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

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138 This chapter examines how safety culture is typically assessed, as well as how it should be measured in the offshore oil and gas industry. It begins by restating the definition of safety culture used in this report (see Chapter 2) and, more important, placing safety culture within the context of a larger organizational and insti­ tutional system. The measurement of safety culture is not an end in itself, but a means of assessing, understanding, and influencing both safety and the overall mission of the organization. The measurement activity takes place within an existing safety culture and, more gener­ ally, within a broader organizational culture and the cultural ecology within which the organization operates (e.g., suppliers, customers, industry groups, professional associations, regulators, governments, the public, markets). Hence, the measurement of safety culture is one step in a set of conversations, decisions, and actions aimed at directing organizations toward safer and more sustainable performance. Given this context, the succeeding sections of this chapter articulate what can and should be assessed and what methods and techniques can be used for assessment. Because the goal is not simply accurate assessment but also improving safety, the discussion of assessment focuses on what is being assessed, how it is assessed, how assessment is used to guide strategy and operations, who should be involved in this process, and how often assessment should occur. SAFETY CULTURE AND ITS ORGANIZATIONAL CONTEXT In Chapter 2, safety culture is defined as “the core values and behaviors of all members of an organization that reflect a commitment to conduct business in a manner that protects people and the environment” (BSEE 2013, 7). This definition identifies safety culture as an aspect or facet of the larger organizational or workplace culture, that is, those elements 5 | Safety Culture Assessment and Measurement

Safety Culture Assessment and Measurement 139 of the organizational culture that pertain to safety, including values, beliefs, assumptions, norms, and practices. Given the complexity of the offshore oil and gas industry, the safety culture concept extends to both companies of various sizes (including business units, divisions, and departments that act like organized entities) and settings or work­ places that demand interdependent activities from individuals working for owners, operators, or service providers. As discussed in Chapter 2, although safety culture is routinely considered to be a shared property of a company or a workplace, all organizations have some degree of cultural variability. For example, the culture of exploration may have a different approach to risk than the culture of production, even within the same company. Likewise, Mearns and colleagues (1998) found considerable variation in safety subcultures among U.K. offshore workers depending upon seniority, occupation, age, shift, and prior accident experience. For example, off­ shore engineers may share more cultural elements with other engineer­ ing professionals in their country than with operators, managers, and others in their own company (Schein 1996). And the culture on an oil rig may have more to do with the contractors who own the rig and the local culture of the workers than with the organizational culture of the multinational oil company that commissioned the drilling. Across hier­ archical levels, moreover, senior executives, middle managers, super­ visors, and workers may have very distinct cultures, including their views of safety. Research consistently finds that as one moves higher up the organizational hierarchy, views of the existing safety culture become more positively biased, because bad news does not readily travel upward (e.g., Sexton et al. 2000; Singer et al. 2009). Cultural variability within an organization or operation, or within an organization’s safety culture, is generally considered a weakness. However, Mearns and colleagues (1998) suggest that a strong, cohe­ sive safety culture may lead to complacency, and retaining cultural variability can be a source of robustness rather than a problem. In a study of organizational culture across multiple industries, Sorensen (2002) found that strength of culture was beneficial in stable environ­ ments but not in less predictable environments. The variable nature of culture in organizations informs the discussion below of what should be assessed, how it should be assessed, and who should do the assessing.

140 Strengthening the Safety Culture of the Offshore Oil and Gas Industry ASSESSING AND MANAGING SAFETY CULTURE The management systems in an organization direct attention toward strategic goals and priorities, one of which is safety. The organization’s culture needs to be aligned with and help support and reinforce the management systems, and safety culture is no exception. Thus, neither safety nor culture can be managed independently from the other man­ agement systems. Safety, culture, and safety culture need to be under­ stood as part of these management systems and therefore should not be delegated to a stand­alone unit (e.g., a safety culture assessment group) that is not highly integrated with the other core operating systems of the organization (Wears et al. 2005; Dekker 2014). An analogy can be drawn to the assessment of individual health, in which a single indicator, such as blood pressure or cholesterol level, is of limited utility without an understanding of what interdependent bio­ logical systems are involved (e.g., cardiovascular) and how they work, and what interventions are available for managing overall health (e.g., medications, diet, exercise, surgery, meditation). Like health, then, safety is best assessed comprehensively and systematically; each is more than the absence of harm or disease. Both health and safety are a function of the presence of wellness in the form of interrelated system functions, including protective structures and processes (Hofmann and Tetrick 2003). Therefore, meaningful improvement efforts must target multiple interconnected elements of organizational systems (e.g., Beer and Nohria 2000), a point discussed in greater detail in Chapter 6. Why It Is Important to Measure Safety Culture Culture, including safety culture, typically is assessed for one of several reasons related to an organization’s strategic goals (Sackmann 2006): 1. To respond to institutional pressures to copy successful organi­ zations, please regulators, meet a standard, or demonstrate that improvement efforts are being made; 2. To describe and understand the organization; 3. To make specific improvements (e.g., in safety); or 4. To improve the organization and management more broadly.

Safety Culture Assessment and Measurement 141 Consideration of these reasons suggests different criteria for choosing an assessment approach, such as whether to select a widely accepted tool or to develop one tailored to the organization, or whether to assess safety culture more narrowly or organizational culture more broadly. Among the reasons listed above, this chapter assumes the pragmatic goal of assessing safety culture to improve safety. However, the commit­ tee also believes that the assessment process is one input into a much broader conversation regarding organizational and safety culture, for­ mal and informal organizational structures, power, relationships with contractors, and other strategic goals (productivity, cost, quality). With these assumptions in mind, the committee believes it is important for organizations to conduct periodic assessments of their organizational and safety culture for the following five reasons: • To move conversations from the vague to the specific. An assess­ ment moves conversations from vague, general perceptions, or a “sense” of how the organization is doing with respect to safety, toward more focused exploration of what lies behind specific and quantifiable met­ rics, such as accident rates and injuries. For example, if an assessment reveals that workers perceive a gap between management pronounce­ ments about the importance of safety and management actions that appear to be unsupportive of safety, this finding can trigger a more targeted conversation about what types of management actions (e.g., never committing significant budget dollars to improving safety) are driving this perception and how management can better align its words with its actions. • To allow for the tracking of progress. Without ongoing assessment and communication of its results, employees cannot evaluate the effec­ tiveness of initiatives designed to improve the safety culture and safety management. Regular assessments allow management (and others) to detect and reinforce slow changes in an organization’s culture that may be beneficial to safety, as well as to identify and address slow changes that may produce a drift into failure (Dekker 2011). • To provide motivation and feedback. Ongoing assessment allows individuals throughout the organization to receive feedback, set goals, and seek to improve the organization’s safety management. It also, if its results are sufficiently communicated, can help close the commu­ nication loop when frontline employees have raised safety concerns

