TRANSIT SAFETY CULTURE AND THE INVISIBLE MAN
TRANSIT SAFETY CULTURE AND THE INVISIBLE MAN
BY
?
Levern McElveen MPA
Introduction
Ralph Ellison’s classic novel The Invisible Man, first published April 7, 1952, hailed immediately as a masterpiece because the storyline addressed the struggle Negros faced in search of racial context and identity. Invisible Man is one of many books by Black authors that have attempted to change the landscape of American literature for African Americans and people of color. Ralph Ellison's nightmare journey across the racial divide tell unparalleled truths about the nature of white supremacy, systemic racism, bigotry, and its effects on the minds of both victims and perpetrators.
The Invisible Man is a compelling story of a young southern Negro, from his late high school days through three years of college to his life in Harlem. The young man dismissal from college because of an innocent mistake, his shocked reaction to the anonymity of the North, his nightmare experiences on a one-day job in a paint factory that landed him in the hospital, his lightning success as the Harlem leader of a community organizer known as the Brotherhood, his involvement in black versus white and black versus black clashes and his disillusion and understanding of his invisibility- all climax naturally in scenes of violence and riot, followed by a retreat which is both literal and figurative.
The young southern Negro upbringing prepared him for a life of humility before white men, but through his experiences with racial injustices-large and small, he came to realize that he was an "invisible man." White people saw in him only a reflection of their preconceived ideas of what he was, denied his individuality, and ultimately did not see him at all. Racism then and racism today have a toxic effect on life. Researchers have long known that racism creates health problems, but now results from a small study using RNA tests show that discrimination increases chronic inflammation among African Americans (Science Daily, 2020).
There is a particular classic quote in this outstanding novel that provides context and identity to not only the narrator’s story but to the many worker knowns as “essential workers” on the frontline of the Coronavirus COVID-19 pandemic today who have been and remain invisible.
"I am a man of substance, flesh, and bone, fiber, and liquids—and I might even be said to possess a mind. I am invisible, understand, simply because people refuse to see me. Like the bodiless heads you sometimes see in a circus sideshow, it is as though mirrors of hard, distorting glass have surrounded me. When they approach me, they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me."
Joseph Fuller, Manjari Raman, Eva Sage-Gavin, and Ladan Davarzani defines frontline workers as the “Hidden Workers.” In their article How Businesses Can Find “Hidden Worker,” cites,
The Covid-19 pandemic exposed who the real “essential” workers are — often low-- and middle-skills workers like grocery store employees, health care aides who care for Covid-19 patients separated from their families, and warehouse workers who package and ship goods. It also revealed that low and middle-skills workers in particular were acutely vulnerable when large swaths of the economy suddenly shut down; today, these individuals may be less likely to find stable work after a layoff and more likely to struggle paying their bills, rent, or mortgage compared to higher-skills workers.
Throughout history, essential workers have been invisible, and many remain invisible, even during the pandemic, in the eyes of many decision-makers. Even though frontline workers, many of whom are African Americans and people of color, have always been at the forefront of the national economy's and part of many national success stories. Yet, essential workers are still fighting to construct personal context and identity in a divided society.
Coronavirus
COVID-19 has uncovered the 21st Century version of Ralph Ellison’s story, The Invisible Man. The pandemic has revealed the depth and brevity of racial disparity and the social divide in the United States (U.S.). To this end, many essential workers are hurting, stressed, afraid, tired, burned-out, and emotionally drained, throughout industries, such as healthcare and transit. Healthcare workers are the heroes at the forefront of this pandemic. During a crisis like no other, healthcare workers have put their lives on the line to keep all of us safe and they are getting attention. For example, the December 21-28 issue of Time Magazine noted frontline healthcare workers as the 2020 Guardians of the Year. Additionally, networks and social media outlets have focused attention on healthcare heroes' severe plight, and they are truly deserving of the attention.
