Safety Culture in High Hazard Environments
Part II: Nuclear Safety Culture with Comment from Edgar Schein
Not everyone feels the term “safety culture” or “nuclear safety culture” helps in the goal to avoid failure. They point out that a well-led and managed organization seems not only profitable but safe as well. Why add language that is often confusing? It is possible that the biggest benefit of introducing a discussion on defining nuclear safety culture is the discussion itself. The radical idea that the nature of the conversations taking place in an organization drives outcomes is out there and it is fueled by the research on quantum physics and complex responsive processes. Enter Sydney Dekker and Eric Hollnager with their emphasis on resilience engineering and adaptive safety.
With all this said, let us not forget why the term “safety culture” was and has been so widely adopted: the shortcomings of the engineering and behavioral reinforcement approaches to accident prevention. Root cause investigations continually led to human error. Of course now with systems and complexity thinking we’ve moved beyond blaming individuals (at least at the intellectual level), however the human performance issues remain very real. In short we turned to culture to help us understand more about managing the influences on human behavior.
In a famous quote attributed to John Beck a well regarded consultant at Millstone he said to managers after the turn around, “… trust in management can be ephemeral…Never forget that previous management failed so miserably, not because they were not intelligent, and not because they did not clearly understand what successful economics looked like in a competitive environment. They failed because they were arrogant, dismissive and refused to listen to the issues and concerns of the people who make this place run.”[1]
So, while we acknowledge that the technical and hardware aspects are a critical aspect of safety, our investigations also find that the way people make decisions, communicate, and relate to each other come up far more often as perceived obstacles in almost any survey where performance problems exist. The following table is a list of typical negative comments brought up in nuclear safety assessments. The right column attempts to look at some of the implications from a complexity framework.
| Comment | Challenge/ Complexity Framework |
| “We expend a lot of time and effort addressing comments on why we don’t follow our processes and procedures, and then revise them to make them more complex.” | We believe that if we fix the procedure, we can fix the problem. Maybe we are addressing the wrong problems in the wrong way. The following comments build on this thought. |
| “Upper management should spend time in the field talking to employees and seeing the work.””A guy who walks around the plants and talks to people, asks questions, and generally comes to us, rather than dragging us out to his amphitheater in the processing center 4 times a year would be a welcome change.””Managers, superintendents, supervisors in general don’t have established relationships with their workers. Need to spend less time managing us and more time with employees.””Is it possible for management to just walk around and talk to people every once in a while?””I am a manager and have yet to see xxx [Chief Nuclear Officer] within the xxx control room area – that in itself is amazing to me.” | Managers feel they don’t have time to be in the field, talking to people and establishing relationships. They feel many pressing priorities I have to attend to.There is also a lack of understanding of effective communication. It isn’t about achieving clarity and moving on. It is about a continuous dialogue to deal with a constantly changing environment. |
| ‘In issues other than nuclear safety voicing a dissenting opinion gets you labeled as a non-team player or worse “just a cry baby.”“Through every reorganization, I have usually seen a number of “quality” people leave this company, mainly (or so it seems) because they would speak their minds and not tell management only what they want to hear. Usually what is left are people who “kiss up” and cronies of the current regime.””My first line supervisor reacts in a negative way when concerns are introduced.””The first line supervision will not take any feedback from our group. They will listen, but it goes in one ear then out the other.” | It takes more than training and an employee concerns program to achieve trust and open communication.This goes back to believing that spending time in conversation and dialogue is the main tool to influence behavior. |
| “Safety Council meeting and e-mail information doesn’t appear to be making any improvements. Need to get employee actively involved in safety meetings rather than just throwing data at them.” “Communications between departments is poor. Too much finger pointing. We need to become a team and tear down our silos. All departments need to realize we sink or swim together.” | There is a natural barrier that arises between departments, professions, and roles. They cannot be broke down with emails, one-way communication or sporadic meetings. Continuous communication is the only way to maintain a common understanding of priorities. |
Edgar Schein commented on a paper I published in 2011, Complexity and Safety[2] that included practical tools to address these human performance issues. He also proposes an alternative view for management. These are excerpts from the publication.
“Carrillo’s paper is an important addition to this difficult dialogue in highlighting that we may be using the wrong models of how to think about safety in the first place. Her emphasis on complexity theory, sense making and polarity theory focus us on the two most fundamental problems of safety- 1) We will never be able to predict all the things that can go wrong, that nature will throw at us, that human beings will, in their efforts to do things better, actually make things more complex and, therefore, maybe worse; 2) We will never be able to avoid the polarity between absolute safety (at any cost) and competing economic and psychological values…
We should have learned by now that better design or more detailed procedures is only a partial answer. In fact, the more we try to design fail-safe systems and the more we write procedures for how to do things, the greater the complexity and the potential of surprises of all sorts that we hope the operators in our plants have the ingenuity to deal with. Without their ability to make sense out of surprises and innovate to get the job done we would be much worse off. If we take complexity and polarity theory seriously it will point the way out of these dilemmas—we have to keep learning. We have to learn to think in terms of new models and develop some new skills.
…From working in the safety industry, I learned from employees that the biggest obstacle to improving safety performance is failed communication and lack of trust. Employees feel management doesn’t listen. Management feels employees don’t understand the bigger picture and suffer from entitlement. We can only fix that problem by creating a climate where employees feel they can tell their boss the truth. Bosses need to communicate that they really need employees’ help. Managers need to know what is going on. However, employees won’t speak up unless they trust management. The trust is developed as they see management respond to the information. Better information leads to better decisions. In my experience this happens when managers are able to ask for help and employees feel their help is needed and valued.
How we can construct the relationships and communication structures that create successful and safe organizations? How do you develop trust? What if I want to trust more and I don’t know how? What if I trusted someone and they betrayed me? Helping is the basis of trust. Trust is the basis of communication. Communication is the basis of organizational effectiveness. We have to pay more attention to mutual helping to create both safety and effectiveness. I have reached the conclusion that helping skills at all levels of an organization will be the necessary ingredient to a more effective and safe nuclear industry. (Schein, E. H. Helping: How to offer, give and receive help,
Berrett/Kohler, 2009).”
Next, in Part III we will look at alternative approaches.
