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171 The history of change in the offshore oil and gas industry reveals a great deal of progress and innovation over the past decades, especially following the Piper Alpha explosion in the North Sea in 1988, but it also shows frustration and delay. While some data indicate a downward trend in recordable and lost workday incident rates offshore (see Chapter 3, Figure 3-1), significant concerns about safety offshore remain as the industry expands drilling in more challenging locations (e.g., deeper waters farther from shore) and transfers marginal assets to smaller, lower-cost operators. These circumstances motivated the priority accorded to having a Safety and Environmental Management System (SEMS), first as a voluntary program, later as a partial require- ment, and perhaps in the future as a more extensive requirement. But as argued in Chapters 3 and 4, having SEMS as a management structure needs to be complemented by appropriate safety culture features and leadership behaviors, which are not easy to develop. Entire fields of study and practice have emerged around change management and implementation science. In a broad set of industries, studies of change initiatives have found that fewer than half meet their goals (Seo et al. 2004). Change plans may take years to craft and more years to implement. For example, it took more than a decade for the American Petroleum Institute (API) to develop and issue an updated cementing standard (issued just after the Macondo blowout) that improved upon existing guidance and recommendations. The culture change process is more like a journey than a project: even highly suc- cessful and respected organizations can behave in ways that bring the strength of their safety cultures into question. For example, following the 2009 Montara blowout off the coast of Australia, one defensive reaction by some in the United States was to explain why such an accident could not happen hereâand then it did, in the form of 2010 Macondo explosion and oil spill. 6 | Implementing Change in Offshore Safety Culture
172 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Therefore, this chapter focuses on how to implement change in a sustainable way, especially culture change that involves everyone from top to bottom in an organization. It first briefly summarizes change principles from the extensive literature on change, including strategies for culture change, and examines the illustrative cases of the U.S. Navyâs SUBSAFE program and one international oil and gas companyâs safety culture journey. The chapter then turns to the challenges faced by the offshore industry in changing safety culture. Some are general chal- lenges for managing change of any sort, and some are specific to culture change in this particular context. The challenges are described, along with strategies for overcoming them. The final section presents find- ings and conclusions, as well as recommendations for the industry as a whole and for particular stakeholders (large integrated companies, small operators, regulators). CHANGE PRINCIPLES Kotter (2012) offers a relatively simple and generic recipe for change, but it is only a starting point. His recipe involves eight steps in the fol- lowing sequence: 1. Create a sense of urgency; 2. Build a guiding coalition; 3. Shape a strategic vision and change initiatives; 4. Enlist participation; 5. Enable action by removing obstacles; 6. Generate short-term wins; 7. Gather momentum by aligning systems, structures, processes, and people; and 8. Institutionalize change with leadership development and culture. By looking behind these steps, one can identify several principles underlying effective change. First, people have to want change more than they want stability and fear change. Lewin (1947) suggests that change begins with âunfreez- ingâ as people become convinced that current practices are failing. For example, the safety transformation of the Norwegian offshore industry drew its impetus from two major accidents: the Ekofisk Bravo blowout
Implementing Change in Offshore Safety Culture 173 and major oil spill in 1977 and the capsizing of the Alexander L. Kielland in 1980, which led to 123 fatalities. Although major accidents provide pressure for change, successful transformation also requires a compel- ling vision and a practical plan for moving forward that can motivate stakeholders. In every organization, there are forces favoring change and those resisting change. An effective change strategy will strengthen the forces favoring change, such as by connecting the specific change(s) to stakeholder interests (i.e., âWhatâs in it for me?â), while also working to reduce the varied impediments to change, such as limited time and resources and fear of being fired. Beckhard and Harris (1977) popular- ized a âchange equationâ according to which successful change requires: Ã Ã >D V F R where D is Dissatisfaction with the current situation (WHY is this change necessary?); V is Vision of what is possible in the future (WHERE are we going?); F is First Steps that are achievable toward the vision (HOW do we get there?); and R is Resistance to change. For change to occur, the combination of D, V, and F must be greater than R. Second, different people have different values and priorities, and to be successful, change must engage those who are ready for it and gain the support of those inclined to wait for it (Beckhard and Harris 1977). Although the offshore industry is quite diverse, the major players in deepwater operations and typical shelf (shallow-water) operators already have or could develop and share protocols that could help advance the industryâs safety culture. That the change process requires getting individuals with formal authority as well as respected and influ- ential opinion leaders involved early in a guiding coalition, enlisting wider participation, generating small wins, and building momentum suggests that the process is as much a social movement as a âprojectâ to be managed. And the process is never completed, even when change is embedded in cultural practices and beliefs as well as in organizational structures and processes.
174 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Third, because organizations are so complex and their parts so inter- dependent, it generally is not possible to change one thing at a time. Any change has intended and unintended consequences and reverberations, some of which reinforce the desired change, but some of which interfere with it or raise new challenges. Virtually every change brings surprises that must be dealt with, so the change process is iterative, uneven, and not fully predictable. For example, some companies have built a rotation assignment in safety into the career path to upper levels of management, intending thereby to elevate and reinforce the importance of safety to career advancement. However, if these well-intentioned assignments are taken as required âget your ticket punchedâ experiences with no intrinsic motivation or accountability, they waste time and resources and, even worse, breed cynicism and degrade the safety culture. Thus, leaders and change agents would do well to heed the saying from Zen Buddhism, âEverything changes; everything is connected; pay attention.â Fourth, change tactics must be appropriate to the context. The same change plan may work in one setting (e.g., a large integrated operator) and not in another (e.g., a small independent operator). Change can be top-down, bottom-up, or middle-up-down. It can be incremental or radical, gradual or sudden, led from within or imposed from outside. Change can focus on incentives and rewards or on mission and pur- pose, exploiting existing capabilities or building new ones (DiBella and Nevis 1998; Beer and Nohria 2000). In short, change must involve an assessment of the situation, including the strategic goals, the formal organization, the key stakeholders and their interests, the companies involved, the cultural underpinnings, and the iterative reassessments and shifts in direction as the process unfolds (Beckhard and Harris 1977; Brown and Eisenhardt 1997). Finally, leadership plays a critical role in change. Leaders supply meaningful interpretations, a vision of a better future, a network of interpersonal relationships, and innovative action, but it is not neces- sary for a single leader to do everything; leadership as a change function is distributed across many individuals (Ancona et al. 2004). Formal leaders, such as the top management team or change project team, bring authority and visibility. Informal leaders, often impossible to identify on the organization chart, provide important role models and network connectors in their organizations whose support or resistance can make or break a change effort.