142 Strengthening the Safety Culture of the Offshore Oil and Gas Industry (or concerns about work and managerial practices that are not speci­ fied as related to safety). Even in the absence of tangible progress, it is important for management to communicate to frontline employees that they are being heard and that management is investigating how to address the issues they have raised. • To identify strengths, weaknesses and gaps, and potential improve- ments. An assessment spanning different subgroups, functions, and operational areas of the organization can provide an opportunity to examine the consistency of the culture and tailor improvement efforts to specific concerns. For example, different interventions will be needed if senior management is viewed as strongly committed to safety, but frontline management frequently trades off safety for more pressing goals, or if frontline management is viewed as being strongly committed to safety, whereas senior management is more focused on financial performance. • To provide leading indicators. A growing body of research (e.g., Zohar 2010; Morrow et al. 2014) and recent meta­analyses (Christian et al. 2009; Narhgang et al. 2011) show that safety culture can predict both safety behaviors and accidents/injuries. Assessments of safety culture hold promise for providing leading indicators of safety issues that can trigger proactive interventions and serve as complements to lagging indicators, such as incident rates. However, this research has focused on personal safety (e.g., use of personal protective equipment, days away from work) rather than process safety; therefore, more research is needed to explore the relationship between safety culture and process safety. Approaches to Assessment of Safety Culture Unfortunately, across both academic research and reports from multiple industries, there is no single agreed­upon approach to assessing organi­ zational and safety culture. Not surprisingly, approaches for assessing safety culture (e.g., IAEA 2002) generally parallel those for assessing organizational culture (e.g., Sackmann 2006). Still, because the goals of assessing safety culture tend to be more improvement­oriented and more institutional than those of assessing organizational culture, the most common approaches for safety culture assessment are more prag­

Safety Culture Assessment and Measurement 143 matic. This section briefly examines culture assessment in general and then turns to safety culture assessment in particular, considering both the content and process of the assessment. Assessments of Organizational Culture A fundamental difference among approaches to culture assessment is whether each culture is seen as a unique grouping of elements or cultures are scored or categorized on a limited number of dimensions (Sackmann 2006; Guldenmund 2015). Whereas the classic anthropo­ logical approach to culture sees each culture as unique from the view­ point of a cultural insider, that approach is time­consuming and does not lend itself readily to comparisons or recommended improvements (thus really constituting description rather than assessment). In con­ trast, a number of different models and typologies of organizational culture have been developed over the years, many of which have associ­ ated measures, typically on questionnaires (Zohar and Hofmann 2012). Hofstede (1980, 1998) measured national cultures based on five dimen­ sions grounded in the working world: (a) power distance or degree of inequality, (b) uncertainty avoidance, (c) individualism­collectivism, (d) masculinity–femininity (competitiveness and material ism versus relationships and quality of life), and (e) long­ versus short­term orienta­ tion. Cameron and Quinn (1999) and Denison (2000) used dimensions of internal versus external orientation and flexibility versus stability to define four cultural types. Goffee and Jones (1996, 2001) and Cooke and Szumal (1993, 2000) used other dimensions to create a different set of three or four cultural types. Variations in the above approaches arise in part from what is meant by culture (Sackmann 2006; Zohar and Hofmann 2012). Some defini­ tions focus on values, some on organizational practices, some on norms and expectations, and others on commonly held beliefs. Some of the cultural dimensions focus on structures (external/internal, flexible/ stable), while others focus on social interaction (solidarity/sociability) or behavioral orientations (task/people, promotion/prevention). Some aspects of culture are relatively easy to assess, often by means of self­ reported perceptions on a survey (typically called “climate” [e.g., Denison 1996; Guldenmund 2000]). Schein’s (2010) influential model of cul­ ture asserts that there are surface features of culture that can be seen and

144 Strengthening the Safety Culture of the Offshore Oil and Gas Industry heard, including visible artifacts and communicated values and beliefs, whereas the essence of culture, comprising underlying assumptions, is “deeper” and difficult even for cultural insiders to perceive and articulate. How Safety Culture Can Be Assessed To assess safety culture, one must start with a clear concept and then build a set of assessment procedures suited to that concept. A broad concept of safety culture requires a broad set of data for assessment and means for collecting those data, including both quantitative and qualita­ tive approaches. Given the wide range of organization sizes, resources, and work activities involved with safety culture, organizations can be expected to use a great variety of approaches to assess their safety cultures. There are several established methods for assessing culture, including safety culture. None of these methods is perfect; each has its strengths and weaknesses (see reviews by IAEA 2002; Sackmann 2006). To build on these strengths and compensate for these weaknesses, multiple methods can be used for a given assessment. The various methods are reviewed here in terms of (a) accuracy (scientific validity), or how well the method captures the key aspects of (safety) culture, and (b) practical­ ity, or how much money, time, and scarce expertise is needed to execute the method. Figure 5­1 depicts the methods to be discussed. FIGURE 5-1 Methods for assessing safety culture. Ethnography Episodic fieldwork + document review Document reviews Episodic fieldwork Surveys + guided self-analysis Surveys + focus groups Interviews, focus groups Climate surveys Guided self-analysis Practicality (cost, time, expertise) Mo re be ne fit/ co st A cc ur ac y (s ci en tif ic v al id ity ) Trade-offs