However, healthcare attention has not occurred equally for other essential workers such as police, firefighters, trash collectors, assembly line workers, and transit frontline employees facing pandemic challenges. Yet, while the benefits of gratitude are widely acknowledged for the healthcare heroes, the lack of attention may leave other essential workers like transit frontline workers feeling left out. Leaders must step in and fill the empty void. For transit frontline workers, transit leaders must step up and fill the void.
At a minimum, during and after the pandemic, transit leaders can begin developing and implementing the safety culture process by taking the time to thank essential workers because the compassion will help dampen loneliness, amp up social connections, and generate generosity. Transit leaders must understand that frontline workers feel stressed, fear, and having anxieties about the virus and other stressors, which can be overwhelming and lead to mental health concerns.
For one, being thankful to your team is the right thing for leaders to do. Transit essential workers are battling fears, stressors, and other anxieties about the pandemic and juggling home and work in proximity. Transit frontline workers are essential, but they are not in disposal. Almost every employee needs to hear that their dedication is noticed, and it matters (Nawaz, 2020). The recognition of commitment is the essence of any safety culture, making the teams feel psychologically safe.
During this pandemic, transit leaders should learn a lesson in the “Crucible of Leadership” by taking lessons learned and making things better for the invisible workers. The crucibles experience of the COVID-19 pandemic is a true trial, a test, a point of deep self-reflection that forces transit leadership to question who they are and what is most important. Warren Bennis and Robert J. Thomas’ article define Crucibles of Leadership as “The skill required to conquer adversity and emerge stronger and more committed than ever, which are the same virtues that make for extraordinary leaders.”
The COVID-19 pandemic will require transit leaders to examine their values, question their assumptions, hone their judgment, meet the challenge, and become better leaders. If transit leaders entertain these crucibles, they will emerge stronger and surer of themselves and their purpose—changed in some fundamental ways that will be felt by essential workers and customers alike. Courageous transit leaders can take the many lessons learned from the COVID-19 pandemic and begin the process of developing and implementing a sustainable transit safety culture to address the pain and suffering felt by the invisible frontline workers.
Lack of A Sustainable Transit Safety Culture
To understand the rationale behind the lack of a sustainable transit safety culture in the transit industry, readers must examine transit history, including systemic racism, sexism, and classism. If transit leaders are to be successful in addressing these racial inequities, they must understand transit history in their efforts to developing and implementing a sustainable transit safety culture. Let me offer this example. As a former bus operator in the 1970, transit systems had in place an upward mobility policy and this is how it works.
The policy requires a bus operator to serve in place three years before becoming a bus supervisor. The policy requires a bus supervisor to serve in place three years to become an Assistant Superintendent. The policy requires an Assistant Superintendent to serve in place for three years to become a Superintendent. The upward mobility policy allows rank and file employees to enter the rank of senior leadership over time. Let me remind readers that the frontline population was predominately white at that time.
The upward mobility policy had an advantage for the transit system because it included in the management and senior leadership ranks a group that produce better-than-average leaders, due to their unique transit experience. A United Kingdom (UK) research study shows that when a disadvantage group is well represented among the corporate managers, the disadvantage group receives more effective advocacy. This suggests a trickle-down policy theory. In this case, the policy theory argues that if transit systems had more managers and senior leaders from the rank and file of frontline workers, employees and customers alike could and would receive greater advocacy.
However, in the mid and late 1980, frontline population became predominately Black and people of color. As a result, the upward mobility policy was changed by senior leadership, which left frontline employees disappointed, devastated, and angry because the policy action denied them the same privilege given white employees. Conscientiously or unconscientiously, the policy action further created a disadvantage social class origin and the policy no longer work on behalf of the current and future frontline workers. However, senior leadership did not care because the policy action was necessary and important to promote systemic racism and white supremacy in the transit system.
Paul Ingram article titled; The Forgotten Dimension of Diversity offers an excellent read on the impact of social-class origin in the workplace. He cites the following:
Class origins certainly have an effect in the workplace. The class disadvantage matters for organizations because it excludes from the management ranks a group that may produce better-than-average leaders. A study using data from the U.S. military, for example, suggests that individuals with lower social-class origins are less self-centered, which sets them up to be more effective as leaders.
