Strengthening the Safety Culture of the Offshore Oil and Gas Industry (2016)

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26 Safety culture has become an increasing focus of conversation and research since the late 1980s, particularly after a series of orga-nizational disasters including the U.S. space shuttle Columbia explosion in 2003, the Fukushima Daiichi nuclear plant meltdown in Japan in 2011,1 and the South Korean Sewol Ferry capsizing in 2014. The term safety culture is often invoked in the offshore oil and gas industry as well, having been used to explain disasters from the Piper Alpha accident (1988) to the Deepwater Horizon blowout and spill (2010) (see Chap- ter 1). Investigations into these disasters frequently have identified their cause as a culture that insufficiently prioritized safe and reliable perfor- mance relative to other objectives, such as efficiency or shareholder value (e.g., Cullen 1990; CAIB 2003; BP U.S. Refineries Independent Safety Review Panel 2007; CSB 2007; Montara Commission of Inquiry 2010; National Commission on the BP Deepwater Horizon Oil Spill and Off- shore Drilling 2011). Independent investigations of both the BP Texas City onshore refinery and BP Deepwater Horizon catastrophes found that the safety culture in each instance was deficient—a deficiency that led to the tragic loss of life and, in the case of Deepwater Horizon, nearly led to the economic collapse of one of the world’s largest corporations (BP). This focus on safety culture appears to be increasing. In 2009, it was estimated that the number of papers referencing safety culture had increased to more than 2,250 (Silbey 2009, 341). DEFINITION OF SAFETY CULTURE To understand safety culture, one must have a working understanding of organizational culture. Organizational culture is typically thought to consist of artifacts (e.g., surface aspects that are easy to discern, such as 2 | Safety Culture 1 Both the nuclear power utility and its regulator had deficient safety cultures (NRC 2014, 238).

Safety Culture 27 dress), espoused beliefs and values, and basic underlying assumptions (i.e., unconscious, taken-for-granted beliefs and values) that are learned by a group as it solves its problems of external adaptation and internal integration (Schein 2004). Values consist of what members believe is important in their organization—for example, whether production is more important than safety. Norms are the behaviors expected by peo- ple who are important to one and one’s work (Mearns and Flin 1999). For example, the offshore oil and gas industry in the Western world is often characterized as having organizational cultures that are male- oriented, macho, rough and tough, and “can do” (Wright 1994). Organizational culture is not static, but is a dynamic characteristic of the organization as enacted among people and between people and orga- nizational systems. In other words, it is a dynamic phenomenon that surrounds members of the organization at all times, and is constantly enacted through their interactions with each other and shaped by leaders’ behavior and organizational structures, routines, rules, and norms (Schein 2010; Blazsin and Guldenmund 2015). The dynamic cycle of culture enactment and refinement consists of experimentation, inter- action (and the development of shared understandings), institution- alization (translation into norms and behaviors), and internalization (transformation into basic assumptions) (Berger and Luckmann 1966). Organizational culture is not unitary, but differs systematically across subgroups (Schein 2010). For example, professions (e.g., engineering) and subunits (e.g., a specific organizational department) often evince distinc- tive cultures. Similarly, subcultures exist within hierarchical levels of an organization, meaning that senior executives, middle managers, engineers, and frontline workers may have distinctive cultures, including their views regarding safety (Schein 1996). Research consistently finds that senior executives tend to view an organization’s safety culture as stronger relative to the perceptions of middle managers and frontline employees (Sex- ton et al. 2000; Singer et al. 2009). The enacted, multifaceted, and pervasive nature of organizational culture means it is something an organization is and is challenging to change deliberately, rather than something an organization has that can be changed directly and readily (Schein 2010). Organizational culture reflects the shared, tacit assumptions that have come to be taken for granted and that determine members’ daily behavior. The subset of assumptions about safety in an organization

28 Strengthening the Safety Culture of the Offshore Oil and Gas Industry can be loosely labeled safety culture (Schein 2010), encompassing the organization’s values, beliefs, attitudes, social norms, rules, practices, competencies, and behaviors regarding safety (Mearns and Flin 1999). In other words, safety culture can be characterized as the actions taken and decisions made when no one is watching. More formally, Uttal (1983, 66) defines safety culture as “shared values (what is important) and beliefs (how things work) that interact with an organization’s struc- tures and control systems to produce behavioral norms (the way we do things around here).” Silbey (2009, 343) notes that in engineering and management scholarship, safety culture is referred to as “a set of stable, commonly shared practices in which all members of an organization learn from errors to minimize risk and maximize safety when perform- ing organizational tasks.” The U.K. Health and Safety Commission (HSC 1993, 23) defines safety culture as “the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs.” The U.S. Nuclear Regula- tory Commission (U.S. NRC) defines safety culture as “the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure pro- tection of people and the environment” (U.S. NRC 2011). Finally, the Bureau of Safety and Environmental Enforcement (BSEE) defines safety culture as “the core values and behaviors of all members of an organization that reflect a commitment to conduct business in a man- ner that protects people and the environment” (BSEE 2013). As with all the definitions of safety culture given above, as well as the character- istics of strong safety cultures outlined below, the committee’s concept of safety culture encompasses both the personal safety of workers and process safety, as well as the prevention of harmful events and resilient responses to accidents and emergencies (Amalberti 2013). Across the above definitions, safety culture reflects the extent to which an organization’s culture understands and accepts that safety comes first, with a majority of organizational members directing their attention and efforts toward its improvement (Vogus et al. 2010). A primary, albeit often implicit, assumption is that the workforce’s choice between being efficient (i.e., productive) and being thorough (i.e., safe and reli- able) and its more general attitudes and behavior toward safety are a function of the organization’s prevailing safety culture (Guldenmund

Safety Culture 29 2000). Supporting this assumption is consistent evidence from multi- ple meta-analyses indicating that safety culture consistently influences safety-related behaviors (increasing compliance with safety rules and participation in safety efforts), as well as personal and process safety (reducing accidents and injuries) (Clarke 2006; Christian et al. 2009; Beus et al. 2010). Recent research in the offshore oil and gas indus- try likewise has found safety culture (particularly staff attitudes and perceptions regarding safety) to be associated with fewer hydrocarbon leaks (Vinnem et al. 2010; Kongsvik et al. 2011). Safety culture is an ongoing accomplishment; it requires sustained effort and continuous adaptation throughout the entire organization (Vogus et al. 2010). Consequently, an organization’s safety culture, like its broader organizational culture, is a function of changes to which the organization has adapted over time (e.g., changes in leadership, govern- ment regulation, competitor actions, mergers and acquisitions, reorga- nizations) and is reflected in its structure (Schein 2004). This view of safety culture belies the popular belief that “a safety culture can only be achieved through some awesome transformation,” such as a cata- strophic organizational accident (Reason 1997, 192). Instead, changes in response to catastrophe are often short-lived because a safety culture “emerges gradually from the persistent and successful application of prac- tical and down-to-earth measures” (Reason 1997, 192). In other words, strengthening safety culture (i.e., placing priority on safety relative to other goals) results from careful practice, leadership attention, and sus- tained effort. Others have cautioned that bottom-up behavioral change programs instituted to improve safety culture (see DeJoy 2005) should not shift the responsibility for safety from management to workers, nor should behavioral change be used as a less costly substitute for top- down investments in improvements that would make facilities and operations safe (Baram and Schoebel 2007; Silbey 2009). The panel that investigated the BP Texas City disaster provides yet another view.2 According to this view, an organization’s culture is enacted and refined through actions taken by all members of the organization, but top management is especially critical (CSB 2007) because “no matter what regulatory system is used, safe operations ultimately depend on the commitment to systems safety by the people 2 The panel was referred to as the “Baker Panel” or the “BP U.S. Refineries Independent Safety Review Panel.”

30 Strengthening the Safety Culture of the Offshore Oil and Gas Industry involved at all levels within the organization” (NAE and NRC 2011, 116). Top management creates the context and sets the tone for that commitment. Amalberti (2013) argues that the specific forms of safety culture vary and that industries differ in the vision of safety culture they espouse. He describes a “resilient” model that handles high levels of risk with individual autonomy and expertise (e.g., seafishing skippers, the early airline industry). The high-reliability organization, or HRO, model (e.g., firefighting, the merchant marine, oil exploration, and chemical manufacturing) blends resilient action with more formal role structures designed to ensure constant attention to risks, flexible detection of and recovery from problems, and regular collective learning and improve- ment. Finally, the ultrasafe systems model (e.g., commercial airline and nuclear power industries) relies on prevention through design (e.g., procedures and standards for normal and abnormal conditions) and training to avoid exposing operators to exceptional risks. It is also important to note what safety culture is not. The term is often confounded with compliance and rule following, but a strong safety culture entails members of the organization viewing safety as intrinsically important. Specifically in the oil and gas industry (Antonsen et al. 2012), a rule- and standardization-focused approach can be inimi- cal to a strong safety culture and organizational capabilities for handling and resolving crises. Rules also can contribute to misleading mind-sets of invulnerability (Wicks 2001), acting as “mock bureaucracies” (Hynes and Prasad 1997) that are neither respected nor enforced (Gherardi 2006, 183). Moreover, an emphasis on rule following can hinder the engagement of those most practiced at recognizing risks and anomalies in operational processes—the frontline people who are most closely associated with complex technical systems and are aware of their inher- ent risks (Vaughan 1996, 228). Instead, safety culture is characterized by managers and people on the front lines making the right choice every time, even when environmental conditions are difficult, when time con- straints are tight, and when no one is looking. In other words, safety culture is not built or sustained solely through such formal means as punishment of individuals for incidents of noncompliance and rewards for compliance, public declarations by the chief executive officer (CEO) and human resources department, or perfunctory discussions of safety in formal notices or safety minutes. Safety culture is something leader-