Implementing Change in Offshore Safety Culture 175 Jacobs (2013) offers behavioral leadership as a framework for under- standing and shaping a culture of effective leader behavior and provides a science-based method for understanding and addressing leadership development that can measurably impact a safety culture. Addressing leadership behaviors and a range of organizational levers in conjunction with effective cross-functional and cross-organizational alignment to enable leadership buy-in can shift collective behavior across an orga- nization toward operational excellence in environment, safety, health, reliability, and productivity.1 Deliberate culture change is difficult, but some strategies can be successful (Schein 2010). For example, leaders can leverage a disaster to instigate change. As previously mentioned, the Norwegian offshore industry responded forcefully to two disasters, and Exxon-Mobil made many changes following the Valdez oil spill. However, companies do not always change even after a disaster. Another strategy is to bring in people from a culture seen as worthy of emulation: the nuclear power industry hires U.S. Navy captains and admirals, and the oil and gas industry hires people from respected companies such as DuPont. Still another possibility arises if the desired culture already exists within part of the organization, and its leaders can be reassigned and promoted to spread the existing model more widely and signal top management support for culture change. Sending employees on benchmarking trips is a strategy that can provide role models for change, and widespread training can instill or reinforce new behaviors, especially if senior man- agement is visibly involved. Providing resources and encouragement for interdisciplinary problem solving can create new cultural practices and assumptions as people work together in new ways to make desired improvements. Finally, instead of trying to replace all of the old culture, some cultural values and practices can be supported, reinterpreted, and linked to new, desired behaviors. At one nuclear power plant, for exam- ple, deeply ingrained concepts of excellence, professional integrity, and safety were reinterpreted to modify the culture (e.g., excellence was now defined as not just knowing everything and having answers but also 1 It can be helpful to envision and strive for a âperfect dayâ with zero incidents. But the concept of âincidentsâ must be broad enough to include both personal and process safety accidents, near misses, nonconformances, anomalies, and surprises. It is dangerous when organizations focus only on what can be counted, which are typically personal safety accidents, or when workers feel reluctant to report a problem that will spoil a record of many days without an incident.
176 Strengthening the Safety Culture of the Offshore Oil and Gas Industry discovering problems and learning new things (Carroll and Quijada ). Schein (2015, 9) offers this observation: If I have learned anything in this field, it is that cultures as a whole donât change; they evolve slowly as bits and pieces of them are changed by systematic change interventions. And these interventions work only when the culture changes are clearly tied to the fixing of some organi- zational problems linked to performance. Described below are two examples of culture change, one from the U.S. Navy and one from the oil and gas industry. These examples are intended to highlight effective principles and processes rather than spe- cific actions to be emulated directly. SUBSAFE Example One informative example of a comprehensive safety system embedded in safety culture is the U.S. Navyâs SUBSAFE program (Sullivan 2003), created at the insistence of Admiral Rickover immediately following the loss of the nuclear submarine USS Thresher in 1963 (Bierly et al. 2014). The purpose of SUBSAFE is quite specificâto maintain hull integrity and operability of crucial submarine systems so as to allow control and recovery. The SUBSAFE program has nothing to do with the safety of the submarineâs nuclear reactor or missiles or with slips, trips, and falls. Its success is evident in the safety record of the Navyâs submarine fleet: in approximately 50 years prior to the establishment of the SUBSAFE program, 16 submarines were lost to noncombat accidents; in the 50 years following its establishment, no submarine that was part of the SUBSAFE program was lost. The core of the SUBSAFE program is a comprehensive set of require- ments that permeates every aspect of submarine design, construction, operations, and maintenance, including how work is conducted, what materials are used, how every element of work is documented, and how inspections and audits are used to verify compliance with the require- ments. Every 10 years, the entire program is evaluated and revised (and small changes are made as needed), so that the program is never viewed as finished or complete. A core element of the program is the certification process that is applied to critical structures, systems, and components. Certification is based strictly on objective quality evidenceâ
Implementing Change in Offshore Safety Culture 177 a statement of fact, quantitative or qualitative, that documents the deliberate steps taken to comply with requirements. Certification can readily be audited throughout the life of a submarine, and without certification, a submarine cannot be operated. In contrast, industrial plants often operate with known and unknown problems (and lists of promises of work to be done). Therefore, risks are nearly impossible to estimate and manage. The SUBSAFE program is also designed to address three cultural challenges: ignorance, arrogance, and complacency. Passionate, engaged, and effective leadership is considered the key factor in the constant strug- gle to overcome these challenges. Leaders actively promote a questioning attitude through critical self-evaluation, a learning orientation (e.g., con- tinuous training, audit philosophy), an assumption that everyone is trying to do the right thing (but it is necessary to verify), and a focus on objective quality evidence rather than opinion. The above cultural challenges also are addressed each year at an annual meeting held on the anniversary of the loss of the Thresher, where lessons learned and changes made dur- ing the past year are summarized. In addition, a video of the Thresher is shown with emotionally laden images of the crew and civilians on board, and relatives of the victims attend and speak of their loss. The heart and soul of the annual meeting is a shared commitment to safetyâand to keeping the emotional experience of the Thresher accident alive. The SUBSAFE audit practices and philosophy also are astutely oriented to the realities of a complex organization. Audits of every SUBSAFE-certified ship and every SUBSAFE-certified facility (e.g., shipyards, contractors) are conducted quite frequently to verify compli- ance with requirements. The audit philosophy encourages learning in a constructive manner, rather than âpolicingâ and punishing the guilty. Consistent with that philosophy, audit teams comprise about 80 per- cent external auditors from peer facilities (that are also subject to simi- lar audits) and 20 percent personnel from the facility being audited. Continuous communication between the audit team and the personnel in the facility ensures full understanding of identified problems; there is no desire to âcatchâ or âsurpriseâ people. The compliance verification organization has status and authority equal to that of the program managers and technical authority. Headquarters also is audited, and just like any other part of the SUBSAFE community, its leaders must accept and resolve audit findings.