Safety Culture Assessment and Measurement 145 Note three issues with respect to this figure. First, proponents of various methods would differ dramatically on where the methods should be placed on the figure, especially in terms of accuracy (scientific validity). Survey proponents argue that ethnographies are subjective and unscientific, while proponents of ethnographies argue that surveys are self­reported answers to possibly misleading questions written and interpreted by cultural outsiders (e.g., Silbey 2009). Second, where a method is placed on the figure depends on the quality of its execution: there are bad ethnographies, bad surveys, and bad interviews. The posi­ tioning shown on the figure assumes a version of the method that is at least of “good” quality (i.e., has reasonable validity) as understood by experts in that method. Finally, no scale is given to the axes of the figure because there is no objective quality standard for and little work systematically comparing the methods. Similarly, on the practicality dimension, managers have to judge what expertise they have or can readily contract, given the size and capabilities of their organization, and how much cost can be tolerated. The classic method for studying culture is ethnography. The method was originated by field anthropologists, who generally spend 1 to 2 years “living” in a culture, often in a nonindustrialized setting not previously studied systematically. The emphasis is typically on understanding a novel culture, particularly with respect to deriving meanings as insiders (“natives”) understand them. Accuracy is assessed in terms of internal coherence and narrative force: Is the ethnographer able to tell a good story that is stimulating and instructive for the reader? Ethnographers observe and ask questions of “key informants” who are willing to share insights with and mentor the researcher. They take detailed notes, often written or rewritten at the end of the day to capture as much as they can remember, and then spend months or years reading their notes to understand what they have seen and heard and decide how best to tell their story. It also is possible to use ethnographic methods in a less intensive way, such as by visiting a site for a week, or making a series of visits to track changes or deepen the investigation. Especially when the setting, work technology, and social arrangements are relatively familiar, such as when the study focuses on an industrial site (factory, drilling rig) with no language barrier, less time may be required to absorb the culture. A representative ethnography in the offshore oil and gas indus­ try is Ely and Meyerson’s (2010) study of how one rig went from a

146 Strengthening the Safety Culture of the Offshore Oil and Gas Industry “masculine” culture in which accidents and injuries were frequent and little learning took place to a more “feminine” culture that reshaped “gender identity” to focus on learning and safety. Although it is debatable how accurate ethnographic approaches can be (e.g., most people want to present a positive impression, and replication is unusual and sometimes has been disappointing when attempted), these methods are designed to reveal “deep” culture or basic assumptions and meanings. In the hands of a skilled ethnographer, levels of accuracy and insight (even wisdom) are high. At the same time, reliance on a highly skilled outsider to conduct the ethnography can require considerable time and resources and yield uncertain ben­ efits, which can be frustrating and even prohibitive for managers and regulators. Yet a skilled ethnographer can add a deep understanding of cultural assumptions and interpretations, as well as organizational processes, that potentially can guide regulators in writing and imple­ menting new policy. In particular, such in­depth exploration may lead to more sensible and grounded rules that can be implemented readily across an industry. Less intensive than ethnography is a set of field­based methods that can be termed episodic fieldwork. These methods include combinations of direct observation of work practices by individuals or teams of visi­ tors, interviews of individuals or groups, and analysis of documentation (e.g., U.S. NRC 2014). This method is typically used by internal and external auditors (e.g., quality assurance personnel, regulators), consul­ tants, benchmarking teams, and peer­assist teams. Episodic fieldwork has some advantages over ethnography: it takes less time (although a 2­week visit by a 10­person team is quite intense), and the visitors are typically experts in and familiar with industry terminology and work practices. Hence, they can work more efficiently than an ethnographer who enters a strange new culture, and the team provides diverse view­ points and can test assumptions, observations, and conclusions. Still, an “outsider” (ethnographer) who resides in the culture for many months may have a better chance of observing the underlying culture, especially those aspects that are part of an industry or local work culture that are taken for granted and invisible to episodic visitors. Leaders and members of organizations, regulators, and researchers also use document review to make sense of and shape an organization’s safety culture in three ways—vicarious learning, learning from near

Safety Culture Assessment and Measurement 147 misses, and operational refinement. First, documents in the form of reports of inquiries or government investigations into an accident can serve as a source of vicarious learning for other organizations through­ out the industry (March et al. 1991). These reports can be important aids to learning as they can be based on a combination of the sources of information discussed in this section (interviews/observation, surveys, documents, and data on accident and error rates). However, to wait for an accident to occur is to miss the opportu­ nity to uncover weaknesses in organizational defenses before they cause an accident (Reason 1997). Known leading indicators of accidents (i.e., near misses) can serve as sources of vicarious learning (March et al. 1991). This, in part, is what motivates the second use of document review—the use of near­miss reporting systems, such as the Aviation Safety Report­ ing System1—to provide a more comprehensive picture and facilitate learning from a wider range of events. Yet while effective in aviation, such systems are known to underrepresent the frequency and range of errors when applied to other industries (Thomas and Peterson 2003). The Bureau of Safety and Environmental Enforcement (BSEE) has its own voluntary near­miss reporting system—the Safe OCS Voluntary Confidential Near­Miss Reporting System (BSEE 2015). However, this system is relatively new, so whether it will receive sufficient reporting to provide useful insights cannot as yet be known. This second use of document reviews also can include incident reports and investigations, maintenance backlogs, activities of corrective action programs, training processes, human resources and employee health records, notes from management walkarounds, and anything else that would provide insight into the functioning of the organization. Third, high­reliability organizations use the development and refine­ ment of operational documents and standard operating procedures as occasions for cross­functional conversations to ensure continuing reli­ ability and safety. For example, Schulman (1993) observed processes for negotiation among several departments of a nuclear power plant designed to ensure careful interdepartmental coordination. Soliciting differing departmental viewpoints on documents increases the likeli­ hood that potential issues will be addressed proactively and sufficiently 1 The U.S. Federal Aviation Administration’s (FAA) voluntary confidential reporting system that allows pilots and other airplane crewmembers to report near misses and close calls.