Safety Culture 31 ship must fully embrace and the entire organization must commit to, engage in, and execute every day. As noted earlier, safety culture is characterized by subcultures for different groups (e.g., departments, professions). In gas distribution, for example, Blazsin and Guldenmund (2015) found that distinctive subgroups of employees—field workers, frontline supervisors, and net- work supervisors—experience the organizational safety culture differ- ently and manage the ambiguity of safety policy and the uncertainty of work situations in their own ways. Mearns and colleagues (1998) simi- larly found considerable variation in safety subcultures among U.K. off- shore workers, depending on their age, occupation, seniority, shift, and prior accident experience. Subcultures are likely to be especially preva- lent on offshore oil rigs given the array of contractors typically working the rig. That is, the culture of an oil rig is more likely to be a function of the varied contractors and specific workers than of the multinational oil company that commissioned the drilling. Thus, even more so than in the typical organization, the number of subcultures offshore makes change especially difficult. Chapter 6 further identifies the barriers to change in safety culture and practices, as well as processes for over- coming them to build and strengthen an organization’s safety culture. Finally, it is important to distinguish between safety culture and safety climate. Organizational culture is often contrasted with orga- nizational climate, with the latter typically seen as being expressed in specific and identifiable practices such that it captures “surface features” of organizational culture (Denison 1996; Flin et al. 2006). Similarly, safety climate is the shared perception among members of an organi- zation of the priority of acting safely based on shared assessments of the behaviors expected, rewarded, and supported by the organization and its supervisors and managers (Zohar 2003). Safety climate also is a snapshot of the workforce’s current perceptions regarding the status of safety in the organization (Mearns and Flin 1999). Members of the organization draw inferences about safety climate based on the pattern of managerial actions in choosing between competing priorities (i.e., production and safety) because these actions indicate the differences between formally declared and enforced policy and practice (Zohar 2003, 2010). Irrespective of formal policy, for example, whenever safety issues are ignored or made contingent on production pressures, workers will infer low safety priority and a weak safety climate (Zohar 2008; see

32 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Wright [1994] for an example from the offshore oil and gas industry). Thus, the safety climate of an organization sends signals regarding the underlying assumptions and values animating its safety culture. WHY A STRONG SAFETY CULTURE IS DIFFICULT TO ACHIEVE Safety culture is elusive both conceptually and empirically because safety itself presents many distinct challenges for organizations. First, safety demands seeing what is not there—an accident in the making (Perin 2005). In this way, it is an “ever-receding chimera, observable only when it ceases to exist” (Silbey 2009, 358). This makes a strong safety culture difficult to manage and sustain because people have difficulty knowing the mistakes they did not make but could have, which means they have a limited sense of the actual level of safety and what produces it. Safety also is difficult to sustain because feedback on system safety is often discontinuous and indirect (March et al. 1991). It is dis continuous because recorded accidents, incidents, and even near misses are relatively rare events, and indirect because these data reflect a system only at a partic- ular moment in time without necessarily indicating its intrinsic resistance to operational hazards (Reason et al. 1998). As a result, safe performance relies on making the unthinkable thinkable, the invisible apparent, such that accidents in the making can be detected more readily (Perin 2005), and producing a “dynamic nonevent” through patterns of practice that entail continual small adjustments (Weick 1987). As noted, an organization’s primary goals (e.g., production) compete or may be perceived as competing with safety (Carroll and Rudolph 2006). In this dynamic, production is seen as an acute problem that needs to be addressed immediately, and safety as a more chronic con- cern (Woods 2005). With a chronic as opposed to an acute concern, it is easier for complacency to set in and for resources to be diverted to more pressing matters. In fact, the failure to assess risk holistically and take mitigation measures has been implicated in the Macondo well incident (NAE and NRC 2011). Moreover, safety often is encouraged by “outsiders” (e.g., regulators, citizens’ groups, media) or safety spe- cialists, who may be seen as interfering with (and not understanding) the organization’s legitimate service and production work (Carroll and Rudolph 2006; Dekker 2014). Thus, both research and theory suggest

Safety Culture 33 that institutionalizing safety as a priority and value is both elusive and uniquely challenging. In practical terms, organizations often wrestle with the inevitable (at least in the short term) tension between safety and production goals. This conflict frequently results in heuristics—such as “ALARP” (keeping risks as low as reasonably practicable) and “ASSIB” (and still stay in business)—that amplify the challenge of strengthening safety culture. A strong safety culture, of necessity, accentuates technological and economic feasibility in promoting continuous improvement. In recognition of these difficulties, organizations such as the Campbell Institute have attempted to create incentives designed to help rebal- ance some of the trade-offs between safety and production and to illus- trate how organizations can balance strong safety culture with high economic performance. Specifically, the Robert W. Campbell Award3 recognizes organizations that achieve business excellence through the integration of environmental, health, and safety management into their ongoing business operations. The characteristics of these organizations illustrate some of the traits of a strong safety culture: the entire orga- nization (CEO to frontline workers) makes safety a priority relative to business performance, effective practices and processes for safety per- meate the organization across geography and hierarchical levels, leading (maintenance, near misses) and lagging (incidents) indicators of safety performance are actively measured, and training of and investment in employees to deliver safe performance are continuous. As interest in safety culture has grown, the concept has been sub- jected to strong critique, often from researchers in political science and sociology. For example, Perrow (1984) argues that the pursuit of a safety culture in such industries as offshore oil and gas is quixotic, as absolute safety is impossible in complex systems that inevitably produce acci- dents, even though many operators may exhibit excellent safety records over a number of years. Others have argued that culture is not readily changed to pursue specific goals (e.g., reducing accidents and injuries [Silbey 2009]), a topic addressed directly in Chapter 6. The next section identifies practices and processes that strengthen safety culture. The BSEE safety culture taxonomy is presented as the 3 The Robert W. Campbell Award is the most prestigious award in environmental, health, and safety manage- ment worldwide.

34 Strengthening the Safety Culture of the Offshore Oil and Gas Industry guiding framework for this report, and the research support for each of its nine factors is reviewed. ELEMENTS OF A STRONG SAFETY CULTURE Many reviews have focused on safety culture in particular industries in various countries, including oil and gas (NEB 2014), chemicals (AIChE 2005), health care (AHRQ and HHS 2004; Health Foundation 2011), occupational safety (European Agency for Safety and Health at Work 2011), radiation (Reiman and Pletikainen 2010), energy (EFCOG– DOE 2009), and nuclear power (IAEA 2008; U.S. NRC 2011). The academic literature also contains many reviews of safety culture that summarize its recurring elements based on survey research. For the offshore industry, Cox and Cheyne (2000) include mea- sures of nine dimensions in their safety climate assessment toolkit. In the nuclear power industry, the Institute of Nuclear Power Operations (INPO 2013) and the U.S. Nuclear Regulatory Commission (U.S. NRC 2011) have standardized their concept of a strong safety culture to include 10 traits of a healthy safety culture and an assessment pro- cess using a safety climate survey. INPO and U.S. NRC divide these traits into three categories: • Management commitment to safety—leadership safety values and actions, decision making, and respectful work environment; • Individual commitment to safety—personal accountability, ques- tioning attitude, and effective safety communication; and • Management systems—continuous learning, problem identification and resolution, environment for raising concerns, and work processes. In health care, The Health Foundation (2011) used survey data to iden- tify 11 overlapping attributes of safety culture. And following the U.S. space shuttle Columbia accident, Behavioral Science Technology used a survey instrument previously developed with the National Aeronautics and Space Administration (NASA) (2005) that includes 11 organiza- tional, team, and safety-based dimensions. In the academic literature, Flin and colleagues (2000) reviewed 18  safety climate scales and concluded that five dimensions emerge consistently: management priorities, safety policies and systems, risk attitudes, work pressure, and competence. Similarly, Christian and col-

Safety Culture 35 leagues (2009) identify seven dimensions of safety culture. Reason (1997) outlines how a safety culture is a function of practices and pro- cesses that arise from the interaction of four subcultures or cultural features: reporting culture (an environment for raising concerns), just culture (people are treated with respect and fairness and not blamed for what is beyond their control), informed culture (appreciative of knowledge and expertise), and learning culture (that makes changes as needed). Westrum (2004) and Hudson (2007) describe a safety cul- ture ladder with differing forms of culture that increase in complexity and ability to produce safe performance: pathological (power oriented), reactive, bureaucratic or calculative (rule oriented), proactive, and gen- erative (learning oriented). Research on high-reliability organizations (Roberts 1990; LaPorte and Consolini 1991; Weick and Sutcliffe 2007) focuses broadly on what differentiates organizations that oper- ate successfully in high-hazard industries, but includes an emphasis on cultural features such as preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resil- ience, and deference to expertise. The INPO–U.S. NRC taxonomy mirrors academic categoriza- tions of the attributes of strong safety cultures as (a) enabling (leaders’ actions to make safety a priority and make it safe to take interpersonal risks), (b) enacting (translating priorities into concrete actions and prac- tices by frontline employees), and (c) elaborating (structured reflection on and refinement of organizational practices, processes, and behaviors) (Vogus et al. 2010; Singer and Vogus 2013). Enabling maps to man- agement commitment to safety, enacting to individual commitment to safety, and elaborating to management systems. BSEE Taxonomy as Common Ground Although, as reflected in the above overview, there is no formally agreed- upon approach to defining the elements of a strong safety culture, the committee believes the offshore industry needs to reach consensus on a workable, shared direction forward that can be modified following further research and practical experience. Indeed, looking across the various conceptualizations of safety culture, one can see common sets of practices and processes. Therefore, the committee chose to structure this discussion of the elements of a strong safety culture around those identified as essential by BSEE (summarized in Box 2-1). The BSEE

36 Strengthening the Safety Culture of the Offshore Oil and Gas Industry BOX 2-1 Nine Essential Elements of a Strong Safety Culture Identified by BSEE The nine essential elements of a strong safety culture identified by BSEE are as follows: • Leadership commitment to safety values and actions. Leaders demonstrate a commitment to safety and environmental stewardship in their decisions and behaviors. Leaders visibly demonstrate this commitment through how they allocate resources within the organization and prioritize safety relative to production. • Respectful work environment. Trust and respect permeate the organiza- tion, with a focus on teamwork and collaboration. • Environment for raising concerns. A work environment is maintained in which personnel feel free to raise safety and environmental concerns without fear of retaliation, intimidation, harassment, or discrimination. • Effective safety and environmental communication. Communications maintain a focus on safety and environmental stewardship. Knowledge and experience are shared throughout the organization. • Personal accountability. All individuals take personal responsibility for process and personal safety, as well as environmental stewardship. • Inquiring attitude. Individuals avoid complacency and continuously consider and review existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. Workers are expected to question work practices as part of everyday conversations without hesitation. • Hazard identification and risk management. Issues potentially impact- ing safety and environmental stewardship are promptly identified, fully evaluated, and promptly addressed or corrected commensurate with their significance. • Work processes. The process of planning and controlling work activities is implemented in a manner that maintains safety and environmental stewardship while ensuring use of the correct equipment, used in the correct way, for the correct work. • Continuous improvement. Opportunities to learn about ways to ensure safety and environmental stewardship are sought out and implemented. Source: BSEE 2013.