178 Strengthening the Safety Culture of the Offshore Oil and Gas Industry The SUBSAFE program explicitly recognizes the potential conflict among stakeholders with different goals and gives voice and weight to each of three key roles: â¢ The platform program manager is responsible for the design and opera- tion of a particular submarine design, or platform; â¢ The independent technical authority is responsible for providing the necessary technical expertise, such as recommending acceptable designs from which the program manager may choose; and â¢ The independent quality assurance and safety authority is respon- sible for compliance with requirements. None of these actors can make a unilateral decision; designs can move forward only if all three have agreed that their goals are satisfied. This system of checks and balances must be carefully maintained to prevent significant accidents. For example, the investigation of the space shuttle Columbia accident found that shuttle program management had gradu- ally acquired power over the supposedly independent safety organization and had program management staff sit in on, then become members of and even chair safety committees that were, by policy, independent of the program organization (CAIB 2003). In summary, the success of the SUBSAFE program arises not just from its structure as a set of requirements, obsessive documentation of objective quality evidence, roles and responsibilities, audit practices, and so forth, but also from its enacted and reenacted experience with its balance of powers, annual renewal ceremony, audit philosophy and teamwork, and engaged leadership (and much more). The story of the SUBSAFE program illustrates change principles from Kotter (2012) and Schein (2010), among others. The program demonstrates the vital roles played by a clear sense of urgency, leadership at the top, engage- ment of key stakeholders in a joint improvement effort, measurable suc- cess that people care about, and the programâs being embedded within both management structures and cultural values and practices. International Oil and Gas Company Example Each of the major oil and gas companies has its own safety culture story to tell. The committee did not choose the example of this opera-
Implementing Change in Offshore Safety Culture 179 tor for its absolute safety record, which may be no better than that of other operators. However, this story is notable for its long duration, the companyâs global reach and willingness to share details (e.g., Hudson 2007), and the many lessons this example provides. Starting in 1986, the company was the sponsor of the research behind Reasonâs (1990) Swiss cheese model of accident propagation and an early adopter of these new safety concepts. The company made progress in safety but saw less improvement after about 1993. In the early 1990s, the company was implementing safety cases and SEMS- style systems in the postâPiper Alpha period and benefited from having strong senior management support for safety initiatives and a psycholo- gist on the core implementation team. By 1996, there was concern within the company that safety perfor- mance had plateaued, and new approaches were needed. In a business improvement workshop, senior management embraced the concept of a workforce intrinsically motivated to be safe; however, the change management team believed that changing the safety culture would be somewhat easier and more acceptable than improving intrinsic motivation, and would have a similar impact on the companyâs safety performance. After convening researchers and industry experts from several companies, the change team focused on the safety culture development ladder shown in Table 6-1 (Westrum 1991, as revised by Hudson 2007). TABLE 6-1 Safety Culture Development Ladder Stage Concept Sample Discourse Pathological Compliance with statutory requirement. May conceal unfavorable information. No one cares about safety as long as we are not caught. Reactive Respond to accidents. Worry about costs and immediate causes of accidents. We do a lot about safety every time we have an accident. Calculative Focus on objective statistics, number of reports, following rules, hazard analyses. We have procedures in place to manage all accidents. Proactive Investigate the causes, look for trends, bench- mark others, audit, try to be the best. We try to anticipate safety problems before they arise. Generative Benchmark inside and outside the industry, full audit system, engage entire workforce and contractors, no compromises. Safety is how we do business around here. Source: Westrum (1991), as revised by Hudson (2007).
180 Strengthening the Safety Culture of the Offshore Oil and Gas Industry The change team conducted interviews in multiple locations to identify aspects of culture that more than 50 percent of respondents could agree represented each step on the ladder. The result was the Hearts and Minds program (a name used by British Army operations in several parts of the world during the mid-20th century), designed to create engagement between workers and managers that would stimu- late and signify managerial commitment (from top managers down to supervisors) in the area of health, safety, and environment. The program included an engagement and assessment tool (the most recent version of which asks about where the organization could realistically be in 24 months and where it is now) and an evolving set of simple Hearts and Minds tools2 (e.g., Managing Rule Breaking, Risk Assessment Matrix, Working Safely, Improving Supervision) with associated train- ing and workshop experiences to support use of the tools. The program also was made available by the U.K. Institute (a professional association) for the entire industry to use. In the mid-2000s, the company had these tools but no shared safety vision or strategy across different business units and locations. After several years of discussion, senior leaders agreed upon Goal Zero, which set the expectation that zero incidents and injuries for employ- ees and contractors was the only acceptable outcome. Goal Zero repre- sented a fundamental shift in mind-set away from viewing the oil and gas industry as inherently dangerous toward leadership recognition of and commitment to good safety performance as essential to good operational performance. Building on the Hearts and Minds program, the company focused on getting employees and contractors to accept behavioral rules, start- ing with simple measures to protect personal safety, such as holding handrails, and then shifting to more complex procedures intended to reduce higher-risk (including process safety) exposures. Safety mea- sures were incorporated in all aspects of the business and benchmarked internally and externally to make performance transparent and moti- vate improvement. In mid-2009, the company implemented its 12 Life-Saving Rules globally. Five of these rules relate to personal safety, 4 to process safety, and 3 to road safety. Based on an analysis of worldwide fatalities in the 2 http://www.eimicrosites.org/heartsandminds. Accessed February 15, 2016.
