Hogeschool van Amsterdam

Kenniscentrum Techniek

Prerequisites for safety culture development

Project

“Prerequisites for Safety Culture Development” is a project that the Aviation Academy of the Amsterdam University of Applied Sciences executed following a request from a European Nuclear Power Plant (NPP). It was a 3-months project lasting from May to July 2015.

Nuclear Power Plant

The objectives of the project were to:

  1. Identify the prerequisites for safety culture development, as these are referred in the literature;
  2. Assess the extent these prerequisites are present in the NPP and various industry sectors’ documentation (i.e., guidance and policy);
  3. Provide an indication of the position of NPP compared to the safety culture development guidelines of the industry sectors under consideration;
  4. Evaluate the potential gaps amongst the planning, operation and monitoring of safety culture development activities at the NPP.

 

We started with Reason’s suggestion about the five subcultures, which constitute safety culture: Just, Reporting, Flexible, Informative and Learning Cultures. Afterwards, we identified in the literature (Table 1) the preconditions, which are common across all these elements, and the descriptors of Reason’s subcultures. In addition, we linked Reason’s subcultures with concepts of resilience engineering (i.e. anticipation, monitoring, response, learning), as shown in Table 2. These subculture types, common elements and descriptors comprised the benchmarking reference.

Reason’s subcultures Definition Further literature
1. Just culture A culture in which types of acceptable and unacceptable behaviour are communicated and understood.
  1. Dekker (2012).
2. Flexible culture A culture that accepts variability whenever procedures do not suffice to deal with conflicting goals, and which enables reconfiguration of the organisational structure in the face of a dynamic environment.
  1. Fernández-Muñiz, Montes-Peón, and Vázquez-Ordás (2007);
  2. Hollnagel, Woods, & Leveson (2007);
  3. Hollnagel (2014);
  4. Saurin, Righi, & Henrigson (2013).
3. Reporting culture A culture where staff, both in the sharp-end and blunt-end, are prepared to voluntarily report their own hazards, errors, violations, and deviations.
  1. Benn, Koutantji, Wallace, Spurgeon, Healey, & Vincent (2009);
  2. Dekker (2012);
  3. Hollnagel (2014);
  4. Parker, Lawrie, & Hudson (2006);
  5. Wiegmann, Zhang, von Thaden, Sharma, & Mitchell (2002).
4. Informative culture A culture that enables information sharing across the organisation. Such information is derived from the safety information system. The system must collect, analyse and disseminate event data (e.g., incidents, accidents, near misses) and data obtained from proactive checks.
  1. Benn, Koutantji, Wallace, Spurgeon, Healey, & Vincent (2009);
  2. Casey, A. (2005);
  3. Fernández-Muñiz, Montes-Peón, & Vázquez-Ordás (2007);
  4. Gordon & Kirwan (2004)
5. Learning culture A culture that draws valuable conclusions from its safety information system, and drives changes in the organisation based on the lessons learned.
  1. Casey, A. (2005)
  2. Fernández-Muñiz, Montes-Peón, and Vázquez-Ordás (2007);
  3. Gordon & Kirwan (2004);
  4. Hollnagel (2014);
  5. Parker, Lawrie, & Hudson (2006).

  Table 1. Reason’s safety subcultures, and reference list for their operationalisation.

High-level safety culture prerequisites Resilience abilities
Common organisational prerequisites Anticipate, monitor, response, learn
Just culture Anticipate, monitor, response, learn
Flexible culture Response
Reporting culture Monitor
Informative culture Learn
Learning culture Learn

Table 2. Connecting safety culture prerequisites and resilience abilities.

Gap Analysis

The framework was used to analyse the safety culture guidance identified in the NPP planning documents and seven industry sectors: nuclear, aviation, healthcare, maritime, oil & gas, railway and defence (Table 3). The research team consulted the documentation published by international bodies and organisations per industry sector. Whereby such documents or bodies were not identified, it was decided to consider the ones available for the European region, and in case of inadequate resources in Europe, the North American region references were utilized. If more than one document about safety culture was available per industry sector, it was decided to assess the one(s) most recently published. Also, in most of the cases, there was more than one document linked to safety culture development and including references to each other; therefore, the researchers analysed the whole set of such published guidance per sector.

Industry sector Documents
Nuclear
  1. IAEA (2002a)
  2. IAEA (2002b)
Aviation
  1. ICAO (2013)
  2. CANSO (2008)
Healthcare
  1. WHO (2005)
  2. WHO (2009)
  3. EU (2009)
Maritime
  1. IMO (1999)
  2. IMO (2014)
  3. ISF (date unknown)
Oil and gas
  1. OGP (2013).
Railway
  1. EU (2004)
  2. ERA (2013)
Defence
  1. US Air Force (2011)
  2. NATO (2014)

Table 3. Industry sectors documentation.