Safety Culture 37 taxonomy mirrors leading scholarly reviews of safety culture research and leading frameworks in other industries, is grounded in empirical research, is supported by a key regulator, and is useful for the offshore industry. In developing its list of nine essential elements, BSEE relied heavily on the attributes of safety culture (“traits of a healthy safety culture”) identified for the nuclear power industry (U.S. NRC 2011; INPO 2013; NRC 2014). The nuclear power industry itself had derived those attributes from the work of Reason (1997), Weick and Sutcliffe (2007), and others. In short, although there is no single definitive set of essen- tial elements of safety culture, the various taxonomies that have been developed display a great deal of overlap and commonality. Table 2-1 compares the leading conceptualizations of the practices and processes of a strong safety culture summarized above against the nine elements identified by BSEE (Box 2-1). In many cases, these other concepts overlap with and support the BSEE elements. Additional con- cepts that do not appear to fit within the BSEE framework are included in a final row of Table 2-1 as “Other.” The elements identified by BSEE can also be categorized in accor- dance with the academic taxonomy outlined above (Vogus et al. 2010; Singer and Vogus 2013) as factors enabling a safety culture–management commitment to safety (leadership commitment to safety values and actions, respectful work environment, environment for raising con- cerns, and effective environmental and safety communication); enacting a safety culture–individual commitment to safety (personal account- ability and inquiring attitude); and elaborating a safety culture– management commitment to safety (hazard identification and risk management, work processes, and continuous improvement). It should also be noted that the nine elements of a strong safety culture identified by BSEE do not explicitly include the competence of the workforce that is noted in the “Other” row of Table 2-1. For example, the Interna- tional Atomic Energy Agency (IAEA 2002) found that participants at one of its meetings considered the key elements of safety culture to be top management commitment to safety, sufficient competent staff, and open communication. Similarly, INPO and U.S. NRC consider com- petence to be inherent in continuous learning (W. E. Carnes, Myrtle Beach, SC, personal communication, September, 2015). The American Petroleum Institute’s Recommended Practice 1173 also explicitly states

TA B LE 2 -1 C om pa ri so n of S af et y C ul tu re A tt ri bu te s B S EE (s ee B ox 2 -1 ) IN PO ( 20 13 ) an d U .S . N R C (2 01 1) PH M S A ( 20 15 ) Fl in e t al . (2 00 0) C hr is ti an e t al . (2 00 9) C ox a nd C he yn e (2 00 0) Th e H ea lt h Fo un da ti on (2 01 1) R ea so n (1 99 7) R es ea rc h on H ig h- R el ia bi lit y O rg an iz at io ns a Le ad er sh ip co m m itm en t t o sa fe ty v al ue s an d ac tio ns Le ad er sh ip co m m itm en t t o sa fe ty ; d ec is io n m ak in g re fle ct s sa fe ty fi rs t Le ad er sh ip co m m itm en t t o sa fe ty ; s af et y ha s pr io ri ty ov er o th er de m an ds Le ad er sh ip co m m itm en t to s af et y M an ag em en t co m m itm en t to s af et y Le ad er sh ip co m m itm en t to s af et y; sa fe ty is a pr io ri ty Le ad er sh ip co m m itm en t t o sa fe ty R es pe ct fu l w or k en vi ro nm en t Tr us t p er m ea te s th e or ga ni za tio n M ut ua l t ru st be tw ee n em pl oy ee s an d or ga ni za tio n Te am w or k, hu m an re so ur ce pr ac tic es , su pe rv is or su pp or t, an d in te rn al g ro up pr oc es se s (e .g ., pe er su pp or t f or sa fe ty ) Fr on tli ne in vo lv em en t in s af et y Te am w or k (e .g ., pe op le s up po rt ea ch o th er ), w or k en vi ro nm en t (e .g ., pe op le sp ea k up fr ee ly an d re ce iv e fe ed ba ck ), or ga ni za tio na l fa ct or s (e .g ., m an ag em en t su pp or t) Ju st cu ltu re D ef er en ce to ex pe rt is e w ith th e sp ec ifi c sa fe ty is su e, no t t o fo rm al au th or it y En vi ro nm en t fo r r ai si ng co nc er ns O rg an iz at io n is fa ir a nd co ns is te nt in re sp on di ng to s af et y co nc er ns In te rn al g ro up pr oc es se s (e .g ., pe er su pp or t f or sa fe ty ) Su pp or tiv e en vi ro nm en t fo r s pe ak in g up a bo ut sa fe ty Sp ea ki ng u p R ep or tin g cu ltu re R el uc ta nc e to si m pl ify Ef fe ct iv e en vi ro nm en ta l an d sa fe ty co m m un ic at io n O pe n co m m un ic at io n ac ro ss th e or ga ni za tio n C om m un ic at io n C om m un ic at io n an d fe ed ba ck In fo rm ed cu ltu re

Pe rs on al ac co un ta bi lit y Ev er yo ne pe rs on al ly re sp on si bl e fo r sa fe ty C le ar ly d ef in ed ac co un ta bi lit y; em pl oy er s fe el p er so na lly re sp on si bl e Ev er yo ne in vo lv ed in sa fe ty D ef er en ce to ex pe rt is e w ith th e sp ec ifi c sa fe ty is su e, no t t o fo rm al au th or it y In qu ir in g at tit ud e Q ue st io ni ng at tit ud e cu lti va te d R ep or tin g an d in fo rm ed cu ltu re Pr eo cc up at io n w ith fa ilu re (s ee ki ng po te nt ia l th re at s to s af et y sy st em ) H az ar d id en tif ic at io n an d ri sk m an ag em en t Te ch no lo gy re co gn iz ed a s co m pl ex a nd di ff ic ul t t o m an ag e; s af et y un de rg oe s co ns ta nt ex am in at io n R is k at tit ud e Pe rc ei ve d jo b ri sk ; s af et y at tr ib ut es a nd be ha vi or s R is k ap pr ec ia tio n R is k pe rc ep tio n In fo rm ed cu ltu re Pr eo cc up at io n w ith fa ilu re (s ee ki ng po te nt ia l th re at s to s af et y sy st em ) W or k pr oc es se s Sa fe ty u nd er go es co ns ta nt ex am in at io n Sa fe ty tr ai ni ng an d re so ur ce s av ai la bl e Sa fe ty s ys te m s lim it w or k pr es su re s to tr ad e of f sa fe ty fo r pr od uc tiv it y Sa fe ty s ys te m s lim it w or k pr es su re s to tr ad e of f sa fe ty fo r pr od uc tiv it y Sa fe ty ru le s ar e fo llo w ed an d no t sa cr ifi ce d fo r pr od uc tiv it y Sa fe ty s ys te m s lim it jo b de m an ds to tr ad e of f s af et y fo r p ro du ct iv it y Se ns iti vi ty to op er at io ns C on tin uo us im pr ov em en t O rg an iz at io na l le ar ni ng is em br ac ed C on tin uo us le ar ni ng Le ar ni ng cu ltu re C om m itm en t t o re si lie nc e O th er Sa fe ty tr ai ni ng an d re so ur ce s av ai la bl e W or kf or ce co m pe te nc e N o te : I N PO = In st itu te o f N uc le ar P ow er O pe ra tio ns ; U .S . N R C = U .S . N uc le ar R eg ul at or y C om m is si on ; P H M SA = P ip el in e an d H az ar do us M at er ia ls S af et y A dm in is tr at io n. a I nc lu de s R ob er ts ( 19 90 ); L aP or te a nd C on so lin i ( 19 91 ); W ei ck a nd S ut cl iff e (2 00 7) .

40 Strengthening the Safety Culture of the Offshore Oil and Gas Industry that “investment in building competency, like continuous learning, builds trust and confidence that management cares about safety, their employees and contractor personnel, and the public” (API 2014, 23). After deliberating, the committee decided not to expand BSEE’s list of nine elements, but rather to emphasize that competence underlies all of these elements. Specific practices that help foster such competence are discussed in the section below on work processes. The next section reviews research corresponding to each of the nine elements characteristic of a strong safety culture outlined above. Research Evidence on BSEE’s Nine Essential Elements of a Strong Safety Culture Research on safety culture across industries supports each of the nine essential elements of a strong safety culture identified by BSEE. Leadership Commitment to Safety Values and Actions Research on safety culture in multiple industries has found that leaders and their actions play an especially crucial role through a commitment to safety values and actions, the practices instituted to foster a respect- ful work environment conducive to raising safety concerns, and engage- ment in consistent safety communication. The value of such leadership is especially evident in high-hazard operations that face low-frequency, high-consequence events, such as the U.S. Navy’s nuclear submarine fleet (Bierly and Spender 1995). More specifically, the intensity with which safety is pursued is a function of leaders’ emphasizing safety through their personal practices, such as safety rounding (Thomas et al. 2005); through their leadership style (Yun et al. 2005); through their incident command skills (Crichton et al. 2005); and through their commitment to safety and its priority relative to other goals (Zohar 2002). When employees observe a leader implementing and engaging in practices that make safety a priority, they are more likely to do so as well. As noted earlier, a safety culture is also dynamic, and it relies on well-developed processes of collective reflection and organizational learning to help institutionalize safer practices (Reason 1997). These leader and organizational practices inform action on the front lines that is characterized by high levels of personal accountability and inquir- ing attitudes focused on identifying hazards and managing their risks

Safety Culture 41 through action and changes to work processes. These practices also subject safety performance (both good and bad) to careful analysis and corrective action (i.e., continuous improvement). Stated differently, a safety culture is strengthened and sustained by leader and organiza- tional practices that enable such a culture, by frontline enactments, and by elaboration through structured reflection and refinement (Vogus et al. 2010; Singer and Vogus 2013). Leaders single out and draw attention to safety and make it possible for employees to apply this focus on safety to their everyday work. Evi- dence suggests that leaders enable safer practices on the front lines in at least two ways: first, by demonstrating commitment and attention to safety (e.g., through safety communication [Hofmann and Stetzer 1998; Katz-Navon et al. 2005]), and second, by creating respectful work environments that spur a willingness to raise concerns such that all workers feel safe in speaking up and act in ways that improve safety (as seen, for example, in Paul O’Neil’s action to emphasize and reinforce safety at ALCOA [Duhigg 2012]). In sum, the value leaders place on safety significantly influences how employees view its importance. Specifically, employees base their perceptions of safety culture, in part, on leaders’ commitment to safety (e.g., through safety practices and procedures and other investments in safety), the priority they place on safety relative to other goals, and their dissemination of safety information (Katz-Navon et al. 2005). For example, commitment to safety will be low when a supervisor dis- regards safety procedures whenever production falls behind schedule or punishes people for mistakes (Zohar 2000; Carroll and Quijada 2004). As noted earlier, however, aspects of safety are frequently in conflict with other goals that the organization rewards and supports (Zohar 1980). Thus, a safety culture and a safety climate rely on consis- tent managerial action, as evidenced by research in the offshore oil and gas industry (Kongsvik et al. 2011), as well as leading meta-analyses of safety culture (e.g., Clarke 2006; Beus et al. 2010). Respectful Work Environment Formal organizational practices can increase the attention paid to safety and instill a respectful work environment conducive to safety and the ability to raise safety concerns without fear of punitive action. A respectful work environment has been found to be especially necessary