Implementing Change in Offshore Safety Culture 181 prior 10 years, safety leadership estimated that had these rules been in place earlier, compliance with them might have prevented 80 percent of those fatalities. These rules also have been made available to the oil and gas industry through the International Association of Oil & Gas Producers (IOGP Safety Data Subcommittee 2013). At first glance, these rules appear to place the entire burden of maintaining safety on workers; however, they in fact highlight leadershipâs responsibility to clarify the rules and to establish the conditions that make compliance possible (e.g., having the right equipment available, ensuring that pro- cedures are aligned with rule requirements). Although following these rules became a condition of working for the company and people were terminated for noncompliance, the rules were framed as a means of saving lives and demonstrating care for people: The shared assumption was that if one could not follow the Life-Saving Rules, it would be only a matter of time until one hurt oneself or others. The broad acceptance and institutionalization of Goal Zero and the Life-Saving Rules provided a new momentum for safety and improved performance. In a major project in Qatar, for example, which took nearly 7 years to construct and employed as many as 50,000 workers, the com- pany achieved outstanding safety performance. Historical performance would have predicted 20 to 30 work-related fatalities, yet this project had only one. The change in expectations and behaviors led to tangi- ble results (e.g., global fatalities across all company activities dropped from 26 in 2008 to five in 2014). However, it merits noting that an effective safety management program does not eliminate all accidents. The structured safety culture development ladder (Table 6-1) suggests that an organization would use the lessons learned from a previous experience to reduce the likelihood of a similar situation in the future. Challenges also remain as leaders discuss (a) how to strengthen pro- cess safety (systemic interactions and strength of preventive measures against accidents are more difficult to manage than individual actions) and (b) how to partner more effectively with contractors and work with industry associations (e.g., IOGP) to set common standards. Some valuable lessons emerge from this example. First, the journey is lengthy, bumpy, and uncertain. The potential always exists to back- slide or for parts of the organization to lag behind. New initiatives took hold in this company but reached a plateau over some years, and lead- ers had to maintain their commitment and rekindle momentum with
182 Strengthening the Safety Culture of the Offshore Oil and Gas Industry innovative concepts and initiatives that came partly from outside and partly from within the company. Even now, there is variability across the company and its contractors. Whereas in 2004 the company was in general working to reach the calculative stage in the safety culture development ladder, people in the company believe many of its parts have now attained the proactive stage. The strategic goal is not neces- sarily to get everyone to the highest stage of the ladder but to keep everyone engaged in assessment and improvement, thereby moving up the ladder within a dynamic business, with a continuously changing workforce, and with heightened societal expectations. Second, extensive support from and access to top management were critical to make current performance transparent through continual assessment, to acknowledge when performance was unacceptable, and to reenergize the organization when progress began to flag. When lead- ership is about one step higher on the safety culture ladder than most of the organization, it can provide an effective vision of the future and be a catalyst for change. On the other hand, leadership that is lagging will find it difficult to champion change, while leadership that is too far ahead will have difficulty communicating an understandable message about safety improvement that people believe is achievable and worthy of their commitment. Third, having in-house social science capability was critical in this company for generating and implementing ideas and marshaling global experts for help. Culture change is a people challenge, requiring the ability to engage and motivate people as well as to understand organi- zations and cultures. Fourth, the strategies that move an organization from one step on the safety culture ladder to the next are not the same at each step. Moving from the pathological to the reactive stage requires a decision from the top to take action, which then results in a suite of programs and tools that may or may not be implemented. Moving from reac- tive to calculative involves actually implementing the programs and tools, although they may have varying utility and impact. Making the programs and tools more effective and improving performance brings the organization to the proactive level. Moving beyond programs and tools, the organization can progress toward the generative stage when it embeds and sustains leadership behaviors that demonstrate engage- ment and care for people.
Implementing Change in Offshore Safety Culture 183 CHALLENGES IN CHANGING OFFSHORE SAFETY CULTURE In sum, the safety culture journey requires leadership commitment and engagement; significant time, money, and know-how; appropri- ate policies and training; and means of ensuring that new values and behaviors are actually in place. As was the case with the example com- pany described above, there is more explicit focus on culture at some points in the journey and more explicit focus on structures and rules at other points. In the fragmented, competitive, heterogeneous, and ever-changing offshore oil and gas industry, supported by multiple regulators and industry associations, this journey will not be short or straightforward but will present a number of challenges. These chal- lenges are described below, along with approaches to overcoming or at least addressing them. Challenge 1. Safety Culture Is an Ambiguous Concept That Is Difficult to Measure The safety culture concept has existed for more than 25 years (IAEA 1991; Pidgeon 1991), and despite the varying definitions and measures articulated in Chapters 2 and 5, respectively, the committee converged on the Bureau of Safety and Environmental Enforcementâs (BSEE) definition and nine elements as a reasonable starting point for consen- sus. Even with a high-level working consensus, however, each industry segment and each company has to consider what safety culture means in its context; what behaviors are critical to sustaining such a culture; and how it can implement an effective measurement system, which takes more thought and resources than simply adopting standard tools. In particular, there remains greater emphasis on personal safety, with which the term âsafetyâ is commonly equated, as opposed to process safety. Further, for many in the oil and gas industry, safety culture is equated with having a SEMS. SEMS is essentially a management strat- egy and tool, with accompanying processes such as goal setting, mea- surement, and continuous improvement. As such, it is about roles and responsibilitiesânecessary but not sufficient to ensure a healthy safety culture, which complements SEMS by expanding on why and how to manage safety. Until safety culture is defined in the context of a par- ticular organization, including its employee behaviors and management