148 Strengthening the Safety Culture of the Offshore Oil and Gas Industry proceduralized so they can be dealt with reliably by all departments. The negotiation process also creates norms of interdependence and collabo­ ration, reduces mindless execution of tasks, and tends to curb “hubris and bullheadedness” among organizational members. Safety culture and climate2 surveys using questionnaires with rating­ scale measures of various cultural attributes have become increas­ ingly popular in recent years, and regulators are requiring such surveys more routinely, especially of organizations suspected of having a weak safety culture. In its review of methods for assessing safety culture, the International Atomic Energy Agency (IAEA) (2002) found that sur­ veys were endorsed as useful and practical more often than any other method. Table 5­1 lists sample survey items, based on items from the Institute of Nuclear Power Operations (INPO) safety culture assess­ ment instrument, that could be used to assess safety culture in the off­ shore oil and gas industry in terms of the nine elements of a strong safety culture identified by BSEE (2013). The advantages of culture and climate surveys are that they require relatively little time and money (especially if an off­the­shelf survey is chosen, or modified in minor ways to make it more specific to the organization’s context and needs), can be kept anonymous to encour­ age candor (although not everyone trusts “anonymous” surveys), and provide quantitative scores, and results can be compared readily across multiple dimensions—time, organizations, departments, locations, or hierarchical levels. Yet many difficulties remain in the application of surveys. The main disadvantage is that responses are self­reports in response to standard questions that may be interpreted in different ways by different respondents, who may or may not be able (or will­ ing) to report on “deeper” levels of culture. Moreover, the meaning of the questions and the factor structure among them are dependent on whether the culture itself is reactive, calculative (rule oriented), or pro­ active (Hudson 2007). In smaller organizations where anonymity is difficult to maintain or in those with very low levels of trust, it may be difficult to obtain candid replies or a good response rate. Finally, culture and climate surveys can sometimes be treated as the end point of the 2 The term “safety climate” denotes shared perceptions of safety­relevant policies, procedures, and prac­ tices concerning what the organization rewards, supports, and expects (Guldenmund 2000; see also Chapter 2).

Safety Culture Assessment and Measurement 149 assessment (“our scores are good enough”) as opposed to a mechanism to guide a substantive conversation about safety (Schein 2013). Proponents of safety culture and climate surveys argue that the results provide leading indicators of safety problems even better than those derived from near­miss reporting for anticipating and there­ fore proactively managing safety issues. A growing body of research shows statistically significant and practically meaningful relationships between culture and climate scores and safety statistics (e.g., Morrow et al. 2014). However, many of these studies are correlational, such that the direction of causality is ambiguous (Bergman et al. 2014), and others use personal safety measures (e.g., days away from work, number of TABLE 5-1 Sample Survey Items for Use in Assessing Safety Culture BSEE Safety Culture Attribute Sample Survey Items Leadership commitment Leadership frequently communicates the importance of safety. Decision making at this site reflects a conservative approach to safety. Respectful work environment People are treated with dignity and respect by leadership. My supervisor responds to questions and concerns in an open and honest manner. Environment for raising concerns I can raise safety concerns without fear of retaliation. Dialogue and debate are encouraged when evaluating safety issues. Safety and environmental communication There is good communication about safety issues that affect my job. Contractors/vendors understand our expectations for performing work safely. Personal accountability It is my responsibility to raise safety concerns. When an important safety decision must be made, I know who is responsible. Inquiring attitude Overall, workers maintain a “questioning attitude” and a rigorous approach to problem solving. Personnel do not proceed in the face of uncertainty. Hazard identification and risk management Personnel promptly identify and report conditions that can affect safety. Organization weaknesses are identified and resolved. Work processes Our procedures are generally up to date and easy to use. My supervisor discusses safety with me before I start work on a new or infrequent job. Continuous improvement We adopt innovative ideas to improve safety. This site learns from its mistakes. SourceS: For BSEE safety culture attributes, BSEE (2013); for sample survey items, INPO (2013).

150 Strengthening the Safety Culture of the Offshore Oil and Gas Industry injuries) rather than failures of process safety, with some exceptions (e.g., Hofmann and Mark 2006). It is now known that personal safety can be managed successfully with little impact on process or system safety. Process and system safety indicators are more subtle and invis­ ible, based in a confluence of interacting problems or an unanticipated combination of components each functioning as designed (Leveson 2012, 2015). The knowledge and skills needed to manage process and system safety are different from those necessary to ensure personal safety. Indeed, major accident investigations have cautioned that a focus on personal safety and occupational injury statistics can lead to a false sense of security with regard to process safety (HSE 2003; CSB 2007). Fortunately, a growing body of evidence from field experiments shows that specific interventions significantly change perceptions of safety cli­ mate and, in turn, improve process safety outcomes (e.g., Zohar 2002; Zohar and Luria 2004; Thomas et al. 2005). Culture and climate surveys can serve another beneficial function: raising awareness of and creating opportunities for productive conver­ sations about safety. Use of the scores calculated from survey responses to monitor and manage is the most visible and least important aspect of culture assessment and change. Instead, surveys can prompt conversa­ tions about and broaden understanding of the organization’s safety pro­ cesses, as well as participation in generating innovative paths forward and continuing conversation to learn from these efforts (Carroll 2015). It is also important to recognize that this learning process can succeed only if senior leaders are engaged, listening, and pushing for improve­ ment; otherwise, the self­analytic activity will come to a halt, leaving behind a residue of cynicism, mistrust, and resistance to change. One example of how leaders can become involved in such activities to foster psychological safety, problem reporting, and meaningful improvement is a frontline improvement system (Singer and Tucker 2014). Such a system pairs mechanisms by which employees can offer suggestions with forums in which leaders and employees process those sugges­ tions and direct collaborative efforts toward change. For example, the comprehensive unit safety program model features processes by which leaders “adopt a unit” and become a more visible presence to enable dis­ cussion and action (Pronovost et al. 2004). These examples illustrate how surveys can be combined with other methods to foster more com­ prehensive data collection and meaningful opportunities to learn.