42 Strengthening the Safety Culture of the Offshore Oil and Gas Industry offshore, where the traditional macho culture can inhibit disclosure and learning (Ely and Meyerson 2010). Such practices as safety rounds or visits by leaders to frontline facilities (e.g., oil rigs) to discuss safety issues and concerns with operators can be especially valuable (Singer and Tucker 2014). These discussions are then documented and trans- lated into action plans that are fed back to the front lines. Safety rounds are intended to build and sustain good relations between organizational leaders and frontline workers, promote conver- sations to identify hazards, and gather information to enhance deci- sion making regarding safety. Emerging evidence indicates that safety rounds do indeed strengthen safety culture by, for example, drawing attention to safety when managers visit the front lines. Two studies in health care settings found that safety rounds increased the perception that leaders viewed safety as a high priority, were committed to safety, and were responsive to safety issues identified by workers on the front lines (Thomas et al. 2005; Frankel et al. 2008). Direct observation of frontline work, coupled with safety forums, can further highlight and emphasize the priority of safety concerns (Tucker et al. 2008). Virginia Mason Medical Center, like leading organizations in other industries, such as ALCOA and DuPont (Duhigg 2012), conducts safety rounds during which leaders ask staff to describe specific events in the previous few days that resulted in harm, caused a near miss, or impaired their ability to do their work (Spear 2005). The leaders reinforce their com- mitment to the frontline workers and enhance a safety culture by creat- ing a safety alert process that allows any employee to halt immediately any process likely to cause harm to a patient and that requires a “drop and run” commitment from more senior leaders (e.g., vice presidents) to respond immediately to these issues (Spear 2005). Environment for Raising Concerns Leaders shape safety culture by empowering employees to speak up and resolve threats to safety by correcting erroneous procedures or system flaws promptly. Research illustrates how leaders empower employees to raise concerns by creating psychological safety—the belief that it is safe to take interpersonal risks (Edmondson 1999). Leaders create psycho- logical safety by changing the way in which mistakes are discussed— avoiding threatening terms such as “errors” and “investigations” in favor of more psychologically neutral terms such as “accidents” and “analysis”

Safety Culture 43 (Edmondson 2004). Leaders also create psychological safety by actively appreciating others’ contributions (Nembhard and Edmondson 2006), soliciting their input, and pardoning employees who make and share unin- tentional mistakes (Edmondson 1996). Nembhard and Edmondson (2006) found that leaders’ inclusiveness (i.e., soliciting the input of frontline employees) reduced status differences and was associated with higher levels of psychological safety, which in turn enabled greater engagement in improvement initiatives designed to remove hazards that threatened safety in neonatal intensive care units. Likewise, Tucker (2007) found that higher levels of psychological safety enabled front- line employees to suggest potential solutions for common work system failures to their managers and experiment systematically with those solutions. Empowerment and an effective environment for raising con- cerns also rely on adequate resources with which to act; when leaders provide frontline employees with such resources, safer outcomes result (Shortell et al. 1994). In short, an empowering leadership style allows employees to think, apply their knowledge (e.g., speak up), and learn by doing and can lead to both greater learning and safer performance (Yun et al. 2005; Ely and Meyerson 2010). Effective Safety and Environmental Communication When leaders personally commit to safety and make it a high priority, their actions lead to more open communication regarding safety issues and increase the likelihood of internal attributions for safety incidents so that future incidents can be avoided by making changes, thus cre- ating the conditions for learning from error (Hofmann and Stetzer 1998). When leaders make safety a priority and safety information is actively and widely disseminated, employees are more likely to report errors (Naveh et al. 2006) and incidents (Weingart et al. 2004). In contrast, a poor safety climate (e.g., high performance pressure, fail- ure to disseminate safety information) encourages employees to devi- ate from safety procedures and remain silent when others act unsafely (Hofmann and Stetzer 1996). In other words, leaders aid the development of safety culture when they engage directly in safety-related interactions with subordinates by consistently communicating safety messages, disseminating safety infor- mation, and showing how a commitment to safety is practiced in daily functioning (Barling et al. 2002; Zohar 2002), as well as modeling an

44 Strengthening the Safety Culture of the Offshore Oil and Gas Industry openness to learning (Ely and Meyerson 2010). When leaders direct attention to safety culture, frontline workers can understand more clearly the specifics of safer practice (Zohar 2000; Carroll and Quijada 2004). Consequently, these actions by leaders have been shown to increase safety motivation (i.e., willingness to exert effort), participation in voluntary safety activities (e.g., helping coworkers with safety-related issues), and reporting of errors by employees (Naveh et al. 2006; Neal and Griffin 2006). Personal Accountability and Inquiring Attitude Enactment of a safety culture depends on frontline employees’ willing- ness to disclose errors and near misses and to otherwise communicate their ideas and concerns upward in the organization to improve work processes (Carroll and Edmondson 2002; Stern et al. 2008; Tangirala and Ramanujam 2008). Leaders foster an inquiring attitude to identify causes of safety problems, and encourage workers’ personal commit- ment to and accountability for identifying hazards and improving work processes. Unfortunately, frontline employees often are reluctant to report errors, especially errors of commission (Henriksen and Dayton 2006). For example, Blatt and colleagues (2006) found that medical residents spoke up in only 14 percent of cases of reliability lapses (i.e., errors). Of even greater concern, residents spoke up only 39 percent of the time when there was a known, specific opportunity to prevent patient harm (Blatt et al. 2006). These instances of employee silence directly affect work outcomes by reducing managerial access to criti- cal work-related information. They often are due to a fear of reprisal and other risks of speaking up (Edmondson 1996; Blatt et al. 2006; Tangirala and Ramanujam 2008), as well as the fact that errors result- ing from taking action often carry a heavier penalty relative to those resulting from inaction (Henriksen and Dayton 2006). In the offshore oil and gas industry, prior research has found these conditions to be espe- cially common. Instead of raising concerns when conditions are unsafe, workers are expected by site managers to cut corners whenever pro- duction falls behind schedule, despite official claims to the contrary (Paté-Cornell 1990; Wright 1994), although there are some notable exceptions (e.g., Ely and Meyerson 2010). By contrast, when the right conditions are present (e.g., leader com- mitment, an environment for raising concerns, a respectful work envi-

Safety Culture 45 ronment), speaking up and listening have an impact on safety and reflect a strong safety culture. First, speaking up helps improve safety and safety culture by revealing latent and manifest hazards and by making it pos- sible to discuss, learn from, and collectively avoid the same errors in the future (Edmondson 1996). Naveh and colleagues (2006) also found that higher levels of error reporting were a key component of a well- developed safety culture. Second, Schulman (1993) found that promot- ing the orderly challenge of operating routines through regular meetings was a key feature of the highly reliable performance of a nuclear power plant (see Knox et al. 1999 for similar examples from health care). Third, speaking up provides a constructive foundation for the develop- ment of corrective action. Consistently speaking up and raising concerns in work units expands a repertoire of shared experiences regarding what does and does not work (Edmondson 2003). In military units, related improvements in relationships between super visors and frontline staff also foster safety culture in the form of greater personal accountabil- ity as employees expand the definition of their safety role (i.e., viewing safety as part of, not an add-on to, their role [Hofmann et al. 2003]). Likewise, better relationships between supervisors and subordinates in manufacturing facilities enhance safety culture by producing open and constructive communication about safety and errors that allows employees to learn from incidents and increase their commitment to safety (Hofmann and Morgeson 1999). Such high-quality relationships also help sustain the chronic unease needed to maintain a strong safety culture and correspondingly safe performance (Flin and Fruhen 2015). Hazard Identification and Risk Management Management research shows that accurate hazard identification and risk management result from pooling diverse viewpoints such that partici- pants can share what they know and learn through interaction (Weick and Westley 1996). Specifically, valuing stories and storytelling fosters disseminating and refreshing knowledge through interaction so that all participants know more about the risks they face and the errors that may result, and realize that they and their peers have the ability to handle those errors that do occur because others have previously handled simi- lar errors (Weick 1987). In other words, storytelling creates a coherent structure through which gaps and inconsistencies that pose threats to the system can be readily detected (Weick and Browning 1986). Additional

46 Strengthening the Safety Culture of the Offshore Oil and Gas Industry tools, such as root-cause, first-cause analysis teams, incident reviews, and other forms of self-analysis, are evident in industries such as nuclear power and chemical processing as means of providing deeper under- standing of organizational systems that reveals leverage points, suggests new interventions, and strengthens safety culture and safety performance (Carroll 1998). The absence of such practices and processes for systemat- ically and holistically assessing risk and managing the identified hazards has been associated with disasters in the offshore oil and gas industry such as the Deepwater Horizon incident (NAE and NRC 2011). Actions taken in an attempt to resolve threats often consist of indi- vidual workarounds that allow work to continue despite poor work systems (Tucker and Edmondson 2003; Tucker 2004). But truly resolving threats requires mobilizing the resources needed to address their underlying causes (Tucker and Edmondson 2003; Faraj and Xiao 2006). Patching of ineffective work systems occurs offshore and is, in part, a function of not paying sufficient attention to early indicators of larger problems (e.g., blowouts [Skogdalen et al. 2011]). When leaders commit to making safety a priority and integrating it into the organiza- tion’s daily functioning (as described above), frontline employees are able to prevent, solve, and learn collectively from problems and reduce the incidence of errors and other safety issues (Singer et al. 2009). Effective problem solving also relies on a combination of preventive actions that avoid problems and adaptive actions that redress problems. Problem-solving behaviors (e.g., seeking feedback, using a structured problem-solving process) have been shown to lead to the successful adoption of new practices that improve safety and prevent future errors across industries (MacDuffie 1997; Tucker et al. 2007). In the face of nonroutine problems in aviation and in nuclear power control rooms, for example, quickly prioritizing and shifting tasks among team mem- bers to balance demands leads to better and safer performance (Waller 1999; Waller et al. 2004). Faraj and Xiao (2006) found that quickly engaging in practices of dialogic coordination by diagnosing a condi- tion and calling on experts to determine reasonable approaches and relevant factors being missed resulted in more effective and safer out- comes. In other words, all forms of resources need to be made available and usable (i.e., sanctioned and supported by leadership). Mindful organizing—a set of behaviors observed in high-reliability organizations (e.g., aircraft carrier flight decks [Rochlin et al. 1987];