184 Strengthening the Safety Culture of the Offshore Oil and Gas Industry practices, the concept cannot be specified and assessed, nor can efforts to improve safety culture be effectively managed. Overcoming the Challenge One goal of this report is to provide clarity and direction to the offshore industry in its safety culture journey, analogous to what the Norwegian Petroleum and Safety Authority did for its industry in 2002â2003 in articulating a sound health, safety, and environment culture (PSA 2003). The preceding chapters have provided historical context for a useful definition of safety culture and its essential elements and exam- ined ways to assess this culture. Many of the companies in the offshore industry are well under way on this journey and can serve as instructive examples to others. The nuclear power and airline industries also pro- vide helpful role models for many other industries and have exhibited a notable willingness to share information, both within their own and with other industries. For example, these industries have successfully created, implemented, and institutionalized near-miss reporting sys- tems, employee concerns programs, safety climate surveys, and other means of ensuring that information flows upward and is acted upon (a critical element of safety culture). Amalberti (2013) asserts that very distinct safety models exist in different industries (see Chapter 2): a resilient model based on individ- ual expertise, a high-reliability organization model based on organized expertise and collective learning, and an ultra-safe model based on pre- vention and supervision. Important for this discussion of improvement strategies, he points out that improvements can be made by a factor of 10 within a particular safety model (e.g., improving as a high-reliability organization), but the models cannot easily be mixed. Switching to another model (e.g., from high-reliability organization to ultrasafe) requires a âchangeover eventâ (sometimes imposed by regulators after a disaster) that affects the entire profession or industry. In that change- over, some of the gains of the new model are offset by the loss of ben- efits of the prior model. For example, the culture of aviation shifted from one of resilient, heroic pilots to the ultrasafe model because of technological advances such as electronic air traffic control, automated aircraft, and systematic flight data recording and analysis, as well as eco- nomic changes in the airline industry. However, some current pilots struggle to fly a plane designed for computer control, and although acci-
Implementing Change in Offshore Safety Culture 185 dents are less frequent, some rare accidents reflect the reduction in pilot resilience that characterized the old safety model. In the offshore industry, each company need not invent its own safety culture policies, practices, and measurement tools, but each has to decide how to translate (and put into practice) the knowledge and tools that come from the experiences of other companies or industry groups into structures and actions that address its own specific needs and goals. The committee believes that the offshore industry can continue to develop safety culture resources and guidance by sharing informa- tion through existing collective institutions, such as trade associations, working groups, the Society of Petroleum Engineers (SPE), and the Center for Offshore Safety (COS). Effective sharing will take leader- ship at the industry level as well as from each organizationâthe topic of the next challenge described below. Challenge 2. Leadership Commitment to Building and Sustaining Safety Culture Varies Among Organizations Senior leaders and owners of organizations in the offshore industry vary in their understanding of, commitment to, and engagement with developing and sustaining a strong safety culture. Although there are pockets of excellence, leadership challenges remain in the areas of set- ting strategy, deploying initiatives, and meeting business goals while modeling safety as a value. Leaders who reward productivity but do not consistently recognize safety performance, or who send intentional or unintentional messages that safety is less important than production, too expensive, or something the organization addresses to comply with regulations but does not really believe in, create an environment in which safety culture (and safety) erodes. Leadership transitions also can derail an organizationâs safety culture if new leaders are not care- fully oriented as to its importance and do not assume full ownership of its enactment, even when a good system is in place. Overcoming the Challenge Leaders can create and communicate a vision that describes safety as a fundamental value of the organization, not just a transient priority. Pri- orities change, but values endure and become embedded in the organiza- tionâs culture. For leaders to be committed to maintaining a strong safety
186 Strengthening the Safety Culture of the Offshore Oil and Gas Industry culture, they must first believe that the tangible and intangible benefits of doing so far outweigh the costs, as the two case examples described above illustrate. Then, they must provide support and convince others to commit themselves as well. A number of researchers (e.g., Schein 1996) have noted that leaders rarely change the culture of their organization by their comments; instead, a modified culture is the result of collaborative effort on a common problem in which the leader demonstrates his/her values and commitment to safety. People need to envision a compelling future state of safe operations and understand how their own behav- ior relates to achieving that vision if they are to have a clear sense of their contributions to change and why that change is important. People throughout the organization have to enact safety processes and prac- tices with behaviors that often go beyond written requirements. A clear and engaging picture of leadershipâs commitment to sustaining a strong safety culture will spur people to action. They will see a future desirable enough to motivate them to change the present to achieve it. A key attribute of leadership is that leaders go first; employees watch carefully what leaders do and observe whether it matches what the leaders say. Leaders need to be visible role models who live safety as a value, consistently demonstrate the importance of safety-related behaviors, and instill the courage to change. They need to focus not only on get- ting results but also on getting results in the right way and behaving in a manner consonant with a strong safety culture. Workers, supervisors, and managers will not speak up about safety issues or be willing to stop work unless they believe their leader will support them. Senior leaders may believe they are willing to support these actions, but if there is no precedent for such support (or, worse, a history of negative reactions) and employees are afraid even to try, there will be no opportunity to reinforce safe behaviors. Leaders have to be proactive with their mes- sages and actions and ensure that no learning opportunity goes to waste. Effective leaders build an emotional connection to the workforce. Establishing an open-door policy or specifying times for employees to visit personally goes a long way toward establishing trust. The com- monly used term âmanagement by walking aroundâ describes a leader who frequents all parts of an organization, getting to know the people who make it work and seeing firsthand what is working well and where opportunities for improvement lie. When members of an organization see leaders who are âwalking aroundâ and engaging workers by ask-