Safety Culture Assessment and Measurement 151 A method that is not as time­ and labor­intensive as ethnography but not as broad­brush or “distant” as surveys is a process that can be called guided self-analysis. This method relies primarily on cultural insiders to analyze their own culture through one or more workshops or meetings (hence, self­analysis), while also recognizing the need for skilled facili­ tation by either an internal specialist or an external consultant (hence, guided). The process engages a cross section of participants who are knowledgeable about the culture but also have the curiosity and critical thinking skills to step outside their own culture. Individuals who are already bicultural, such as those who have worked in another company or in another part of the same company that has a different culture, may be a good choice as participants. It is desirable to have a diverse group for these discussions, but if the existing culture is low on trust (low psychological safety, high conflict), it may be necessary to have more homogeneous groups within a single hierarchical level and even a single department so as to encourage candid conversation. It is usually easier to start the discussion with what is readily observ­ able about the organization, such as its espoused values (“What are our goals? Why does this organization exist? What do we care about?”) and the ways in which the culture expresses itself in artifacts of technol­ ogy, physical space, and communication. Questions about the “culture” are often difficult to answer; it is often easier to ask, “What is it like working here?” or “How does this place differ from other places you have worked or other parts of the company?” Schein (2015, 16) sug­ gests that “bringing employees of an organization into a room together and asking them to provide some examples of what kinds of things are expected of them, listening carefully for those things on which there is obvious consensus and ignoring things that are clearly individual quickly . . . brings out what the important elements of a given culture are.” It may also be useful to ask about what has changed in the past 5 or 10 years, why it has changed, and in what ways the change is important (see Cooperrider and Whitney [2005] for a discussion of appreciative inquiry as a form of guided self­analysis). One way to surface cultural assumptions is to explore apparent contra­ dictions between espoused values and observed practices—for example, if an espoused value is “safety is our top priority,” but everyday behaviors privilege production and “doing what is necessary to get the work done.” When the group has raised apparent contradictions and appears pre­

152 Strengthening the Safety Culture of the Offshore Oil and Gas Industry pared to discuss them, the next step is to explore the contradictions—for example, to ask, “Why do we say we value safety but we seem to take actions that value production over safety?” It may be that there are deeper understandings of safety and production that resolve the contradiction in a way that helps in understanding the culture. Or underlying assump­ tions about the need to please external audiences, the pressures of short­ term incentives, the way managers think, or the lack of resources to invest in work improvements may surface. Strong research evidence shows that self­analysis strategies for prob­ lem detection and resolution have improved safety in a variety of indus­ tries. The Israeli Defense Force is renowned for its use of after­event reviews, whereby both successes and failures are probed by all mem­ bers participating in a mission for possible improvements (e.g., Garvin 2000; Ellis and Davidi 2005). Successes are examined for near misses and close calls, an approach that has been shown to improve group cohesion and psychological safety in addition to identifying actionable problems (Ron et al. 2006). In health care, many leading organiza­ tions use safety rounding, whereby leaders go on the floor to talk with frontline staff about what they see as risks and threats to safety. Prior research has found that safety rounding improves perceptions of safety climate (Thomas et al. 2005); however, actual improvement depends on the consistency and rigor of its implementation, such that surfac­ ing problems is followed up with concrete actions and status updates (Singer and Tucker 2014). After­action reviews and safety rounds that are enacted as a ceremonial duty with no expectation of learning or, even worse, as an opportunity to punish guilty parties and reinforce authority will create cynicism and resistance to change. Although after­ action review and safety rounding focus on problems rather than cul­ ture, they illustrate how organizations can establish opportunities for self­analysis through discussion of what people do and why they do it, and thereby bring important facets of culture to light. Finally, as illustrated in Figure 5­1, the use of multiple methods com­ bines the strengths and mitigates the weaknesses of individual meth­ ods to achieve a practical mix of benefits without crippling costs. For example, a safety culture or climate survey could be used to provide broad background information and raise questions about dimensions, departments, or hierarchical levels with higher or lower scores. Typically, attention focuses on the lower scores as areas for improvement, but it may

Safety Culture Assessment and Measurement 153 be useful to think about the organization’s strengths and attempt to learn from its successes. It is essential for interpretation of the mean­ ing of the scores to go beyond numerical averages or the intuitions of a few people preparing the survey report. Many organizations use focus group interviews following a survey to discuss its results and to obtain specific examples and details as to what the responses mean to workers, supervisors, and managers. Some organizations include work obser­ vations (as in episodic fieldwork) conducted around the time of the climate survey to add further richness to the data. Then, diverse teams can begin to assemble ideas about how to intervene and how to evaluate whether progress is being made. This process helps elevate concerns so they receive attention, resources needed to address them are available, and steps are taken to gather further information and engage broad participation in sense­making and change initiatives (Weick 1979; Carroll 2015). Monitoring of safety culture requires more than an assessment every 2 years through a survey. Periodic surveys and audits are most helpful when paired with other, more regular (monthly or quarterly) assessments. Larger organizations often have a “dashboard” of indica­ tors that are used for various management concerns, including produc­ tivity, cost, environment, human relations, and safety. For example, the Gulf of Mexico business unit of one large multinational company has a monthly “Process Safety Scorecard” that includes lagging indicators of loss­of­control events (major and minor) and, importantly, leading indicators that include overdue critical equipment inspections and tests, safety system activations, overdue and open process hazard analysis rec­ ommendations, number of discrepant material nonconformances, and overdue permanent and temporary management­of­change analyses. The scorecard includes objectives and color coding for status against objectives. Another large multinational has a suite of process safety key performance indicators, including both lagging indicators such as loss of primary containment and fires and leading indicators such as process control overrides, maintenance deviations, canceled inspections, failed assurance tasks, and number of management assessments offshore. Increasingly, safety culture is a part of such a dashboard, with mul­ tiple indicators being examined regularly. These indicators may include codes for safety outcomes, near misses, problem reports, incident investigation results, employee concerns and suggestions, management

154 Strengthening the Safety Culture of the Offshore Oil and Gas Industry walkarounds, observations of prejob briefings and after­action reviews, and union concerns. Some of these indicators may be quantitative, others a simple green­yellow­red assessment, and still others qualita­ tive comments. Indicators may assess strengths and positive examples as well as weaknesses and problems. The intent is to keep everyone thinking about safety culture along with other management concerns, and to feed this information into the safety management system for improvement efforts. As an illustration, one company in the nuclear industry uses the 10 INPO safety culture traits (similar to BSEE’s nine attributes, detailed in Chapter 2) to structure a dashboard of indicators that are examined in a quarterly meeting attended by senior management and 10 middle managers who are designated as subject matter experts, one for each trait. The dashboard is available online through the company intranet to all employees and contractors. For example, “environment for raising concerns” is given a trait health rating (color code and emoticon), calcu­ lated by combining the most recent safety culture survey results on the same trait with the most recent indicators from the Employee Concerns Program (number of concerns, average time to close concerns, average satisfaction as rated by the employees who raised the concerns, and per­ centage of participants who would recommend the program to others). The dashboard’s online page for this trait also includes a plan of action for improvement and metrics for tracking plan implementation and results. In addition, the subject matter expert writes a short qualitative narrative describing the strengths and weaknesses of the organization on that trait. Who Should Assess Safety Culture? As with any aspect of safety, assessment of safety culture requires objec­ tivity, expertise, and sensitivity to context. Some organizations already have the right capabilities and motivation to conduct a safety culture assessment, but many others need assistance from outside auditors, corporate experts, consultants, peer organizations, or industry groups. In some circumstances, external organizations may be more trusted by respondents and therefore elicit more candid responses, and they also may have better access to benchmarking data. Use of existing tools (such as climate surveys widely used in the nuclear industry) offers the advan­ tages of requiring less development and support, as well as facilitating