Safety Culture 47 air traffic control [LaPorte and Consolini 1991]; and nuclear power control rooms [Schulman 1993])—represents an inquiring attitude focused on hazard identification, risk management, and personal accountability. Mindful organizing is a process by which frontline employees come to understand the situation they face and their collec- tive capabilities for managing it (Weick et al. 1999; Weick and Sutcliffe 2006, 2007). Mindful organizing consists of five interrelated organi- zational processes: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise (Weick et al. 1999). Preoccupation with failure is chronic wariness that drives analysis of possible vulnerabilities and treats any failure or near miss as an indicator of potentially larger prob- lems (LaPorte and Consolini 1991; Weick and Sutcliffe 2007; Flin and Fruhen 2015). Reluctance to simplify interpretations means actively questioning received wisdom and seeking differing opinions and view- points to better uncover blind spots and avoid complacency (Schulman 1993; Fiol and O’Connor 2003; Weick and Sutcliffe 2007). Sensitivity to operations denotes creating and maintaining a current, integrated understanding of operations and where expertise resides (Weick et al. 1999). Commitment to resilience involves growing employee and orga- nizational capabilities to adapt, improvise, and learn in order to better recover from unexpected events (van Dyck et al. 2005). Finally, defer- ence to expertise occurs when decisions migrate to the people with the greatest expertise in handling the problem at hand, regardless of formal rank (Roberts et al. 1994). Research suggests that interacting in ways that are more mindful contributes to strengthening safety culture (Vogus et al. 2010; Singer and Vogus 2013). In addition to the above-cited studies of aircraft car- riers and nuclear power control rooms supporting the components of mindful organizing, a multiyear qualitative study of a pediatric inten- sive care unit (Roberts et al. 2005; Madsen et al. 2006) found that introducing practices that embraced mindful organizing (and the enact- ment of safety culture) led to earlier detection of potential threats to safety. Staff regularly discussed what they might be missing that would jeopardize safety (preoccupation with failure). Regular in-service training helped employees better understand their work and more readily question their assumptions and hypotheses (reluctance to sim- plify). Collaborative rounding by the entire care team helped create a

48 Strengthening the Safety Culture of the Offshore Oil and Gas Industry shared understanding of potential threats to safety throughout the unit (sensitivity to operations). Frequent and inclusive postevent debrief- ings illustrated new and varied ways for participants to respond to and recover from unexpected events (commitment to resilience). Finally, the person with the most experience and expertise in a specific domain (e.g., a patient) made the final decision about the course of action (deference to expertise). Together these ongoing enactments of mindful organizing were associated with improved safety performance (Roberts et al. 2005; Madsen et al. 2006). Similarly, Vogus and Sutcliffe (2007) found that higher levels of mindful organizing in hospital nursing units were associ- ated with safer performance (i.e., fewer errors) over time. These prac- tices also have been noted in a fire incident command system (Bigley and Roberts 2001) and wildland firefighting (Weick and Sutcliffe 2007), and their absence has contributed to failures of platform supply vessels (Sandhåland et al. 2015). Work Processes Ensuring that work activities are planned and managed with safety as a priority and carried out by competent, skilled people in an effective way is essential to strengthening safety culture. Work processes are both important to a stronger safety culture and organizationally chal- lenging because they often entail significant resource commitments (e.g., equipment, training). Consequently, they serve as an important sign of leaders’ and the organization’s tangible commitment to safety (Zohar 1980; Katz-Navon et al. 2005) and enhance organizational (and employee) capabilities. A willingness to invest in equipment, training, and otherwise sound work processes also reflects management that is focused on avoiding future problems such as lost-time injuries, mechanical breakdowns due to equipment failure, and errors. A longer- term view of performance allows for these investments to enhance pro- ductivity rather than merely create costs. Building the knowledge, skills, and abilities of the workforce has been shown to foster safety culture and safety performance. Leaders need to know that their workforce possesses the ability to do the work and do it safely (i.e., without injury to themselves or harm to the organization). Investments in training and related organizational practices influence perceptions of safety culture and personal safety outcomes (Zacharatos et al. 2005). Training, especially continuous training that simulates a

Safety Culture 49 range of possible scenarios, including low-frequency, high-consequence events, has long been a part of nearly error-free high-reliability orga- nizations (Rochlin et al. 1987; LaPorte and Consolini 1991). Select- ing and training for interpersonal skills paired with empowerment of frontline employees has been shown to enhance the quality of work- place interactions, mindful organizing, and safety (Vogus and Iacobucci 2016). In other words, high-reliability organizations build the capac- ity to recognize and respond swiftly to potential hazards (Weick et al. 1999). Also important is demonstrating a commitment to safety by designing in adequate time for safety briefings, stop-work orders, and audits (e.g., Pisano et al. 2001). Assurances that contractors operating at a facility are doing the same further strengthens the safety culture. Work processes that contribute to an effective safety culture also reflect operational discipline. For example, a hallmark of high-reliability organizations is that they combine a disciplined set of cognitive pro- cesses (described above as mindful organizing [e.g., Weick et al. 1999]) with carefully designed and executed work processes. In other words, they are rigorously disciplined at following established process steps. Continuous Improvement Continuous improvement entails a sustained effort to pinpoint sub- tle details and uncover capabilities that have gone unrecognized and develop these revealed capabilities in the pursuit of safer performance. Management research has identified practices for instilling a continuous improvement orientation through structured learning practices such as after-event reviews (AERs). AERs are collective guided discussions of past experience that direct learners to understand the specific causes of their failures and successes and thereby derive performance-enhancing lessons (Popper and Lipshitz 1998; Ellis et al. 2006). In other words, when people engage in AERs, they elaborate experiential data, taking special note of unexpected failure, disruption, or significant differences between expectations and reality (Ellis and Davidi 2005). AERs have been studied extensively in military settings, such as the Israeli Defense Force Air Force. There is evidence of the value of structured learning and AER-like activities in other high-hazard industries, including offshore oil and gas production and air traffic control (Ely and Meyerson 2010; Mearns et al. 2013). AERs are most informative when they occur imme- diately after the event and include all who took part in the operation.

50 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Their structured format guides participants in jointly constructing a comprehensive representation that integrates their individual interpre- tations (Ron et al. 2006). Elaborating is most fruitful when feedback is exchanged without defensiveness and when the review is continued until a shared understanding has been achieved (Popper and Lipshitz 1998; Ron et al. 2006). Recent research has indicated that AERs also can be powerful vehi- cles for elaborating success, especially when success may be a near fail- ure in disguise (Ellis and Davidi 2005). In elaborating success, AERs probe the internal logic of the mental model of task performance to identify potential misalignment between specific actions and the condi- tions under which they were executed (Ellis et al. 2006). Helpful reflection also occurs through regular (daily) debriefing ses- sions that analyze whether the day’s work met all its requirements and objectives and determine whether it has yielded lessons for subsequent operations (Vashdi et al. 2007). Questions asked include what hap- pened, why it happened, and what can be learned so the operation can be done better next time. A recurring theme is that continuous improvement furthers safety culture when frontline employees reflect on small but important prob- lems (e.g., having to correct someone else’s mistake, missing materials, inadequate staff ), experience a heightened sense of efficacy, and develop greater trust in the organization’s leadership. Their reflections strengthen the other essential elements of safety culture discussed above by commu- nicating upward to managers and others in positions to fix the systems involved (Tucker 2007). Structured learning practices also help foster continuous improve- ment of safety culture by altering other practices. AERs reinforce such behaviors as mindful organizing. In focusing on failures, they reinforce a preoccupation with failure. When people volunteer detailed accounts of what happened, they counter the tendency to simplify interpretations. An AER by definition is sensitive to operations while enabling a more resilient repertoire of responses and greater clarity about the importance of expertise. Frontline system elaborations such as these reinforce safety communication, an inquiring attitude, collective efficacy, and personal accountability (Tucker 2007). Lastly, research on AERs has shown that improvement through lessons learned often diffuses throughout the organization (Ron et al. 2006), creating the coherence and shared per- ceptions that constitute safety culture.

Safety Culture 51 Continuous improvement through structured learning practices also helps make the work environment more respectful, encourages raising concerns, and enhances work processes such as cross-checking orders. These practices support leaders’ provision of concrete and action- able feedback (Vashdi et al. 2007) and cross-functional (e.g., operators and engineers) communication (Edmondson 2003), as well as improve- ments to work processes such that the right materials are in the right place at the right time (Vashdi et al. 2007). For example, debriefing practices in surgical teams led to changes in the ways procedures were structured and teams were staffed, which then led to more success in implementing new technology and improved safety (Pisano et al. 2001). Finally, AERs can simultaneously reinforce a commitment to safety values and actions and an environment for raising concerns. For exam- ple, AERs reinforce psychological safety by treating errors and near misses as legitimate inputs to learning (Lipshitz et al. 2002). At the same time, AERs produce a better understanding of acts that cannot be tolerated and therefore reinforce personal accountability. Leaders accomplish this by implementing specific “red rules” that must be fol- lowed at all times. Deviations from these rules bring work to an imme- diate halt until compliance is achieved (Dekker 2007). Not only do AERs clarify “never” acts formalized by “red rules,” but they also create a context of greater accountability for leaders and peers. However, addi- tional accountability does not mean additional “blaming and shaming,” but rather reinforcing the idea of shared accountability to keep every- one on a safe path (Popper and Lipshitz 1998). Conclusion The nine elements of a strong safety culture discussed above and sub- stantiated by research findings need to be considered together. For example, the disciplined execution of work processes is aided substan- tially by leaders’ commitment to safety. Similarly, continuous improve- ment depends on a respectful work environment in which employees are encouraged to raise concerns. Overall, while the committee embraces the BSEE elements of a strong safety culture, such cultures do not merely exist within organizations; rather, they are negotiated and revised fre- quently with various stakeholders. Unless stakeholders are aware of safety culture practices and engaged in their execution, meaningful changes are unlikely to be achieved. Consequently, the committee also recognizes the importance of promoting transparency and engagement

52 Strengthening the Safety Culture of the Offshore Oil and Gas Industry with relevant stakeholders to stimulate their participation in continu- ously strengthening the safety culture. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS • Despite the many definitions of safety culture, overall consistency across industries regarding the essential elements of such a culture enables the establishment of norms to facilitate clear communication across systems and industries. • A robust safety culture permeates an entire organization. Accord- ingly, safety culture needs to flow from the top of the organization (whether operator, contractor, or subcontractor) to all the workers in offshore locations, including contractor and subcontractor staff, while being supported by regulators. • Safety culture is not a destination. It needs to continuously adapt, evolve, and be reinforced. Creating a strong safety culture requires alignment, effort, resources, and time. • Research demonstrates that safety culture is significantly enabled by all leaders’ commitment to safety, actions that reflect broad personal accountability for safety, consistent safety communication, an atti- tude of inquiry throughout the organization, diligent hazard identi- fication and swift management of identified hazards, and a respectful work environment that encourages raising concerns and addressing unsafe conditions. • A strong safety culture is reinforced and sustained by structured learning practices focused on continuous improvement. Recommendation 2.1: The committee recommends that the off- shore industry and government regulators adopt the BSEE definition of safety culture and its essential elements as a guide for assessment and practice. DIRECTIONS FOR FUTURE RESEARCH Although research supports each of the nine elements of a strong safety culture reviewed in this chapter, further research is needed on the rela- tive importance of each element. This research would best be conducted