Implementing Change in Offshore Safety Culture 187 ing them questions (Schein 2013) and offering appropriate assistance, they know these leaders care about what they are doing and how well they are doing it. Leaders also need to communicate about safety so the workforce can connect emotionally to salient events and progress in risk reduction. Such behavior creates an environment in which people see the value leaders place on the safety of people and assets, learn the scope of their authority for dealing with unsafe situations, and are inspired and confident to do the right thing as a matter of practice. Challenge 3. The Industry Is Fragmented and Diverse As discussed in Chapter 1, drilling and production take place under many different organizational arrangements, from huge deepwater rigs with a large onboard staff (e.g., well over 100, including a diverse set of contractors and subcontractors) to small platforms that are unmanned or have just one or two crewmembers. Because of this heterogeneity, as well as competition, it is challenging to set uniform rules, reach industry- level agreements, or even share information. Efforts are under way through COS and BSEE to develop toolkits and guidance documents, but these efforts have not yet engaged the entire offshore industry. For example, not all of the large operators are members of COS, and many independent companies with operations on the Outer Continental Shelf have elected not to join COS. Persuading each entity in a fragmented industry to embrace safety culture is challenging. As with the organizational heterogeneity noted above, the economic costs and benefits and cultural values around safety vary across the range of operations, such as seismic, drilling, produc- tion, construction, and logistics (air and marine). Most larger operators and contractors recognize the benefit of investing in safety in light of the long-term costs to their operations and their corporate reputation of failing to do so. However, smaller operators and small contractors and subcontractors are more varied in their approach to safety. Some have excellent internal communication about safety and a focused and innovative approach to its achievement, while others may maintain a mind-set and practices focused on a minimum level of safety (e.g., less safety training, selection of contractors based on low cost without con- sideration of their safety records). Those who believe they cannot afford the near-term costs of investments in safety may withhold information
188 Strengthening the Safety Culture of the Offshore Oil and Gas Industry regarding unsafe practices and accidents to minimize further costs (in dollars and reputation). Even the most conscientious organizations can be subject to greater pressures to deemphasize safety when projects run late and financial incentives are in jeopardy. Many parts of the industry have a dispersed and multicultural work- force (see Chapter 1), which creates challenges either within a work- place, among contractors, or between contractors and their customers. Some of the cultural issues are intercultural. For example, some skilled craft workers in the Gulf of Mexico are employees from various national cultures whose languages and safety attitudes and practices may differ and may not accord with English and U.S. approaches. Some foreign- flag drilling rigs move around the world with long-term, non-American crews. These rigs have consistent expertise and a coherent rig culture (which may be very safe), but this culture may vary from that of the opera- tor. Even within a single national culture, such as that of the United States, there exist cultural and status differences among professional groups (e.g., engineers versus operators versus managers [Schein 1996]), hierarchical levels, generations of workers, and local sites. Overcoming the Challenge To strengthen and sustain safety culture, a commitment to safety must start at the top. Senior leaders in each company involved in offshore operations and leaders of industry associations (e.g., API, SPE, IOGP, COS) must consistently demonstrate their commitment to safety, align- ing their actions with their words. The industry as a whole, led by the more progressive operators, contractors, and industry associations, needs to be thoughtful about extending safety culture to the hetero- geneous organizations and workers in the offshore industry. There are many ways to encourage the development of a strong safety culture in the offshore oil and gas industry and share ideas, tools, and approaches, and industry leaders need to determine which of these are most effective and appropriate. Options include encouraging the development of safety leaders throughout the industry; supporting safety standards and values; recognizing effective safety practices; and providing tools, training, and expertise that can be tailored to the needs of diverse organizations. In addition, each organization needs to develop supervisory practices and training programs for offshore workers that are effective regardless of the workersâ native language or preexisting attitudes about safety.
Implementing Change in Offshore Safety Culture 189 Given the many industry groups that are stakeholders in the off- shore industry (see Appendix B), a coalition of informed, interested, and respected parties will be needed to influence others to participate. Cul- ture cannot easily be imposed by one organization on another, whether it is large operators telling contractors how to think and act or regulators telling operators; a better strategy is collaborative engagement. Although the regulators have considerable authority and must be part of the change process, they are not well positioned to lead this effort. An inappropriate regulatory approach could result in a compliance mentality and signifi- cant resistance; the industry does not want new regulations, but it does want an improved regulatory process that is more effective for all stake- holders and less adversarial. For example, the National Research Council (NRC) (1997) report on the U.S. Coast Guardâs (USCG) Prevention Through People program praises its âbold departure from the traditional use of regulation to address safety issues . . . [as] extremely valuable, par- ticularly in its balanced approach to risk management and its emphasis on partnership.â Challenge 4. The Industry Safety Culture Is Still Developing The offshore oil and gas industry has some heritage of risk taking from the onshore oil and gas industry, as well as the mining industry, which celebrated individual heroics rather than teamwork, discipline, rules, and protection of people and the environment. The offshore industry has changed significantly in the past decades, as have many other indus- tries, and as reported in Chapter 3, there are signs that the number of incidents is decreasing. It is more common now for anyone to report safety concerns or to stop a job. But both the heritage of risk taking and the rapid growth and influx of new operators and contractors result in a complex mÃ©lange of cultural values and competencies. In this industry as in many others, there is an existing culture of indi- vidual blame for noncompliance with rules. Unfortunately, a blaming culture often works against a reporting culture, so that workers are reluctant to report near misses or small accidents, which can be pre- cursors of larger problems. In addition, problems may be concealed to avoid paperwork; please the boss; receive bonuses; or avoid manage- ment attention, peer annoyance, and regulatory enforcement. Even when incidents are reported, those that receive attention are often those