Safety Culture Assessment and Measurement 155 comparisons and industry­level sharing with other organizations using the same tools. However, existing tools have the disadvantages of being generic and therefore less useful in terms of the specific issues and context of an organization; such tools also may instill less sense of ownership of safety culture. Therefore, the long­term goal should be to bring the organization’s self­assessment and self­reflection capabilities as close to the work as possible, involving everyone in the safety cul­ ture assessment process. Internalizing the capability for gathering and analyzing data on safety culture is especially important in the offshore industry because offshore organizations vary greatly in size, resources, risks, and sophistication, so it is necessary to tailor safety culture assess­ ment to each organization. Given that surveys provide only a partial view of the safety culture of an organization, a more comprehensive assessment often engages a team of specialists who use a combination of tools, such as inter­ views, document reviews, observations, and focus groups. The size and makeup of assessment teams need to flow from the scope and purpose of the undertaking and the complexity of the methods used. Consistent with the finding that multiple cultures exist within organizations (see Chapter 2), a broad, comprehensive understanding of an organization’s safety culture (or cultures) will require a range of assessment tools and a diverse assessment team. In a larger organization, this means gathering data from multiple levels (executives, managers, frontline employees) and across functional areas (e.g., drilling, engineering). A more focused investigation of one particular aspect of safety culture (e.g., issues with lockout, tagout procedures) likely will require a much smaller team (or even an individual) using a more limited set of tools. Regardless of the final composition of the assessment team, it is important for several reasons that the host organization retain owner­ ship of both the process and follow­up actions on the recommenda­ tions resulting from the assessment. First, if employees perceive that management has outsourced the safety culture assessment (and per­ haps the broader problem) to an outside agency or contractor, they may conclude that the organization is not really serious about the issue. Second, the safety culture assessment ultimately will require some actions and changes within the organization. One of the key factors predicting the success of change initiatives is management commitment (Zohar and Luria 2005). Management’s staying involved in and retain­

156 Strengthening the Safety Culture of the Offshore Oil and Gas Industry ing ownership of the assessment process will increase its engagement in and commitment to the process and any resulting recommended changes. Third, assessments that are conducted and evaluated closer to the organization’s work processes typically result in more timely feed­ back and therefore greater flexibility and learning. There is a hierarchy of people and organizations that establish and implement safety plans and evaluate safety processes and performance, from workers to super­ visors, safety auditors, middle managers, senior executives, regulators, and legislators (Leveson 2012, 2015). Some safety indicators will be common across many levels of this hierarchy, but more real­time indica­ tors and methods for controlling safety and making improvements are needed for those levels closer to work operations. Finally, only manage­ ment can ensure that safety culture assessments fit within the organi­ zation’s broader safety management system (Branch and Olson 2011). Each organization has to match the strategic scope and complex­ ity of its safety culture assessment to the right balance among local involvement and ownership, local expertise, breadth of perspective, outside expertise, and trust of internal or external parties (see DOE [2012] regarding diversity of background and training of assessment team members). The Nuclear Energy Institute (NEI 2009) has iden­ tified three types of assessment teams: internal self­assessment, inde­ pendent, and third­party. An internal self­assessment team consists of employees from the local site, as well as staff from other locations and headquarters. An independent assessment team has no members from the site being evaluated, but is made up of a mix of staff from other sites and members from outside the organization. A third­party assess­ ment team consists of members exclusively from outside the organiza­ tion. As noted in a recent report from the Belgian Nuclear Research Centre (2012), however, each potential assessment team approach has strengths and weaknesses, with none emerging as “best.” Employee Participation in the Assessment Process Effective employee participation is a key component of the safety culture assessment process and successful follow­up actions. A report of the U.K. Health and Safety Executive (HSE 2015) notes that employee involve­ ment is one of the greatest influences on safety culture. Yet despite their critical role, workers may be hesitant to participate. For example, the International Labor Organization (ILO 2011) observes that workers

Safety Culture Assessment and Measurement 157 may be hesitant to participate in safety culture assessments because their opinion has not often been valued: “Workers generally know where many of the safety problems are, but since no one asks them their opinion, they resist getting involved in the safety program.” In addi­ tion, workers may fear that making reports of safety issues or negative comments could jeopardize their job, create conflict in the workplace, increase workload for themselves or their coworkers, and fail to result in improvements. Companies need to build trust in management and provide positive incentives to encourage reporting and participation in the learning process (e.g., Baram 1997). Baker and colleagues (2007) had to grapple with this hesitancy during the Baker Panel’s safety culture investigation of BP’s U.S. oil refineries. BP created the Baker Panel in response to an urgent recom­ mendation issued by the U.S. Chemical Safety Board in August 2005. Five months earlier, BP’s Texas City Refinery had experienced a cata­ strophic fire and explosions that killed 15 and injured 170. The panel recognized that employees might be hesitant to trust and participate in the panel’s safety culture survey, interviews, and meetings. This hurdle was overcome through the production of a video featuring Leo Gerard, president of the United Steelworkers Union, which represented most BP refinery workers, and Carolyn Merritt, chair of the Chemical Safety Board, both of whom urged employees to participate fully in the safety culture assessment activities. In addition, Glenn Erwin, a long­time union leader, was a member of the Baker Panel. The reports of both the ILO (2011) and Baker and colleagues (2007) emphasize that frontline employees need to have a feeling of “psycho­ logical safety” (Edmondson 1996, 1999) to be willing to disclose dif­ ficult conditions or events without fear of being embarrassed by their peers or punished by their managers. Indeed, this feeling is the founda­ tion of a reporting culture (Reason 1997) and the starting point for improvement (see also Hofmann and Stetzer 1998). Psychological safety can be enhanced by messages from legitimate leaders (e.g., union presidents), as well as by an open, fair, and participative process. For example, the European Agency for Safety and Health at Work (2012) suggests that employee involvement should include union involvement and entail more than informing or consulting activities, stating that “full participation goes beyond consultation; workers and their representa­ tives are also involved in making decisions.”