Safety Culture 53 in partnership among regulators (e.g., BSEE), industry (e.g., the Center for Offshore Safety), and academic researchers and combine primary data collection (e.g., qualitative and survey data) with statistical analysis. Important questions to be addressed include the following: • Do aspects of an effective safety culture matter differentially for dif- ferent types of organizations (e.g., operators, contractors, and large and small companies)? • Do aspects of an effective safety culture matter differentially for dif- ferent outcomes, including personal safety, design safety, and process safety and leading and lagging indicators (e.g., gas releases)? • In terms of low-frequency, high-consequence events, how is it possi- ble to identify whether an organization is close to the safety envelope (i.e., the point at which a disaster becomes more likely)? • What are the best practices (e.g., recruiting, hiring, training) for ensuring that an organization has sufficient competence in its leader- ship and workforce to create and sustain an effective safety culture? • Do operations comprising multiple organizations have a safety record that is consistent with the weakest safety culture? the strongest? REFERENCES Abbreviations AHRQ Agency for Healthcare Research and Quality AIChE American Institute of Chemical Engineers API American Petroleum Institute BSEE Bureau of Safety and Environmental Enforcement CAIB Columbia Accident Investigation Board CSB U.S. Chemical Safety Board DOE U.S. Department of Energy EFCOG Energy Facility Contractors Group GAO U.S. Government Accountability Office HHS U.S. Department of Health and Human Services HSC Health and Safety Commission IAEA International Atomic Energy Agency INPO Institute of Nuclear Power Operators NAE National Academy of Engineering

54 Strengthening the Safety Culture of the Offshore Oil and Gas Industry NASA National Aeronautics and Space Administration NEB National Energy Board of Canada NRC National Research Council PHMSA Pipeline and Hazardous Materials Safety Administration U.S. NRC U.S. Nuclear Regulatory Commission AHRQ and HHS. 2004. 2004 National Healthcare Quality Report. AHRQ Publication No. 05-0013. December. http://archive.ahrq.gov/qual/nhqr04/nhqr2004.pdf. Accessed April 6, 2016. AIChE. 2005. Building Process Safety Culture: Tools to Enhance Process Safety Performance. Center for Chemical Process Safety of the American Institute of Chemical Engineers, New York. https://www.aiche.org/sites/default/files/ docs/embedded-pdf/Piper_Alpha-case-history.pdf. Accessed April 6, 2016. Amalberti, R. 2013. Navigating Safety: Necessary Compromises and Trade-Offs: Theory and Practice. Springer, New York. Antonsen, S., K. Skarholt, and A. J. Ringstad. 2012. The Role of Standardization in Safety Management: A Case Study of a Major Oil & Gas Company. Safety Science, Vol. 50, No. 10, pp. 2001–2009. API. 2014. Pipeline Safety Management System Requirements. API Recommended Practice 1173, Draft Version 11.2. http://ballots.api.org/ecs/RP1173Ballot%20 DraftJune2014.pdf. Accessed April 26, 2016. Baram, M., and M. Schoebel. 2007. Editorial: Safety Culture and Behavioral Change at the Workplace. Safety Science, Vol. 45, No. 6, pp. 631–636. Barling, J., C. Loughlin, and E. K. Kelloway. 2002. Development and Test of a Model Linking Safety-Specific Transformational Leadership and Occupational Safety. Journal of Applied Psychology, Vol. 87, No. 3, pp. 488–496. Berger, P. L., and T. Luckmann. 1966. The Social Construction of Reality: A Treatise in the Sociology of Knowledge. Anchor Books, New York. Beus, J. M., S. C. Payne, M. E. Bergman, and W. Arthur, Jr. 2010. Safety Climate and Injuries: An Examination of Theoretical and Empirical Relationships. Journal of Applied Psychology, Vol. 95, No. 4, pp. 713–727. Bierly, P. E., III, and J. C. Spender. 1995. Culture and High Reliability Organizations: The Case of the Nuclear Submarine. Journal of Management, Vol. 21, No. 4, pp. 639–657. Bigley, G. A., and K. H. Roberts. 2001. The Incident Command System: High- Reliability Organizing for Complex and Volatile Task Environments. Academy of Management Journal, Vol. 44, No. 6, pp. 1281–1300. Blatt, R., M. K. Christianson, K. M. Sutcliffe, and M. M. Rosenthal. 2006. A Sense- making Lens on Reliability. Journal of Organizational Behavior, Vol. 27, No. 7, pp. 897–917. Blazsin, H., and F. Guldenmund. 2015. The Social Construction of Safety: Comparing Three Realities. Safety Science, Vol. 71, pp. 16–27.

Safety Culture 55 BP U.S. Refineries Independent Safety Review Panel. 2007. The Report of the BP U.S. Refineries Independent Safety Review Panel. January. http://www. propublica.org/documents/item/the-bp-us-refineries-independent-safety- review-panel-report. Accessed Oct. 29, 2015. BSEE. 2013. Final Safety Culture Policy Statement. http://www.bsee.gov/uploadedFiles/ BSEE/Final%20Safety%20Culture%20Statement.pdf. Accessed April 22, 2016. CAIB. 2003. Report of Columbia Accident Investigation Board. Vol. I. http://www. nasa.gov/columbia/home/CAIB_Vol1.html. Accessed Oct. 29, 2015. Carroll, J. S. 1998. Organizational Learning Activities in High Hazard Industries: The Logics Underlying Self-Analysis. Journal of Management Studies, Vol. 35, pp. 699–717. Carroll, J. S., and A. C. Edmondson. 2002. Leading Organizational Learning in Health Care. Quality and Safety in Health Care, Vol. 11, pp. 1–56. Carroll, J. S., and M. A. Quijada. 2004. Redirecting Traditional Professional Values to Support Safety: Changing Organizational Culture in Health Care. Quality and Safety in Health Care, Vol. 13, No. 1, pp. 16–21. Carroll, J. S., and J. W. Rudolph. 2006. Design of High Reliability Organizations in Health Care. Quality and Safety in Health Care, Vol. 15, pp. 4–9. Christian, M. S., J. C. Bradley, J. C. Wallace, and M. J. Burke. 2009. Workplace Safety: A Meta-Analysis of the Roles of Person and Situation Factors. Journal of Applied Psychology, Vol. 94, No. 5, pp. 1103–1127. Clarke, S. 2006. The Relationship Between Safety Climate and Safety Performance: A Meta-Analytic Review. Journal of Occupational Health Psychology, Vol. 11, No. 4, pp. 315–327. Cox, S. J., and A. J. T. Cheyne. 2000. Assessing Safety Culture in Offshore Environ- ments. Safety Science, Vol. 34, Nos. 1–3, pp. 111–129. Crichton, M. T., K. Lauche, and R. Flin. 2005. Incident Command Skills in the Management of an Oil Industry Drilling Incident: A Case Study. Journal of Contingencies and Crisis Management, Vol. 13, No. 3, pp. 116–128. CSB. 2007. Investigation Report, Refinery Explosion and Fire, BP, Texas City, Texas, March 23, 2005. Report No. 2005-04-1-TX. U.S. Chemical Safety and Hazard Investigation Board, Washington, D.C. Cullen, W. D. 1990. The Public Inquiry into the Piper Alpha Disaster. H.M. Stationery Office, London. DeJoy, D. M. 2005. Behavior Change Versus Culture Change: Divergent Approaches to Managing Workplace Safety. Safety Science, Vol. 43, No. 2, pp. 105–129. Dekker, S. W. A. 2007. Just Culture: Balancing Safety and Accountability. Ashgate Publishing, Ltd., Burlington, Vt. Dekker, S. W. A. 2014. The Bureaucratization of Safety. Safety Science, Vol. 70, pp. 348–357. Denison, D. R. 1996. What Is the Difference Between Organizational Culture and Organizational Climate? A Native’s Point of View on a Decade of Paradigm Wars. Academy of Management Review, Vol. 21, No. 3, pp. 619–654.

56 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Duhigg, C. 2012. The Power of Habit: Why We Do What We Do in Life and Business. Random House, New York. Edmondson, A. C. 1996. Learning from Mistakes is Easier Said than Done: Group and Organizational Influences on the Detection and Correction of Human Error. Journal of Applied Behavioral Science, Vol. 32, No. 1, pp. 5–28. Edmondson, A. C. 1999. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, pp. 350–383. Edmondson, A. C. 2003. Speaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams. Journal of Management Studies, Vol. 40, No. 6, pp. 1419–1452. Edmondson, A. C. 2004. Learning from Failure in Health Care: Frequent Oppor- tunities, Pervasive Barriers. Quality and Safety in Health Care, Vol. 13, pp. 3–9. EFCOG–DOE. 2009. Assessing Safety Culture in DOE Facilities: EFCOG Meeting Handout. EFCOG–DOE Safety Culture Task Team. January 23. Ellis, S., and I. Davidi. 2005. After-Event Reviews: Drawing Lessons from Success ful and Failed Experience. Journal of Applied Psychology, Vol. 90, No. 5, pp. 857–871. Ellis, S., R. Mendel, and M. Nir. 2006. Learning from Successful and Failed Experi- ence: The Moderating Role of Kind of After-Event Review. Journal of Applied Psychology, Vol. 91, No. 3, pp. 669–680. Ely, R. J., and D. E. Meyerson. 2010. An Organizational Approach to Undoing Gender: The Unlikely Case of Offshore Oil Platforms. Research in Organiza- tional Behavior, Vol. 30, pp. 3–34. European Agency for Safety and Health at Work. 2011 Annual Report. https:// osha.europa.eu/en/tools-and-publications/publications/corporate/2011full. Accessed April 5, 2016. Faraj, S., and Y. Xiao. 2006. Coordination in Fast-Response Organizations. Management Science, Vol. 52, No. 8, pp. 1155–1169. Fiol, M., and E. J. O’Connor. 2003. Waking Up! Mindfulness in the Face of Band- wagons. Academy of Management Review, Vol. 28, No. 1, pp. 54–70. Flin, R., and L. Fruhen, 2015. Managing Safety: Ambiguous Information and Chronic Unease. Journal of Contingencies and Crisis Management, Vol. 23, No. 2, pp. 84–89. Flin, R., K. Mearns, P. O’Connor, and R. Bryden. 2000. Measuring Safety Climate: Identifying Common Features. Safety Science, Vol. 34, pp. 177–192. Flin, R., C. Burns, K. Mearns, S. Yule, and E. M. Robertson. 2006. Measuring Safety Climate in Health Care. Quality and Safety in Health Care, Vol. 15, pp. 109–115. Frankel, A., S. P. Grillo, M. Pittman, E. J. Thomas, L. Horowitz, M. Page and B. Sexton. 2008. Revealing and Resolving Patient Safety Defects: The Impact of Leadership WalkRounds on Frontline Caregiver Assessments of Patient Safety. Health Services Research, Vol. 43, No. 6, pp. 2050–2066.

