen’s caveat (that there is little correlation between audit reports and injury records in large companies because audits are gener- ally as much about paperwork and regulatory compliance as they are about the effectiveness of a safety program) applies (Petersen, 1996). Surveys There are numerous benefits to assessing safety culture using safety surveys. Blair and O’Toole (2010) state that “sur- veys provide a snapshot of an organization’s culture and can be a useful tool in developing measures to drive culture.” They argue that well-designed surveys provide benefits to an organization. They are: • Practical. They address the primary safety issues. Even if the issue is one of perception, perceptions are real to those who hold them and must be addressed. • Predictive. They fulfill the definition of what a leading indi- cator is supposed to do. • Prescriptive. The results generally indicate clearly what needs to be addressed. • Proactive. They are preferable to accident investigation, which is a reactive measure (Blair and Spurlock as cited in Blair and O’Toole, 2010). The most significant limitations are that surveys are some- what inflexible and may not necessarily yield high response rates (introducing potential bias). The only information that can be obtained is the direct response to each specific question posed. The elicitation of subtle distinctions is difficult to obtain from a survey. Safety culture assessments can be tools to detect man- agement blind spots. Research has shown that the views of management and frontline staff members at times tend to vary dramatically. The differences can be instructive. Ques- tionnaires can be designed to explore a specific dimension of safety culture. Other advantages of safety culture surveys include their ability to reach large numbers of employees at a relatively low cost, the retention of anonymity by responders, the identification of problems and issues, and the ability to track progress over time using successive surveys. Interviews and Focus Groups Interviews can also play a significant role in the assess- ment of safety culture. They can be used to develop informa- tion directly on the state of safety culture in an organization. Alternatively, they can be used as a means of providing input to survey design or to explore issues in greater depth that have emerged from a survey. An advantage of the interview is that respondents are not limited by the wording or structure of a written survey. The greater flexibility in an interview allows the interviewer to drill down until an issue or problem is fully clarified and any ambiguity resolved. However, generalization is risky over the whole organization if the interviews are lim- ited in number. Also, as with direct observation, interviews are time-consuming and expensive if done in large numbers (EFCOG/DOE, 2009). Focus groups are more efficient but less flexible than indi- vidual interviews. The efficiency comes from the ability of one interviewer to elicit the views of multiple employees in a single session. Flexibility is somewhat reduced because the interviewer generally uses a set of prepared questions to pro- vide basic organization and direction. A significant downside to focus groups is that, without a skilled facilitator, a minority of participants can dominate a discussion and provide input that might differ significantly from the results obtained from individual interviews with all members of the group (Cox and Cheyne, 2000). Performance Indicator Tracking Many aspects of safety culture are not visible, so assess- ment is not a simple task (Ahmed, 2011). Metrics must be directional, hold individuals accountable, relate to injury reduction, and be highly motivational (Blair and O’Toole, 2010). The Blair and O’Toole research shows that lagging indicators alone do not address or contribute to improve- ments in safety culture (Blair and O’Toole, 2010). (Lagging indicators are measures of past performance; leading indi- cators indicate future performance.) Metrics used to assess safety and safety culture should include a combination of leading and lagging measures; lagging or trailing measures alone are not effective indicators. As previously noted, Blair and O’Toole (2010) maintain that “leading indicators serve as a catalyst for change, meaningful metrics are motiva- tional for both employees and management, and leading

22 indicators ultimately drive safety performance” (Blair and Spurlock, 2008). In an interview with Safety + Health, Harold Yoh III, listed among the magazine’s “2011 CEOs who get it,” said that his company, which does engineering, construction, and main- tenance of nuclear plants, “religiously measures and reports our safety results as we work toward our goal of zero injuries and safety incidents. One of our most important measure- ments is tracking off-the-job injuries, which helps determine how well we are building a robust safety culture that is 24/7, not just on the job. We believe the true challenge is to go beyond the standard regulatory requirements and track the leading indicators that determine the ultimate success of our safety program” (Froetscher, 2011). There are a number of accepted means of measuring and assessing progress in safety management systems, both quali- tative and quantitative. Many sources cite employee surveys and questionnaires and face-to-face interviews as ways to capture information. Wiegmann et al. (2004) suggested that combining qualitative and quantitative methods will yield a comprehensive understanding of safety culture, but go on to say that “quantitative approaches, especially surveys of indi- viduals’ responses, are often more practical in terms of time and cost effectiveness.” While surveys and interviews are widely used, specific metrics are being developed in some industries to measure safety in a more quantitative way. In the aviation industry, for example, the Volpe Center is working with the FAA to create a runway incursion severity calculator that will categorize the outcome severity of runway incursions (Volpe Center Highlights, 2009). In the chemical industry, the Center for Chemical Process Safety recommends that “all companies and trade associations collect and report the three lagging met- rics: Process Safety Incidents Count, Process Safety Incident Rate, and Process Safety Severity Rate” (Center for Chemical Process Safety, 2011). “While many safety executives understand trailing mea- sures, such as trend analysis, control charts, and evaluating the effectiveness of safety initiatives, these measures often- times do not provide feedback for continuous safety process improvement, nor do they contribute to the development of safety culture. Positive safety culture remains unaffected when the above measures are the primary focus for metrics in an organization” (Blair and O’Toole, 2010). The practice of developing leading measures and concurrent measures using qualitative metrics for system and employee behaviors was noted by Toellner (2001), who studied the oil industry. Five specific measures were scored for quality and quantity: safety meetings, housekeeping, barricade performance, job safety analysis, and safety walks. Employee engagement is impor- tant to any safety management process, and Blair and O’Toole provide an example of a large brewery where employees use individual score-carding activities such as: • Observation cards, • Job safety analysis (training and auditing), • Safety meetings and safety audits, • Maintenance walkthroughs, and • Pre-shift stretching. Safety culture assessment is a critical component of safety culture improvement. Measures should be well thought out and relate to industry standards. Blair and O’Toole (2010) offer six critical and effective guidelines for implementing safety measures: 1. Customize measures specifically for individual sites. 2. Use risk assessment to prioritize safety measures by severity. 3. Simplify by limiting the total number of safety measures used at any time. 4. Engage employees meaningfully in the development of safety measures and related safety goals. 5. Use a thoughtfully chosen mix of performance and out- come measures. 6. Design measures to specifically influence the safety culture.

Next: Chapter 2 - Safety Culture Within Public Transportation »
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TRB’s Transit Cooperative Research Program (TCRP) Report 174: Improving Safety Culture in Public Transportation presents research on the definition of safety culture within public transportation, presents methods and tools for assessing safety culture, and provides strategies and guidelines that public transportation agencies may apply to initiate and build a program for improving safety culture.

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