158 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Frontline employees and all key stakeholders also need to stay involved, or at least be informed on an ongoing basis, once the safety culture assessment has been completed. Many organizations fail to communicate the results of the self­assessment back to employees, who are likely to conclude that the assessment was a ceremonial exercise carried out to comply with external demands and that no meaning­ ful changes will result. Indeed, given that respect and communication are key aspects of safety culture, it appears obvious that a safety cul­ ture assessment must communicate respectfully with employees both during the information­gathering process and again when results are reported and improvement plans are made. Doing so will not only maintain employee interest and engagement in change efforts, but also shape the culture (see Chapter 6) with respect to how management and employees treat each other as part of the same team. Psychological safety is important not just for frontline employees but for all participants, including senior management. Companies are under­ standably cautious about producing reports that may expose them to regulatory sanctions or legal actions asserting negligence. Making safety a priority entails executives showing leadership by supporting the flow of information necessary for organizational learning, because the cost of hid­ ing problems is likely to be higher in the long run than the cost of facing them as early on as possible. The safety culture assessment process also serves as an opportunity to engage the organization in a set of conversations and change efforts that can have a major beneficial impact on the culture itself. An effec­ tive assessment process brings together a wide range of people to talk about their concerns and opportunities for improvement, and thereby begins to break down the vertical silos and the horizontal barriers in large organizations. The process results in the development of per­ sonal networks that act as a resource for information flow, interdepen­ dent work, and organizational learning. The assessment process can be conducted in a way that informs and engages employees, treats them respectfully and shows sincere interest in what they have to say, and leads to taking collaborative action to achieve small wins (and maybe bigger wins as well). If people are engaged in actively effecting needed changes and those changes are seen and valued as successes, the culture reflects the assumption that this is the way members of the organiza­ tion work together to improve.

Safety Culture Assessment and Measurement 159 At the same time, the process of assessment raises expectations of improvement, and unless visible change is communicated to the work­ force (change in which they ideally have been actively engaged), the process will likely increase cynicism and further entrench the existing culture. If the assessment process is conducted by outsiders who report to management, it may provide the appearance of objectivity, but it also will have the unintended consequence of imbuing the culture with the assumptions (or reinforcing existing assumptions) that insiders are helpless to effect change and that expertise and power reside in top management and external consultants. When safety culture assessment is conducted as a checklist process run by outsiders and imposed on workers, with little communication of results and little visible change, it reinforces the gaps among owners, managers, workers, and contractors and erodes trust. Role of the Safety Regulator Just as regulatory authority differs substantially across industries and countries, the role of the regulator in safety culture assessment can be established in more than one way. The U.S. Nuclear Regulatory Com­ mission (U.S. NRC) provides one model for how a safety regulator assesses safety culture. In general, the U.S. NRC does not conduct safety culture assessments, although it reserves the right to do so in special situations. Instead, the U.S. NRC publishes general criteria for assess­ ments (e.g., U.S. NRC 2014). There are both advantages and disadvantages to having the regula­ tor actually conduct the safety culture assessment. On the plus side, doing so ensures that the assessment will be carried out and conducted in a reasonable and uniform manner and that its results will be shared. However, this approach also shifts the context from self­initiated learn­ ing to reactive oversight and compliance. If there is a true partnership, it may be possible for the regulator to be more proactive without under­ mining learning by other parties, but in a more adversarial situation, defensive behavior may interfere with the flow of data and the oppor­ tunities for learning. For a regulator such as BSEE to play a greater role in safety culture assessment (for example, serving as a clearinghouse for methods, offering advice, validating quality), the agency must have the capacity—including both the technical expertise and cultural values and assumptions—to

160 Strengthening the Safety Culture of the Offshore Oil and Gas Industry perform this role. For example, the U.K. Health and Safety Executive offshore regulator employs senior nontechnical staff trained and experi­ enced in social science. BSEE currently has little expertise in this area but could build such capabilities by hiring experts, training current employees, and/or using external contractors. If the regulator wishes to support a strong and advanced safety culture (a proactive learning culture), the regulator itself should lead the way. A regulator with a calculative culture is likely to instill checklist compliance despite its expressed desires. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS Safety in the offshore industry is a strategic issue that needs to be man­ aged along with operations, costs, human resources, and innovation. Safety management requires assessment of safety outcomes and pro­ cesses that enable safety, including the attitudes, beliefs, and behaviors of everyone in the organization. Safety culture is not a perfect concept, but its assessment directs attention to how people think, feel, and act, from top leadership to frontline workers. Whether the process actu­ ally focuses on culture or on communication, management, leadership, work design, respect, or teamwork probably is not as important as the fact that the people involved are working on these interrelated topics. However, it will be challenging for many organizations (especially smaller ones) to build the capabilities needed to assess safety culture and use the results to draw actionable conclusions consistent with the organization’s overall strategy. Recommendation 5.1.1: Operators and contractors should assess their safety cultures regularly as part of a safety management sys- tem. To this end, they should discuss salient inputs, even if only abbreviated data and qualitative impressions, at periodic manage- ment meetings (weekly, monthly, or quarterly) and as safety culture issues emerge in operations (e.g., incidents, investigations, audits, industry bulletins). Recommendation 5.1.2: The committee strongly recommends that companies use multiple assessment methods, including, in particular, the application of both leading and lagging indicators