Safety Culture 57 Gherardi, S., 2006. Organizational Knowledge: The Texture of Workplace Learning. Blackwell, Malden, Mass. Guldenmund, F. W. 2000. The Nature of Safety Culture: A Review of Theory and Research. Safety Science, Vol. 34, pp. 215–257. Health Foundation. 2011. Evidence Scan: Measuring Safety Culture. The Health Foundation, London. http://www.health.org.uk/publications/measuring- safety-culture. Accessed October 14, 2015. Henriksen, K., and E. Dayton. 2006. Organizational Silence and Hidden Threats to Patient Safety. Health Services Research, Vol. 41, No. 4, pp. 1539–1554. Hofmann, D. A., and A. Stetzer. 1996. A Cross-Level Investigation of Factors Influencing Unsafe Behaviors and Accidents. Personnel Psychology, Vol. 49, No. 2, pp. 307–339. Hofmann, D. A., and A. Stetzer. 1998. The Role of Safety Climate and Commu- nication in Accident Interpretation: Implications for Learning from Negative Events. Academy of Management Journal, Vol. 41, No. 6, pp. 644–657. Hofmann, D. A., and F. P. Morgeson. 1999. Safety-Related Behavior as a Social Exchange: The Role of Perceived Organizational Support and Leader– Member Exchange. Journal of Applied Psychology, Vol. 84, No. 2, pp. 286–296. Hofmann, D. A., F. P. Morgeson, and S. J. Gerras. 2003. Climate as a Moderator of the Relationship Between Leader-Member Exchange and Content-Specific Citizenship: Safety Climate as an Exemplar. Journal of Applied Psychology, Vol. 88, No. 1, pp. 170–178. HSC. 1993. ACSNI Study Group on Human Factors. 3rd Report: Organising for Safety. Her Majesty’s Stationery Office, London. Hudson, P. 2007. Implementing a Safety Culture in a Major Multinational. Safety Science, Vol. 45, No. 6, pp. 697–722. Hynes, T., and P. Prasad. 1997. Patterns of “Mock Bureaucracy” in Mining Disasters: An Analysis of the Westray Coal Mine Explosion. Journal of Management Studies, Vol. 34, No. 4, pp. 601–623. IAEA. 2002. Self-Assessment of Safety Culture in Nuclear Installations: Highlights and Good Practices. IAEA-TECDOC-1321. http://www-pub.iaea.org/MTCD/ publications/PDF/te_1321_web.pdf. IAEA. 2008. SCART Guidelines: Reference Report for IAEA Safety Culture Assessment Review Team. http://www-ns.iaea.org/downloads/ni/s-reviews/scart-guidelines. pdf. Accessed Oct. 14, 2015. INPO. 2013. Traits of a Healthy Nuclear Safety Culture. Revision 1. INPO 12-012. http://nuclearsafety.info/wp-content/uploads/2010/07/Traits-of-a-Healthy- Nuclear-Safety-Culture-INPO-12-012-rev.1-Apr2013.pdf. Katz-Navon, T., E. Naveh, and Z. Stern. 2005. Safety Climate in Healthcare Orga- nizations: A Multidimensional Approach. Academy of Management Journal, Vol. 48, No. 6, pp. 1073–1087.

58 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Knox, G. E., K. R. Simpson, and T. J. Garite. 1999. High Reliability Perinatal Units: An Approach to the Prevention of Patient Injury and Medical Malpractice Claims. Journal of Healthcare Risk Management, Vol. 19, No. 2, pp. 24–32. Kongsvik, T., S. Å. K. Johnsen, and S. Sklet. 2011. Safety Climate and Hydro- carbon Leaks: An Empirical Contribution to the Leading–Lagging Indicator Discussion. Journal of Loss Prevention in the Process Industries, Vol. 24, No. 4, pp. 405–411. LaPorte, T. R., and P. M. Consolini. 1991. Working in Practice but Not in Theory: Theoretical Challenges of “High-Reliability Organizations.” Journal of Public Administration Research and Theory, Vol. 1, No. 1, pp. 19–47. Lipshitz, R., M. Popper, and V. J. Friedman. 2002. A Multifacet Model of Organiza- tional Learning. Journal of Applied Behavioral Science, Vol. 38, No. 1, pp. 78–98. MacDuffie, J. P. 1997. The Road to “Root Cause”: Shop-Floor Problem-Solving at Three Auto Assembly Plants. Management Science, Vol. 43, No. 4, pp. 479–502. Madsen, P. M., V. M. Desai, K. H. Roberts, and D. Wong. 2006. Mitigating Hazards Through Continuing Design: The Birth and Evolution of a Pediatric Intensive Care Unit. Organization Science, Vol. 17, No. 2, pp. 239–248. March, J. G., L. S. Sproull, and M. Tamuz. 1991. Learning from Samples of One or Fewer. Organization Science, Vol. 2, No. 1, pp. 1–13. Mearns, K. J., and R. Flin. 1999. Assessing the State of Organizational Safety: Culture or Climate? Current Psychology, Vol. 18, pp. 5–17. Mearns, K., R. Flin, R. Gordon, and M. Fleming. 1998. Measuring Safety Climate on Offshore Installations. Work and Stress, Vol. 12, No. 3, pp. 238–254. Mearns, K., B. Kirwan, T. W. Reader, J. Jackson, R. Kennedy, and R. Gordon. 2013. Development of a Methodology for Understanding and Enhancing Safety Culture in Air Traffic Management. Safety Science, Vol. 53, pp. 123–133. Montara Commission of Inquiry. 2010. Report of the Montara Commission of Inquiry. http://www.industry.gov.au/AboutUs/CorporatePublications/MontaraInquiry Response/Documents/Montara-Report.pdf. Accessed Oct. 29, 2015. NAE and NRC. 2011. Macondo Well–Deepwater Horizon Blowout: Lessons for Improving Offshore Drilling Safety. National Academies Press, Washington, D.C. NASA. 2005. Interim Assessment of the NASA Culture Change Effort. http://www. nasa.gov/pdf/108679main_BST_culture_Feb05.pdf. Accessed Oct. 14, 2015. National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drill- ing. 2011. Deepwater: The Gulf Oil Disaster and the Future of Offshore Drilling. U.S. Government Printing Office, Washington, D.C. Naveh, E., T. Katz-Navon, and Z. Stern. 2006. Readiness to Report Medical Treat- ment Errors: The Effects of Safety Procedures, Safety Information, and Priority of Safety. Medical Care, Vol. 44, No. 2, pp. 117–123. Neal, A., and M. A. Griffin. 2006. A Study of the Lagged Relationships Among Safety Climate, Safety Motivation, Safety Behavior, and Accidents at the Individual and Group Levels. Journal of Applied Psychology, Vol. 91, No. 4, pp. 946–953.

Safety Culture 59 NEB. 2014. Advancing Safety in the Oil and Gas Industry: Safety Culture Framework. http://www.neb-one.gc.ca/clf-nsi/rsftyndthnvrnmnt/sfty/sftycltr/sftycltr-eng. html. Accessed Oct. 14, 2015. Nembhard, I. M., and A. C. Edmondson. 2006. Making it Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams. Journal of Organizational Behavior, Vol. 27, pp. 941–966. NRC. 2014. Lessons Learned from the Fukushima Nuclear Accident for Improving Safety of U.S. Nuclear Plants. National Academies Press, Washington, D.C. Paté-Cornell, M. E. 1990. Organizational Aspects of Engineering System Safety: The Case of Offshore Platforms. Science, Vol. 250, No. 4985, pp. 1210–1217. Perin, C. 2005. Shouldering Risks: The Culture of Control in the Nuclear Power Industry. Princeton University Press, Princeton, N.J. Perrow, C. 1984. Normal Accidents: Living with High-Risk Technologies. Basic Books, New York. PHMSA. 2015. Safety Management Systems API RP 1173: LGA Pipeline Safety Seminar. New Orleans, LA. July 22. https://primis.phmsa.dot.gov/dimp/docs/ LGA_Wednesday_10AM%20SMS_McLaren_07.22.2015.pdf. Accessed on April 26, 2016. Pisano, G. P., R. M. J. Bohmer, and A. C. Edmondson. 2001. Organizational Differ- ences in Rates of Learning: Evidence from the Adoption of Minimally Invasive Cardiac Surgery. Management Science, Vol. 47, No. 6, pp. 752–768. Popper, M., and R. Lipshitz. 1998. Organizational Learning Mechanisms: A Struc- tural and Cultural Approach to Organizational Learning. Journal of Applied Behavioral Science, Vol. 34, No. 2, pp. 161–179. Reason, J. T. 1997. Managing the Risks of Organizational Accidents. Ashgate Publish- ing, Ltd., Brookfield, Vt. Reason, J., D. Parker, and R. Lawton. 1998. Organizational Controls and Safety: The Varieties of Rule-Related Behavior. Journal of Occupational and Organiza- tional Psychology, Vol. 71, pp. 289–304. Reiman, T., and E. Pletikainen. 2010. Indicators of Safety Culture: Selection and Utilization of Leading Safety Performance Indicators. Swedish Radiation Tech- nical Authority, NTT Technical Research Centre of Finland. http://www. stralsakerhetsmyndigheten.se/Global/Publikationer/Rapport/Sakerhet- vid-karnkraftverken/2010/SSM-Rapport-2010-07.pdf. Accessed Oct. 14, 2015. Roberts, K. H. 1990. Some Characteristics of High-Reliability Organizations. Organization Science, Vol. 1, pp. 160–177. Roberts, K. H., P. M. Madsen, V. M. Desai, and D. Van Stralen. 2005. A Case of the Birth and Death of a High-Reliability Healthcare Organization. Quality and Safety in Health Care, Vol. 14, pp. 216–220. Roberts, K. H., S. K. Stout, and J. J. Halpern. 1994. Decision Dynamics in Two High-Reliability Organizations. Management Science, Vol. 40, pp. 614–624.