Statistical calculations

In order to assess the degree of agreement amongst the NPP and the seven industry sectors, the researchers used two agreement measures: Fleiss Kappa and pairwise agreement. These measures were additional to the simple frequency calculations of the elements present in the documentation per industry and the NPP in total and per safety subculture / general prerequisites.

Interviews with the NPP’s staff

In addition to defining the set of prerequisites for developing safety culture and the results of the benchmarking, it was of high interest to explore the extent to which NPP’s policy and procedures (work-as-designed) are operated (work-as-done), and if any additional methods, tools, approaches, etc. are employed by managers. Under this scope, nine (9) interviews were conducted; this enabled the project team to obtain a more substantial picture of how the NPP develops its culture, and allowed to make more targeted recommendations.

Alignment analyses of the NPP’s safety culture planning, operation, and monitoring

Based on the systems engineering paradigm and the fundamental PDCA quality cycle, the planning, operation, and monitoring activities of safety culture at the NPP should be ideally aligned to each other (Karanikas, 2014). This means that what is planned should be operated, and subsequently monitored in order to achieve continuous interaction and improvement. Under this rationale, the researchers:

  • Assessed the extent to which the feedback mechanisms, which the NPP has in place to monitor progress and effects of its planned safety culture initiatives, are aligned with the actual planning. In order to evaluate such a distance, the project team cross-referenced the NPP’s planning and monitoring  documentation;
  • Compared the interview results with the NPP’s safety culture planning as means to evaluate the extent to which managers implement what is planned;
  • Consulted the NPP’s safety culture meta-analysis document in order to identify any differences between the findings mentioned in this document and the data collected during the interviews.

The research project showed that it was possible and relevant to compare the status in different industry sectors and the NPP, regarding the prerequisites for developing a safety culture.

Industry sectors

In terms of descriptors’ frequencies, the aviation domain scored highest and the maritime domain accumulated the lowest score. The nuclear industry scored higher than the industry average, and is listed fourth out of the seven industry sectors considered in the project.

The analysis per safety subculture and the general prerequisites showed that:

  • Learning culture scored highest across all measures compared to other elements.
  • Just culture is the most underrepresented element in average; there were no relevant references identified in the healthcare, defence and maritime domains.
  • In average, industry sectors provide more guidance about the common organizational prerequisites and the informative and learning cultures than the just, flexible and reporting cultures.
  • Even in the cases of high agreement in terms of frequencies and pairwise comparisons, the moderate Fleiss kappa values showed that such an agreement does not regard the same descriptors across the industry sectors and safety culture elements. Hence, the seven domains have approached safety culture in a diverse way.


Nuclear power plant under research
 

  • Regarding the benchmarking:
    • NPP’s safety culture planning scored lower than the industry average and the nuclear industry when all safety descriptors were considered (i.e. general prerequisites and just, flexible, reporting, informative and learning cultures).
    • NPP has adequately planned for the common organizational prerequisites and the informative and learning subcultures.
    • NPP’s policy is insufficient and weak regarding the just, flexible and reporting subcultures.
  • Safety is valued and comprises an area of continuous concern. However, the perspectives amongst managers regarding safety culture activities are highly diverse.
  • Managers recognise the importance of effective communication as means to minimize the distance amongst the different organizational levels. However, management’s commitment to safety is not quite visible to the work floor.
  • The NPP supports merely a compliance driven professional attitude, without recognising the existence and importance of flexibility and the need to decentralise risk management under defined and agreed boundaries and thresholds.
  • The unacceptance of flexibility and variability hinders the ability to monitor and control them before they unfold to adverse events.

The research team recommended that the NPP must:

  • Communicate, share and explain existing safety culture policy to all staff, starting from senior management and proceeding gradually to all organizational levels in the form of workshops.
  • Consolidate its safety culture related policies in one single document.
  • Based on the framework developed for the scope of the project, maintain and refine the safety culture elements and descriptors which are already planned.
  • Monitor the existing elements in predetermined intervals.
  • Ensure continuous interaction amongst the basic organizational functions of planning, operating and monitoring as means to establish a substantial and impactful improvement program in regard to safety culture and, in general, all organizational interventions.
  • Gradually adopt the guidelines published by the nuclear authorities starting with an update of the NPP policy, and afterwards, communicating such a policy, obtaining acceptance by all levels and amending the monitoring instrument.
  • Introduce smoothly the rest of the safety culture descriptors included in the framework but not yet adopted by the nuclear industry sector.

