A Ladder and A Bowtie are Better than a Bandage

During the past year, I have been invited to speak about the impact of the work environment on safety, productivity, and employee engagement at several Process Safety and STO conferences. What has become apparent is that there seems to be a common thread in discussions at these events leaving the question: Why do many well-meaning efforts to create corporate safety cultures often fall short resulting in unexpected injuries or deaths?

In Houston on March 10th, I will address a room full of safety professionals at the 2016 Process Safety in Oil and Gas Conference produced by the Energy Conference Network. Incidentally, Texas is the nation’s leading producer of oil and gas, refined products, and chemicals with many of the refineries and chemical plants situated east of downtown Houston along the Ship Channel. At this conference, I fully expect to hear this same discussion about serious efforts to create a genuine safety culture again failing to produce the desired results.

"Genuine change for an industry plagued with catastrophic incidents comes in the desire of business leaders to chart a new, safer, more sustainable path to profitability."

Fiery images in the media reveal the consequences of failing in the pursuit of a genuine safety culture. In 2005, a BP refinery in Texas City located south of Houston exploded. Fifteen workers were killed and 180 others injured. Michael Econiomides, Editor In Chief of the Energy Tribune laments, “Unfortunately, the Texas City disaster, bad as it was, probably is not going to be the last one because all the conditions are there for it to happen again.” And it did. In 2013, the Williams facility in Geismar, Louisiana, went up in flames as did the Danlin Chemical Plant in Thomas, Oklahoma. In February of 2015, Houston Chronicle headlines proclaimed, “Safety Flaws Led to Deadly DuPont Leak” resulting in the death of four workers. “What we are seeing in this incident in LaPorte (Texas) is definitely a problem of safety culture in the corporation of DuPont,” said Rafeal Moure-Eraso, Chairman of the U.S. Chemical Safety Board.

And on January 16th of this year, as reported in the Houston Chronicle, “1 dead, 3 injured in Pasadena chemical plant explosion” at the PeroxyChem facility on the southeast side of Houston. But it is not just corporate leaders at DuPont, PeroxyChem, Williams or Danlin who leave employees and members of surrounding communities vulnerable to such tragedies. Numerous companies in various industries throughout the world operate within this belt of uncertainty where their publicly-stated “aspirational” safety culture is a far stretch from the functional culture that actually represents how work is performed.  Given the right circumstances, this disconnect can turn deadly.

Genuine change for an industry plagued with catastrophic incidents comes in the desire of business leaders to chart a new, safer, more sustainable path to profitability. Senior Process Safety Engineer and Consultant Fred Infortunio of ENI, a major integrated energy company, knows that profitability is only sustainable in a genuine safety culture which “requires a secure, competent, assertive, and Independent Safety Technical Authority who can override operations and finance concerns.” Very few safety professionals I have encountered at safety conferences confirm having such a position on their organizational chart.

The path to a genuine safety culture begins with an honest assessment of the current state of the organizational culture. Not the “aspirational” culture that often adorns corporate websites and printed materials but the functional culture that reflects how work is actually performed in the existing workplace environment. The reality faced by many companies is that the functional culture is often negatively influenced by resource and manpower limitations as well as economic and schedule pressures which create undue stress on workers to get the work done no matter what it takes!

“The Safety Culture Ladder provides the means for business leaders and safety professionals to assess the current status of their culture in terms of safety.”

Patrick Hudson, Professor of the Human Factor in Safety at Delft University of Technology, The Hague, Netherlands, suggests that regulators need to shift more attention toward culture as well. “What regulators need to audit is the culture, not the detailed activities that are performed.”

The Safety Culture Ladder serves as an excellent tool for organizational assessment and ranking in one of five successive categories: Pathological, Reactive, Calculative, Proactive, and Generative. The Culture Safety Ladder was developed by Ron Westrum, emeritus professor of Sociology at Eastern Michigan University, in the early 1990s and expanded upon by James Reason, Professor of Psychology at the University of Manchester, UK, in 2005. Professor Hudson along with Professor Dianne Parker, Director of Safety Culture Associates Ltd. and Dr. Matthew Lawrie, Director of Culture Regeneration Associates, Ltd., both of Manchester University, UK, further developed the model later in that decade as part of the Hearts and Minds program at Royal Dutch Shell. The Safety Culture Ladder provides the means for business leaders and safety professionals to assess the current status of their culture. It also offers the foundation to set targets for elevating the overall safety of operations.

Moving up the Safety Culture Ladder means “increasing trust and accountability” throughout the organization along with developing an “increasingly informed” workforce. Dwight Mihalicz, a respected global management consultant with Effective Managers? based in Ontario, Canada, points out the root cause of several key organizational issues is “the absence of a formal accountability and authority framework.” He adds that “when an organization works to improve the accountability of its managers, employees become more engaged in their work.” According to Gallup writer and editor Susan Sorenson, research performed by Gallup in 2012 “confirmed the well-established connection between employee engagement and nine performance outcomes” including safety incidents.