Safety Culture Assessment and Measurement 161 and both quantitative and qualitative indicators of safety culture. Companies should also apply a mix of indicators, including some that are more standard across the industry to facilitate ease of use and comparison across organizations and some that are tailored to the specific needs and concerns of their organization. For example, American Petroleum Institute Recommended Practice 754 (“Pro- cess Safety Performance Indicators for the Refining and Petro- chemical Industries”) addresses the importance of collecting broad leading and lagging indicators of process safety performance. The American Petroleum Institute could revise this guideline to include safety culture indicators and expand its application beyond onshore refining to include offshore operations. This “dashboard” of indica- tors could be examined periodically as part of the standard manage- ment process, even if some indicators (such as those identified by a full-scale climate survey or external audit) would be collected less frequently than others. Recommendation 5.1.3: Given the challenges of developing practi- cal and useful indicators of the strength of safety culture for a wide variety of organizations (large and small operators, contractors, regulators), the nine elements of such a culture identified by BSEE should be adopted as a standard or starting point for safety culture assessment. There is little reason for each organization to develop its own safety culture content, and the BSEE elements are suffi- ciently general and relevant to serve the purpose. Recommendation 5.1.4: The committee recommends that BSEE and other regulators of the offshore industry strengthen their capabilities in the area of safety culture assessment by bol- stering their expertise in safety culture through appropriate hir- ing and training and/or partnering with industry or third-party organizations. These bolstered capabilities would enable regula- tors to offer advice, training, tools, and guidelines to the industry as it conducts self-analysis. These capabilities also would enable regulators to act on their safety culture aspirations by, for exam- ple, enhancing their audits of safety outcomes, practices, and culture.

162 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Recommendation 5.1.5: As a complement to Recommenda- tions 5.1.3 and 5.1.4, the offshore industry should work collectively on the challenges of strengthening safety culture. BSEE should support this effort by serving as a clearinghouse for and facilitator of industry- level exchanges of lessons learned and benchmarking, thereby helping the industry develop a shared language, shared approaches, appropri- ate options, and more practical and efficient assessment practices. Assessment of safety culture requires objectivity, expertise, and sensi­ tivity to context. Some organizations already have the right capabili­ ties and motivation to conduct a safety culture assessment, but many others need outside auditors and experts from corporate staff, consul­ tants, peer organizations, industry groups, or elsewhere. At the same time, however, bringing the self­assessment and self­reflection capabili­ ties as close to the work as possible creates a sense of ownership and accountability and encourages broad participation in the assessment process. Internalizing the capability for gathering and analyzing safety culture data is especially important because offshore organizations vary greatly in size, resources, risks, and sophistication, so the assessment process needs to be tailored to the organization. Recommendation 5.2.1: Organizations that operate in the Outer Continental Shelf should consider their capabilities and priorities in determining to what extent they will rely on internal versus external expertise for assessment of safety culture. When feasible, organiza- tions should seek to acquire internal expertise over time so they can manage the process, interpret results, and increase their ownership and the relevance of the assessments and their results. Of course, smaller organizations will need outside help from customers, contractors, or industry groups in identifying simple yet useful assessment approaches. Recommendation 5.2.2: Given that it is management’s responsi- bility to ensure safety, regulators should define their role in terms of monitoring safety culture and encouraging and supporting the management of regulated entities in identifying the expertise and resources and understanding the priorities for operating safely.

Safety Culture Assessment and Measurement 163 The safety culture assessment process is itself a cultural intervention. The process can reinforce a reactive and cynical culture or help the organization move toward a proactive and generative culture. An effec­ tive assessment process engages a wide range of participants in coming together to talk about their concerns and opportunities for improve­ ment, and thereby begins to break down the vertical silos and the hori­ zontal barriers in large organizations. If people are engaged in actively effecting changes and those changes are seen and valued as successes, the culture reflects the assumption that this is the way members of the organization work together to improve. Recommendation 5.3.1: Organizations should treat the safety culture assessment process as an opportunity to enact a strong safety culture based on frequent and open communication, mutual respect, and widespread participation. Recommendation 5.3.2: Safety culture assessments should include processes for employee feedback and engagement in the development and implementation of appropriate interventions. Assessment should be viewed not as an end in itself but as a means to guide an improvement process. Broad participation is key to any improvement process, and visible improvement motivates continued participation and trust. A useful safety culture assessment will not only provide a score or overall average but also attend to variability across units, locations, and levels of the organization. The safety culture perceptions of senior managers, middle managers, direct supervisors, and frontline workers typically differ. It is difficult for bad news to travel upward, and natural for senior management to believe that safety culture is stronger than it is perceived to be among frontline workers. Similarly, even a company with a good safety culture may have departments or units that vary in the quality of their safety culture. And at a workplace with many employers, such as a single large offshore installation, the safety cul­ tures of the different companies may differ. It is important to direct attention and resources where they are needed, and therefore impor­ tant to examine such variations in perceptions of and the quality of safety culture.

164 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Recommendation 5.4.1: Safety culture assessments should be designed and analyzed to capture variation within the organization, including by hierarchical level, work location or department, and employer. Thus the assessment should collect a broad set of indica- tors from a suitably diverse set of individuals and groups. Recommendation 5.4.2: Safety culture assessments should include employees, contractors, and any others involved in a work process or at a work site who are the responsibility of the operator or who could affect or be affected by safety culture. Although a great deal of knowledge about safety culture and its assess­ ment has emerged in the past 30 years, a great deal more remains to be learned. Recommendation 5.5.1: Regulators, industry organizations, operators, and other participants in the offshore industry should work together to facilitate research and information sharing with respect to safety culture. Priority research topics include the following: • Which safety culture assessment approaches are best suited to specific contexts, such as smaller companies with relatively few employees and few resources? Which aspects of safety culture assessment (e.g., specific items from safety climate surveys) are most relevant for spe- cific types of organizations (e.g., contractors, small operators, large operators)? • How can data and lessons learned best be shared across compa- nies in the diverse offshore industry? Who should facilitate this process—an industry group, the regulator, a new consortium? The committee suggests that at this time, the Center for Offshore Safety is best positioned to serve as a partner and facilitator that can earn the trust of all stakeholders. • What are examples of experience in the development of safety culture, especially in a variety of contexts (smaller operators, larger operators, contractors, regulators)? How can these expe- riences best be compared across countries (e.g., Norway and the United States)? What is the role of infrastructure, such as

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