190 Strengthening the Safety Culture of the Offshore Oil and Gas Industry involving minor personal injuries, transportation incidents, and spills (because they occur most frequently) rather than gaps in process safety that could be precursors of major accidents. As in most industries, the offshore oil and gas industry as a whole lacks systems thinking in which the interrelationships among events and practices are considered. Problems may be seen as one-off and each installation as unique. An operator may share lessons learned internally but be less inclined to share them with another operator. There is a ten- dency to focus on the immediate, proximal causes of an incident (such as human error) rather than systemic causes, including culture. His- torically, fixes have been devised with little understanding of how they would be implemented and validated or what unintended side effects they might have. Like all industries, the offshore industry continues to learn how to teach and encourage systems thinking (e.g., Leveson 2012), including sharing of lessons learned. Overcoming the Challenge Many in the industry recognize the importance of deliberately managing the development and implementation of safety processes organization- wide. Operational excellence and operational discipline are considered key enablers of a strong safety culture. Even before the advent of SEMS, most in the industry had adopted a management system process that promotes goal setting and drives progress toward incident-free opera- tions (including personal and process safety accidents, near misses, and nonconformances). Gaps between current performance and these objec- tives are usually uncovered during safety culture assessment. Plans are developed for closing the gaps, actions are taken, and results are reviewed for validation and learning purposes. Developing and sustaining a strong safety culture requires each member of the workforce to be competent in and accountable for established safety processes. Again, leadership is a critical element of culture change and insti- tutionalization. Unfortunately, the image of the confident, successful, âheroicâ leader can lead to misperceptions regarding the characteristics of a leader that are necessary to effect culture change (Khurana 2002). Leadership is not so special that only the rare charismatic leader can step forward. Rather, the great majority of successful leaders simply have the courage of their convictions and a willingness to work with people toward a common future. Although senior leadership support
Implementing Change in Offshore Safety Culture 191 is essential, positive safety changes also need to involve field supervi- sors and workers in the field who are dedicated to safety improvement and equipped with both the authority and resources to pursue it. This is why the term âsafety cultureâ implies commitment and participation throughout the organization. Competent leaders who are committed to safety can be developed and supported. To this end, organizations need to consider their hir- ing practices and the training and mentoring needed to become a leader of safety culture. Becoming such a leader also is facilitated by a management system that aligns leaders with business outcomes that reflect safety as a priority and that holds them accountable for long- term performance rather than short-term production goals. It is also easier to lead safety culture when safety processes and standards are well designed, effectively implemented, and well suited to the organiza- tion. A complex operation with many possible hazards or an operation in a sensitive environment may require more rigorous processes and standards relative to a less complex operation in another location. It is leadershipâs responsibility to make these distinctions and apply the appropriate safeguards. It is also leadershipâs responsibility to ensure the competence of the entire workforce through the hiring and training processes, the assignment of roles and responsibilities, and continual monitoring. Given the demonstrable progress being made in safety in many parts of the offshore industry, it is desirable to leverage individual suc- cesses to accelerate progress throughout the industry. Industry groups and regulators can help disseminate success stories and lessons learned. Operators can encourage and advise their contractors and contractors can encourage and advise their subcontractors, and vice versa. Bench- marking and peer assist visits can facilitate the exchange of knowledge. The offshore industry can look to the success of the nuclear power industry in creating a strong industry-led organization (INPO) to set standards and facilitate knowledge sharing. Challenge 5. Regulators Have Difficulty Developing Competence in Safety Culture USCG and BSEE are the main agencies with oversight for safety in the offshore industry, although more than 10 other regulators have some
192 Strengthening the Safety Culture of the Offshore Oil and Gas Industry safety-related responsibilities offshore. These two organizations have a good working relationship with each other, which was strengthened in 2012 by a new memorandum of understanding.3 While leaders in both agencies recognize the need to extend their federal role by fostering safety culture in the industry, internal challenges remain with respect to staffing resources. Developing staff in the regulatory agencies who understand and embrace safety culture and have the credibility and competence to support its improvement in the offshore industry nonetheless poses a challenge. Traditional safety oversight consists of inspecting offshore installations to ensure that they comply with a set of construction, equipment, and operational regulations. These federal regulations have been developed over time to address particular safety and environmen- tal hazards. Offshore operators meeting these standards are considered to be in compliance with federal requirements and therefore free to operate. Federal inspectors are trained to check drill rigs and offshore installations for compliance using standard checklists. However, responsible companies and progressive regulators realize that just complying with federal requirements will not ensure safe oper- ations; they recognize the need to go beyond compliance by embracing safety holistically. Using a safety management approach is one impor- tant aid to establishing or strengthening safety culture. BSEE took an important step to support the development of such an approach to safety (which includes meeting equipment regulations) when it issued the SEMS regulations.4 USCG is developing companion safety man- agement system regulations. The SEMS regulations are similar to a voluntary industry standard (API Recommended Practice 75) that has been in place for many years. A challenge for BSEE inspectors is inspecting for compliance with the SEMS regulations. Their prior training in engineering tasks and operational procedures and their experience in identifying equip- ment issues and uncovering deficiencies have not inculcated in them the mind-set or the skill set needed to advocate for safety culture and 3 http://www.bsee.gov/BSEE-Newsroom/BSEE-News-Briefs/2012/BSEEâCoast-Guard-Sign- Memorandum-of-Understanding. Accessed November 2, 2015. 4Â The Workplace Safety Rule became effective on November 15, 2010; The SEMS II Rule became effective on June 4, 2013.