Incremental steps up the safety ladder from the Pathological level lead to increased awareness and employee participation in contributing the safety of all operations.

Pathological, the lowest rung on the Safety Culture Ladder is characterized as “who cares about safety as long as we are not caught?”  This attitude reflects distain for complying with the intent of regulatory mandates in favor of doing the bare minimum only when no way exists to circumvent them.

Companies at the Reactive level proclaim “safety is important; we do a lot every time we have an accident.” However, incident investigations often leave responsibility with the employees involved, ignoring the impact of management behaviors and dysfunctional systemic structures on the work environment and performance. Therefore, the steps genuinely required to implement improvements are not taken.

Noted safety expert Fred A. Manuele, President of Hazards, Ltd., based in Chicago, suggests that “the system is the problem, not the worker.” Professor Reason echoes this sentiment in saying that workers “tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance, and bad management decisions.” As regulatory mandates often represent a baseline requirement in terms of safe operations, an organization with a Reactive culture is unlikely to implement many processes that exceed regulatory mandates. This means that the organization may elevate the issue after an accident but the will to implement changes as well as an organized, meaningful approach to prevention is often absent.

Climbing up another rung to the Calculative level reveals the perspective that “we have systems in place to manage all hazards.” Here safety professionals spend lots of time performing audits and chasing statistics, usually lagging indicators. While many organizations have a safety management system, Professor Hudson indicates that “the possession of a management system, no matter how thorough and systematic it may be, is not, however, sufficient to guarantee sustained performance. What is also needed is an organisational culture that supports the management system.”

At the Proactive level, “we try to anticipate safety problems before they arise.” Even so, companies at this level are still lacking the key element of a genuine safety culture present at the Generative level.

The ultimate target is the Generative level which represents a genuine safety culture where “HSE is how we do business around here.” On the top rung of the ladder, effective management systems are in place and behaviors at all levels throughout the organization are aligned with safety. Stress is managed and risks are properly assessed and factored into all operations. The work environment and processes are designed with safety in mind. In a Generative culture, it is well understood that zero incidents is not the goal, safe operations is.

As reflected in an explanation of the Royal Dutch Shell Hearts and Minds program penned by Professor Hudson with Rob Holstvoogd of Shell Global Solutions and Gerard van der Graaf, Robin Bryden, and Volkert Zijlker of Shell Exploration and Production, “In a mature HSE culture all the elements are executed with enthusiasm and in the belief that this is really what is required to do a better job, make a better company and a better life for everybody involved.”

Once the Safety Culture Ladder is fully understood and accepted by corporate leadership, a strategy for moving up the ladder can be designed and implemented. It is worth noting that organizations climb the ladder one rung at a time through implementation of sustainable improvements to their systems, processes, and behaviors.

A tool that has proven useful in helping sustain a Generative safety culture is the Bowtie Chart. “Royal Dutch/Shell Group was the first major company to integrate fully the total bow-tie methodology into its business practices,” reports Steve Lewis and Kris Smith of Risktec Solutions Limited, based in Warrington, UK. “The benefits of using bow-tie diagrams for risk management have been realized by organizations world-wide across a variety of business sectors.”

CGE Risk, based in The Netherlands, offers a comprehensive application called BowTieXP which is dedicated to the bowtie risk management approach. BowtieXP offers selection options based on expert knowledge, a variety of ways to parse and view data, and the means for users to fine tune the system to meet their needs. Other companies like Houston-based Mangan Software Solutions also offer a bowtie module as part of an enterprise safety management software application.

“The magic of the Bowtie Chart becomes immediately obvious in the simple logic of the approach taken to risk management.”

While the Bowtie Chart is not a cure-all approach to risk management, it does cover most situations and allows for the visual representation of the relationship between threats, top or adverse events, consequences, and the barriers an organization needs to have in place to reduce the risks inherent in most business operations. Additionally, most popular incident analysis techniques such as the well-respected Apollo Root Cause Analysis Methodology? work well in tandem with the Bowtie Chart to identify and narrow gaps in coverage making risk management a dynamic ongoing process that responds to changing circumstances and threats to the operation.

The magic of the Bowtie Chart as a risk management tool becomes immediately obvious in the simple logic of the approach taken to risk management. Implementation of the Bowtie Chart approach, however, can be as complex as the organization’s operational structure and requires a high level of expertise to ensure comprehensive identification of hazards, threats, and consequences as well as an accurate determination that a comprehensive array of layers or barriers have been implemented and that the barriers present real protection.

A hazard exists because of some hazardous element present in the business operation. For instance, a refinery handles hazardous chemicals. Due to the presence of this hazard, the potential for a top event, sometimes known as an adverse event, exists such as a breach in containment. In other words, the vessel containing the chemical ruptures releasing the chemical into the environment. Obviously, this is undesirable and every effort should be taken to avoid it from happening.