Companies may feel daunted by the prospect of another battle to fight, but they need not. By attending to social class disadvantage, they reinforce their efforts to combat other forms of disadvantage. As the Harvard sociologist William Julius Wilson points out, racial disadvantages in particular are intertwined with social class disadvantage in such a way that remediation of the former is impossible without attention to the latter. Any hopes we might have of understanding and addressing racial inequity in the workplace require a clear-eyed analysis of its root causes—and these, recent studies suggest, are increasingly connected to social class.
I have advocated for developing and implementing a sustainable safety culture in the transit industry for more than 20 years through presentations at safety & security conferences, construction roundtables, education, training, and development, writing safety culture study proposals, several published articles on safety culture development, and one-on-one meetings with transit leaders across the industry on the benefit of safety culture development and implementation. And, yet transit senior leadership has not heard or received the safety message largely because they have no relevant connection to the importance of real safety in the transit environment related to workplace safety experience.
One of the key rationales for my safety passion is that I begin my 45 years career in transit as a bus operator for 18 years. I know first-hand the lack of engagement, trust, and actively caring for transit essential workers and my travels on two international transit study missions (Mediterranean Region 2003 and the Asian Railway 2017) that allowed me to compare safety culture in other countries to that of the United States. The difference is day and night. The question that bothers me is why? Why are these countries light years ahead of a superpower nation like the U.S.? Why have so many transit leaders ignored recommendations from myself, the NTSB, and others?
On June 22, 2009, the worst accident in transit history occurred in Washington, DC, on the Red Line of the Washington Metropolitan Area Transit System (WMATA).
"On June 22, 2009, at approximately 5 p.m., train 112 struck the rear of stopped train 214 near the Fort Totten station in Washington, D.C. The lead car of train 112 struck the rear car of train 214, causing the rear car of train 214 to telescope about 63 feet into the lead car of train 112; killed nine people because of the accident, including the train operator and injured dozens" (NTSB.gov, 2010).
After the June 22, 2009 accident at WMATA, a severe pipeline rupture in Marshall, MI, in 2010, a fatal flight of an experimental aircraft in Roswell, NM, in 2011, transit, transportation leaders and investigators sound the alarm to address the need for a transit safety culture. On January 1, 2014, a two-day forum titled "Safety Culture in Transportation" brought together regulators, industry, and academics. The two-day conference was moderated by former NTSB Chairwoman Deborah Hersman. Deborah Hersman cited the following, “Reasonable transportation workers do not wake up and intend to be unsafe. But what leads them to make unsafe decisions, and how can regulator influence safety culture to reduce the likelihood of this happening?
First, I would acknowledge that this forum was a positive step in developing and implementing a sustainable transit safety culture. However, as I reviewed the attendees' list, I did not see union representatives, frontline workers to include operators and maintenance personnel, and middle management, as participants. A safety forum must have participants that are directly impacted by the lack of a sustainable safety culture. Additionally, to the author's knowledge, there has not been another safety culture forum since 2014. If transit leaders are serious about developing and implementing safety culture, the forums, studies, and more safety culture research must continue. Senior transit leaders need to get proximate to those who have different life experiences they need to get proximate to those who do not have a seat at the table. And in doing so, it will make senior leaders’ better leaders.
The Federal Transit Administration has developed Federal Regulation (49, CFR 674, 49 CFR 673) Safety Management System (SMS), as an approach to transit safety, effective December 31, 2020. The FTA Regulation is a safety mandate derived from the Congressional Legislation, Moving Ahead for Progress in the 21st Century (MAP-21), passed by Congress and signed into law by President Obama on July 6, 2012. MAP-21 gave the FTA, for the first time, broad authority for the safety of the transit industry. The FTA took eight years to implement the regulation, and the regulation is again being delayed until July 2021. Is Safety a true Priority for the FTA? The delay only creates a lack of accountability extended for nine years.