Implementing Change in Offshore Safety Culture 193 help a company implement its safety culture philosophy. Further, the public has its own expectations of safety regulators, which appear to include the levying of heavy sanctions and fines when problems arise and generally forcing industry compliance through more inspections and penalties. Overcoming the Challenge BSEE and USCG leadership needs to focus on recruiting practices and training programs for inspectors in the domain of offshore safety culture. Regulators, including inspectors, need new skills and knowl- edge to be helpful to those they regulate and be trusted and respected by the industry and the wider public. To be effective, inspectors need to be selected with this role in mind and trained to have competence in developing, implementing, and maintaining safety systems and culture, not just in the appropriate operation of equipment. To be of assistance to the offshore oil and gas industry, the regula- tory approach needs to shift from focusing on compliance and policing to serving as a safety resource that works with industry to help improve safety from a systems perspective. The regulators then will be able to audit programs and assess practices and priorities, not simply inspect for compliance. At the same time, the regulators will need to have at their disposal a wide range of sanctions and rewards, including stiff penalties for those that need correction and reduced oversight and risk- based inspections for those that perform well. The regulators also can encourage and help the industry organize itself to develop training programs, tools, peer-to-peer sharing and learn- ing practices, standards, and other means of facilitating safety culture. The Nordic model of regulation is a tripartite collaboration among companies, unions, and government. Although the U.S. regulatory approach and legal context are very different, this model offers impor- tant lessons about working together for improvement. In the nuclear power industry, INPO has played a critical role in promoting safety by accrediting training programs, developing standards, working to reduce insurance costs for members in compliance, facilitating peer assist visits and personnel exchanges, and pressuring operators that are fall- ing behind (Rees 1994). As regulators shift their role from inspector to safety resource for the industry, the public will need to be informed of the change and educated as to its benefits.
194 Strengthening the Safety Culture of the Offshore Oil and Gas Industry CONCLUSIONS AND RECOMMENDATIONS Successful culture change is a long-term effort that entails considerable uncertainty and necessary investments and requires sustained commit- ment from senior leadership. Behaviors and relationships will be disrupted, and the organization needs to be supported through the lengthy change process. However, there are many examples of successful culture change in such industries as nuclear power, aviation, the chemical industry, and the military, as well as in the offshore oil and gas industry. Company senior leadership needs to commit to and be personally engaged in a long and uncertain safety culture journey. Even if they find or hire a champion, they still need to be visibly engaged. Convinc- ing senior leadership to embrace safety culture may involve leveraging industry resources, receiving regulatory encouragement, visiting work- places personally to view safety problems and useful improvements, benchmarking with other companies, and engaging external help. Recommendation 6.1: Company senior leadership should com- mit to and be personally engaged in a long and uncertain safety cul- ture journey. Senior leaders should ensure that their organizations take advantage of resources available from other companies, industry groups, and regulators in strengthening their own safety cultures. Smaller companies can reach out to their larger customers or indus- try groups to obtain information on establishing or strengthening safety culture and to learn of success stories from those who have created a safe working environment. Safety improvements do not have to cost enormous amounts of money, and they may return substantial benefits in quality, reliability, reputation, hiring and retention, reduced regulatory attention, and performance. Because the industry is fragmented, it is necessary to work with a coalition of key stakeholders. Compliance by itself is insufficient; pro- active collective action is needed from a coalition of willing parties. This is especially likely to be the case in the offshore oil and gas indus- try given the sheer number of groups charged with its operation and the regulatorsâ limited ability to impose changes. Referring to the safety culture development ladder (Table 6-1), those from reactive
Implementing Change in Offshore Safety Culture 195 and pathological cultures will not appreciate the need for change until they see others change successfully and feel pressure and encouragement to move forward. Recommendation 6.2.1: Industry leaders should encourage col- lective and collaborative action to effect change in an industry as fragmented as the offshore oil and gas industry. A starting point is to engage personally and encourage key employees to participate in industry organizations, conferences, benchmarking opportunities, standards-setting groups, pilot projects, and exchanges of informa- tion and lessons learned. Recommendation 6.2.2: Leadership from BSEE, USCG, API, the International Association of Drilling Contractors (IADC), the Pipe- line and Hazardous Materials Safety Administration (PHMSA), SPE, IOGP, COS, and others should continue to be involved early in this process. It would help to have a focal organization that is suf- ficiently independent and can engage the entire industry. There is an opportunity for BSEE and other regulators to provide encourage- ment and leadership, but demands from a regulator are likely to be met with resistance from the industry. Regulators can help convene senior industry leaders and experts to craft a vision, provide feed- back and encouragement, reinforce well-intentioned actions, and coach from the sidelines. Recommendation 6.2.3: The industry as a whole should lever- age the knowledge and experiences of those organizations that are already moving ahead with safety culture and trying new approaches. In a heterogeneous industry, it is not necessary for every organiza- tion to move at the same pace. By increasing awareness and inter- est among the industry as a whole and sharing lessons learned from early adopters and benchmarking cases, each organization can access learning opportunities and build momentum. Although the industry is composed of a wide variety of organizations of varying sizes and capabilities, and the work is carried out by combi- nations of operators and contractors, there are opportunities to find agreement and take steps to improve safety culture industry-wide.
196 Strengthening the Safety Culture of the Offshore Oil and Gas Industry Recommendation 6.3.1: The industry as a whole should create additional guidance for establishing safety culture expectations and responsibilities among operators, contractors, and subcontractors. Regulators should assist in these efforts and ensure consistency. Recommendation 6.3.2: The industry should work with regula- tors to consider changes in policy (and laws when necessary, such as modifying any that inhibit information flow between operators and contractors) that would help accelerate improvements in safety cul- ture, including information exchanges, cooperation across operators and contractors, and protection of all personnel from retaliation if they speak up. As elaborated in Chapter 5, the safety culture assessment process var- ies considerably from organization to organization. At the industry level and in individual companies, the safety culture assessment and improvement process is still evolving, while benefiting from examples in various industries. Safety culture assessments help identify oppor- tunities for improvement, but also guide and evaluate improvement efforts and provide lessons learned for the development of better safety culture assessment and change tools and practices. Although a great deal is known about culture change, a great deal more remains to be learned. Offshore safety culture in particular war- rants additional research. Recommendation 6.4: Regulatory agencies, industry organi- zations, operators, and other participants in the offshore industry should work together to facilitate research and information sharing. High-priority research topics include the following: â¢ Develop industry-level data that can be shared and compared across organizations and over time, including data not only on safety outcomes but also on near misses and organizational pre- cursors such as safety culture assessments. â¢ Analyze positive cases. What works to generate awareness and interest? How have others encouraged experiments and trials? What arguments for enhanced safety are most compelling to decision makers? What strategies enhance safety culture, and
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