The far left side of the Bowtie Chart tracks threats that if unaddressed could lead to an adverse event. In the case of a chemical containment vessel, a threat could be damage resulting from heavy equipment operating near the tank. Therefore, layers of protection or preventative barriers need to be in place to monitor such activity and prevent damage.

But suppose the preventative barriers fail and the top event occurs. To prevent further consequences, which appear on the far right of the Bowtie Chart from making a bad situation worse, there are mitigative layers or mitigative barriers located between the top event and the consequences. The consequences of a leak at a chemical plant might include ignition of the chemical cloud resulting in a huge explosion and fireball. Suitable mitigative barriers could include an emergency response team available to quickly intervene and an effective process to coordinate with local authorities to warn members of surrounding communities.

The point is to ensure that all serious threats and consequences are identified by a team of operational experts and both preventative and mitigative barriers whose effectiveness has been verified have been established. This is not a one-time exercise because as prevailing conditions change over time some barriers will naturally degrade. Therefore, an essential component of the bowtie-based risk management system is a robust ongoing process of review and upgrade to ensure a comprehensive and accurate assessment of threats and the effective implementation and maintenance of barriers.

“If establishing a genuine culture of safety and minimizing unnecessary exposure to risk is a key component of your organization’s business plan moving forward then investing in a ladder and a bowtie is a much better strategy than spending money on bandages.”

Let us return to the question posed at the beginning of this article: Why do many well-meaning efforts to create corporate safety cultures often fall short resulting in unexpected injuries or deaths?

The simple answer is that not enough business leaders adequately identify, understand, and fully manage the risks to their organizations. This is particularly true in the area of human behavior where excessive workplace stress degrades the effectiveness of behavior-based barriers.

According to the National Institute for Occupational Safety and Health, “job stress results when the requirements of the job do not match the capabilities, resources, or needs of the worker.” With current economic conditions driving business leaders to push workers to do more with less, increased stress is the expected outcome.

Eustress, as defined by the Business Dictionary, “is a psychological term that refers to the good form of stress that helps an individual or business grow and remain healthy.” Research shows that the optimum levels of eustress reside in the green zone shown in the diagram below and correspond with high levels of performance. Exceed this level of stress and performance quickly degrades into exhaustion, ill-health, and ultimately breakdown.

When safety resides primarily in the “aspirational” culture but profits rule the functional culture, workers are forced to make a decision to perform the job safely or complete it on schedule. And most workers know management clearly expects the latter. Management may offer lip service to safety but unless safety has a seat at the table and an influential voice when budgetary and operational decisions are made, safety will always take a back seat in the functional culture.

The bottom line is that the Safety Culture Ladder provides the mechanism for assessing an organization’s safety culture and the Bowtie Chart combined with an effective root cause analysis methodology offers the means for moving an organization steadily up the Safety Culture Ladder by identifying and managing a comprehensive spectrum of risks, especially those that have the potential for extremely catastrophic consequences.

Business leaders who seek sustainable profitability, especially in challenging economic times, must devote serious attention to safety. As recent events have revealed, those who fail to ensure the safety of their operations can see hundreds of millions of dollars in profits go up in smoke in a matter of seconds along with the potential destruction or failure of the entire enterprise.

If establishing a genuine culture of safety and minimizing unnecessary exposure to risk is a key component of your organization’s business plan moving forward then investing in a ladder and a bowtie is a much better strategy than spending money on bandages.

Learn more about:

• Safety Culture Ladder (Safe Work Australia)
• Accountability & Authority Framework (Effective Managers?)
• Bowtie Chart (CGE Risk)
• Apollo Root Cause Analysis Methodology?

ABOUT THE AUTHOR:

Fred Stawitz, a national award-winning educator and writer, is recipient of the Leadership 500 Awards LEAD 2016 Circle of Winners and author of Don’t Run Naked Through The Office! This intriguing book offers employee engagement from the employee’s perspective while explaining the four types of workplace environments and providing actionable guidance on navigating the challenges of each. His next book will provide guidance to business leaders and HR professionals on creating a workplace environment that supports safe, productive, profitable, and sustainable operations.

“’Don’t Run Naked Through The Office’ provides a great guide on how to leverage more control in any workplace environment. Badly needed advice!” Jean Caden; Director Global Accounts; Xerox; New York, New York

“As an employee engagement scholar, I find this book captivating!” Dr. Marie A. Valentin, MBA; HRD and Employee Engagement Scholar; Texas A&M University; College Station, Texas

“If only this book was available to me several jobs ago. I have no doubt it would have saved me from repeating the same mistakes as I moved from job to job hoping that things would get better simply by changing the address of my workplace.” Matthew Searle; Creative Director, Facilitator, and Author; Winterlea Studio; Queensland, Australia

“Thank you for the most honest and comprehensive book on avoiding the pitfalls and gaining understanding into the psyche of bosses. This is a ‘how to’ not only survive but raise above the discord and toxic situations.” M. Helen Cavazos, Human Resource Management & Diversity Consultant, M.H. Cavazos & Associates, Houston, Texas

Don’t Run Naked Through The Office!