60 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Rochlin, G. I., T. R. LaPorte, and K. H. Roberts. 1987. The Self-Designing High- Reliability Organization: Aircraft Carrier Flight Operations at Sea. Naval War College Review, Vol. 40, No. 4, pp. 76–90. Ron, N., R. Lipshitz, and M. Popper. 2006. How Organizations Learn: Post-Flight Reviews in an F-16 Fighter Squadron. Organization Studies, Vol. 27, No. 8, pp. 1069–1089. Sandhåland, H., H. A. Oltedal, S. W. Hystad, and J. Eid. 2015. Distributed Situ- ation Awareness in Complex Collaborative Systems: A Field Study of Bridge Operations on Platform Supply Vessels. Journal of Occupational and Organiza- tional Psychology, Vol. 88, No. 2, pp. 273–294. Schein, E. H. 1996. Three Cultures of Management: The Key to Organizational Learning. Sloan Management Review, Vol. 38, No. 1, pp. 9–20. Schein, E. H. 2004. Organizational Culture and Leadership, 3rd ed. Jossey–Bass, San Francisco, Calif. Schein, E. H. 2010. Organizational Culture and Leadership, 4th ed. John Wiley, Hoboken, N.J. Schulman, P. R. 1993. The Negotiated Order of Organizational Reliability. Adminis- tration and Society, Vol. 25, No. 3, pp. 353–372. Sexton, J. B., E. J. Thomas, and R. L. Helmreich. 2000. Error, Stress, and Team- work in Medicine and Aviation: Cross Sectional Surveys. British Medical Journal, Vol. 320, pp. 745–749. Shortell, S. M., J. E. Zimmerman, D. M. Rousseau, R. R. Gillies, D. P. Wagner, E. A. Draper, W. A. Knaus, and J. Duffy. 1994. The Performance of Intensive Care Units: Does Good Management Make a Difference? Medical Care, Vol. 32, No. 5, pp. 508–525. Silbey, S. S. 2009. Taming Prometheus: Talk About Safety Culture. Annual Review of Sociology, Vol. 35, pp. 413–469. Singer, S. J., and A. L. Tucker. 2014. The Evolving Literature on Safety WalkRounds: Emerging Themes and Practical Messages. BMJ Quality & Safety, Vol. 23, No. 10, pp. 789–800. Singer, S. J., and T. J. Vogus. 2013. Reducing Hospital Errors: Interventions that Build Safety Culture. Annual Review of Public Health, Vol. 34, pp. 373–396. Singer, S. J., S. Lin, A. Falwell, D. Gaba, and L. Baker. 2009. Relationship of Safety Climate and Safety Performance in Hospitals. Health Services Research, Vol. 44, No. 2, Pt. 1, pp. 99–421. Skogdalen, J. E., I. B. Utne, and J. E. Vinnem. 2011. Developing Safety Indicators for Preventing Offshore Oil and Gas Deepwater Drilling Blowouts. Safety Science, Vol. 49, No. 8, pp. 1187–1199. Spear, S. J. 2005. Fixing Health Care from the Inside, Today. Harvard Business Review, Vol. 83, No. 9, pp. 78–91. Stern, Z., T. Katz-Navon, and E. Naveh. 2008. The Influence of Situational Learn- ing Orientation, Autonomy, and Voice on Error Making: The Case of Resident Physicians. Management Science, Vol. 54, No. 9, pp. 1553–1564.

Safety Culture 61 Tangirala, S., and R. Ramanujam. 2008. Employee Silence on Critical Work Issues: The Cross Level Effects of Procedural Justice Climate. Personnel Psychology, Vol. 61, No. 1, pp. 37–68. Thomas, E. J., J. B. Sexton, T. B. Neilands, A. Frankel, and R. L. Helmreich. 2005. The Effect of Executive Walk Rounds on Nurse Safety Climate Attitudes: A Randomized Trial of Clinical Units. BMC Health Services Research, Vol. 5, pp. 8–36. Tucker, A. L. 2004. The Impact of Operational Failures on Hospital Nurses and Their Patients. Journal of Operations Management, Vol. 22, pp. 151–169. Tucker, A. L. 2007. An Empirical Study of System Improvement by Frontline Employees in Hospital Units. Manufacturing and Service Operations Manage- ment, Vol. 9, No. 4, pp. 92–505. Tucker, A. L., and A. C. Edmondson. 2003. Why Hospitals Don’t Learn from Failures. California Management Review, Vol. 45, No. 2, pp. 55–72. Tucker, A. L., I. M. Nembhard, and A. C. Edmondson. 2007. Implementing New Practices: An Empirical Study of Organizational Learning in Hospital Intensive Care Units. Management Science, Vol. 53, No. 6, pp. 894–907. Tucker, A. L., S. J. Singer, J. E. Hayes, and A. Falwell. 2008. Front-Line Staff Per- spectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems. Health Services Research, Vol. 43, No. 5, pp. 1807–1829. U.S. NRC. 2011. Safety Culture Policy Statement (76 FR 34773). http://www.nrc. gov/about-nrc/safety-culture/sc-policy-statement.html. Uttal, B., 1983. The Corporate Culture Vultures. Fortune Magazine, Oct. 17. van Dyck, C., M. Frese, M. Baer, and S. Sonnentag. 2005. Organizational Error Management Culture and Its Impact on Performance. Journal of Applied Psychology, Vol. 90, No. 6, pp. 1228–1240. Vashdi, D. R., P. A. Bamberger, M. Erez, and A. Weiss-Meilik. 2007. Briefing– Debriefing: Using a Reflexive Organizational Learning Model from the Military to Enhance the Performance of Surgical Teams. Human Resource Management, Vol. 46, No. 1, pp. 115–142. Vaughan, D. 1996. The Challenger Launch Decision. University of Chicago Press, Chicago, Ill. Vinnem, J. E., J. A. Hestad, J. T. KvalØy, and J. E. Skogdalen. 2010. Analysis of Root Causes of Major Hazard Precursors (Hydrocarbon Leaks) in the Norwegian Offshore Petroleum Industry. Reliability Engineering & System Safety, Vol. 95, No. 11, pp. 1142–1153. Vogus, T. J., and D. Iacobucci. 2016. Creating Highly Reliable Health Care: How Reliability-Enhancing Work Practices Affect Patient Safety in Hospitals. Industrial and Labor Relations Review. Vogus, T. J., and K. M. Sutcliffe. 2007. The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units. Medical Care, Vol. 45, No. 1, pp. 46–54.

62 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Vogus, T. J., K. M. Sutcliffe, and K. E. Weick. 2010. Doing No Harm: Enabling, Enacting, and Elaborating a Culture of Safety in Health Care. Academy of Management Perspectives, Vol. 24, No. 4, pp. 60–77. Waller, M. J. 1999. The Timing of Adaptive Group Responses to Nonroutine Events. Academy of Management Journal, Vol. 42, No. 2, pp. 137–147. Waller, M. J., N. Gupta, and R. C. Giambatista. 2004. Effects of Adaptive Behaviors and Shared Mental Models on Control Crew Performance. Management Science, Vol. 50, No. 11, pp. 1534–1544. Weick, K. E. 1987. Organizational Culture as a Source of High-Reliability. California Management Review, Vol. 29, No. 2, pp. 12–127. Weick, K. E., and L. D. Browning. 1986. Argument and Narration in Organizational Communication. Journal of Management, Vol. 12, No. 2, pp. 243–259. Weick, K. E., and K. M. Sutcliffe. 2006. Mindfulness and the Quality of Organiza- tional Attention. Organization Science, Vol. 16, No. 4, pp. 409–421. Weick, K. E., and K. M. Sutcliffe. 2007. Managing the Unexpected: Resilient Perfor- mance in an Age of Uncertainty, 2nd ed. Jossey–Bass, San Francisco, Calif. Weick, K. E., and F. Westley. 1996. Organizational Learning: Affirming an Oxy- moron. In Handbook of Organizational Studies (S. Clegg, C. Hardy, and W. Nord, eds.), Sage Publications, London, pp. 440–458. Weick, K. E., K. M. Sutcliffe, K. M., and D. Obstfeld. 1999. Organizing for High Reliability: Processes of Collective Mindfulness. In Research in Organizational Behavior, Vol. 21 (B. M. Staw and L. L. Cummings, eds.), JAI Press, Inc., Greenwich, Conn., pp. 81–123. Weingart S. N., K. Farbstein, B. Davis Roger, and S. Phillips Russell. 2004. Using a Multihospital Survey to Examine the Safety Culture. Joint Commission Journal on Quality and Patient Safety, Vol. 30, No. 3, pp. 125–132. Westrum, R. 2004. A Typology of Organizational Cultures. Quality and Safety in Health Care, Vol. 13, No. 1, pp. 22–27. Wicks, D. 2001. Institutionalized Mindsets of Invulnerability: Differentiated Institutional Fields and the Antecedents of Organizational Crisis. Organization Studies, Vol. 22, No. 4, pp. 659–692. Woods, D. D. 2005. Creating Foresight: Lessons for Enhancing Resilience from Columbia. In Organization at the Limit: Lessons from the Columbia Disaster (W. H. Starbuck and M. Farjoun, eds.), Blackwell, Malden, Mass., pp. 289–308. Wright, C. 1994. A Fallible Safety System: Institutionalised Irrationality in the Off- shore Oil and Gas Industry. The Sociological Review, Vol. 42, No. 1, pp. 79–103. Yun, S., S. Faraj, and H. P. Sims. 2005. Contingent Leadership and Effectiveness of Trauma Resuscitation Teams. Journal of Applied Psychology, Vol. 90, No. 6, pp. 1288–1296. Zacharatos, A., J. Barling, and R. D. Iverson. 2005. High-Performance Work Systems and Occupational Safety. Journal of Applied Psychology, Vol. 90, No. 1, pp. 77–93.

Safety Culture 63 Zohar, D. 1980. Safety Climate in Industrial Organizations: Theoretical and Applied Implications. Journal of Applied Psychology, Vol. 65, No. 1, pp. 96–102. Zohar, D. 2000. A Group-Level Model of Safety Climate: Testing the Effect of Group Climate on Microaccidents in Manufacturing Jobs. Journal of Applied Psychology, Vol. 85, No. 4, pp. 587–596. Zohar, D. 2002. Modifying Supervisory Practices to Improve Subunit Safety: A Leadership-Based Intervention Model. Journal of Applied Psychology, Vol. 87, No. 1, pp. 156–163. Zohar, D. 2003. Safety Climate: Conceptual and Measurement Issues. In Handbook of Occupational Health Psychology ( J. C. Quick and L. E Tetrick, eds.), American Psychological Association, Washington, D.C., pp. 123–142. Zohar, D. 2008. Safety Climate and Beyond: A Multi-Level Multi-Climate Frame- work. Safety Science, Vol. 46, No. 3, pp. 376–387. Zohar, D. 2010. Thirty Years of Safety Climate Research: Reflections and Future Directions. Accident Analysis and Prevention, Vol. 42, pp. 1517–1522.