Benn, J., Koutantji, M., Wallace, L., Spurgeon, P., Rejman, M., Healey, A., & Vincent, C. (2009). Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care, 18(1), 11-21.

CANSO (2008) Safety Culture Definition and Enhancement Process, Civil Air Navigation Services Organisation, Amsterdam.

Casey, A. (2005). Enhancing Individual and Organizational Learning A Sociological Model. Management Learning, 36(2), 131-147.

Dekker, S. (2012). Just culture: Balancing safety and accountability. Ashgate Publishing, Ltd.

ERA (2013). Application guide for the design and implementation of a Railway Safety Management System: Developing and Improving Safety Culture In The Organisation, European Railway Agency, Valenciennes.

EU (2004). Directive 2004/49/EC on safety on the Community's railways, European Parliament and the Council.

EU (2009). Council Recommendation on Patient safety, Including the Prevention and Control of Healthcare Associated Infections (2009/C 151/01).

Fernández-Muñiz, B., Montes-Peón, J. M., & Vázquez-Ordás, C. J. (2007). Safety culture: Analysis of the causal relationships between its key dimensions. Journal of safety research, 38(6), 627-641.

Gordon, R., & Kirwan, B. (2004). Developing a safety culture in a research and development environment: Air traffic management domain. In Europe chapter of the Human Factor and Ergonomic Society conference. Delft: The Netherland.

Hollnagel, E. (2014). Safety-I and Safety–II: The Past and Future of Safety Management. Ashgate Publishing, Ltd

Hollnagel, E., Woods, D. D., & Leveson, N. (Eds.). (2007). Resilience engineering: Concepts and precepts. Ashgate Publishing, Ltd.

IAEA (2002a), Safety Culture in Nuclear Installations: Guidance for Use in The Enhancement of Safety Culture, IAEA-TECDOC-1329, International Atomic Energy Agency, Vienna.

IAEA (2002b), Key Practical Issues in Strengthening Safety Culture INSAG-15, International Atomic Energy Agency, Vienna.

ICAO (2013), Safety Management Manual, International Civil Aviation Organization, Canada.

IMO (1999). Principles of Safe Manning, Resolution A.890(21), International Maritime Organisation, London.

IMO (2014). ISM Code and Guidelines on Implementation of the ISM code, International Maritime Organisation, London.

ISF (date unknown). Safety Culture Leaflet, International Shipping Federation, London.

Karanikas, N. (2014), An Organizational Structure based on Risk and Quality Fundamentals, MERC’s Global International Journal of Management, 2(1), pp. 1-19.

Nemeth, C. P. & Hollnagel, E. (2014). Resilience Engineering in Practice, Volume 2: Becoming Resilient, UK: Ashgate.

NATO (2014). Standard for Air Traffic Management Safety Management System, Edition A Version 1, North Atlantic Treaty Organization.

OGP (2013). Shaping safety culture through safety leadership OGP Report No. 452, International Association of Oil and Gas Producers, London.

Parker, D., Lawrie, M., & Hudson, P. (2006). A framework for understanding the development of organisational safety culture. Safety Science, 44(6), 551-562

Patankar, M. S. (2012). Safety culture: building and sustaining a cultural change in aviation and healthcare. Ashgate Publishing, Ltd.

Reason, J. (1998). Achieving a safe culture: theory and practice. Work & Stress, 12(3), 293-306.

Saurin, T. A., Righi, A., & Henriqson, E. (2013). Characteristics of complex socio-technical systems and guidelines for their management: the role of resilience. In 5th Resilience Engineering Association Symposium.

Sellers, R. (2015). The Influence, Measurement, and Development of Organizational Safety Culture. Journal of the International Society of Air Safety Investigators. p. 16-19.

US Air Force (2011). The US Air Force Mishap Prevention Program, Instruction 91-202, Virginia.

WHO (2005). Draft Guidelines for Adverse Event Reporting and Learning Systems, World Health Organization, Geneva.

WHO (2009). Guidelines for Safe Surgery, World Health Organization, Geneva.

Wiegmann, Zhang, von Thaden, Sharma, & Mitchell (2002). A synthesis of safety culture and safety climate research. Technical Report ARL-02-3/FAA-02-2. University of Illinois, Aviation Research Lab.

  • Dr. Nektarios Karanikas, Aviation Academy
  • Pedram Soltani, Aviation Academy
  • Dr. Robert Jan de Boer, Aviation Academy
  • Dr. Alfred Roelen, Aviation Academy
  • Dr. Sidney Dekker, Griffith University

Dr. Nektarios Karanikas, n.karanikas@hva.nl

Gepubliceerd door  Kenniscentrum Techniek 3 september 2015