The FTA will not be capable of developing and implementing a sustainable safety culture in the transit industry with the SMS approach, and here is why. SMS and associated policies and procedures depend upon the invisible essential workers' actions for successful implementation. For example, a safety procedure may accurately reflect the desired intent and be adequately detailed in its instructions. However, the successful execution of the process requires the actions of professionally trained essential workers, who understand the importance of the underlying intent, who accept responsibility for the task, and who appreciate that taking an obviously simplifying but potentially unsafe shortcut would be, quite simply, wrong (safety culture toolkit). If essential workers feel invisible, taking ownership of these policies and procedures remain a distance.
Let us cite another example; the failure of a critical interlock might have been caused by the transit maintenance worker who failed to calibrate the pressure switch and falsified the maintenance records. Alternatively, it might have been caused by the transit maintenance superintendent, who failed to verify maintenance records and lack of understanding maintenance workers' values, norms, and behaviors. Additionally, the problem could have been transit leadership, who denied the funding requested to address staffing shortages in the maintenance department. These are important multilevel events that have occurred in the transit environment and continue to happen today (safety culture toolkit).
Safety culture failures not only centers on the examples cited above; there are multilevel challenges to a sustainable safety culture that are not being addressed by SMS such as poor communication, supervisory problems, inadequate education and training, poor human engineering, bad quality control, poor leadership, and most important a failure of leadership to understand the synergy, interdependence, and interrelationships needed between systems and sub-systems and the transit system culture and the many different sub-cultures.
COVID-19 has brought about a new safety standard, which requires transit leaders to shift from traditional methodology to more innovative safety techniques moving forward. Safety culture development and implementation is now a priority in the transit industry more than ever. Customers and employees are now looking to transit leadership to improve their workplace safety culture. Transit safety culture must focus on a holistic approach, including collective responsibility, diversity & inclusion, mental health and well-being, resilience, innovation, and sustainability. These are the critical drivers for safety culture success that are not essential elements of SMS.
How Is Transit Safety Culture Defined?
How do we define a transit safety culture? First, it has been argued theoretically that every system has a safety culture, no matter how good, bad, or indifferent that culture might be (Galloway, 2015). Every organization has a safety culture, operating at one level or another. Literature references that many leaders and safety professionals believe they have a strong safety culture when, in fact, they have nothing more than a safety climate consisting primarily of plans, policies, and procedures. A safety culture operates at a much higher level than a safety climate (Zohar, 1980, Glendon and McKenna, 1995)). Let us examine some safety culture definitions.
The U.K. Health and Safety Executive define safety culture as “. . . the product of the individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety programs.” (1) A more succinct definition has been suggested: “Safety culture is how the organization behaves when no one is watching.”
The U.S. Nuclear Regulatory Commission (NRC) defines nuclear safety culture as the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure people and the environment's protection. The NRC recognizes that it is essential for all organizations. The NRC acknowledges that it is necessary for all organizations performing or overseeing regulated activities to establish and maintain a positive safety culture commensurate with the safety and security significance of their actions and the nature and complexity of their organizations and functions.
Dow Chemical Company defines its safety values as follows: "Safety is Dow's top priority and an integral part of Dow's culture. It is woven deeply into every decision we make about workplace and laboratory resources and processes. Our commitment to safety is fundamentally based on the belief that organizational culture and systemic employee engagement can help prevent accidents before they happen. We've developed the Dow Lab Safety Academy to enhance the awareness of safe practices in academic research laboratories and to promote a safety-first mindset in the future workforce of the chemical industry."
How does the transit industry define its safety culture? There is no specified definition for transit safety culture. Transit leaders have failed to define safety culture for the industry. Transit leaders have been unwilling to conduct academic research to begin developing concepts toward the theoretical building blocks for a transit safety culture. One of the many rationales for this failure is transit essential workers are invisible in transit leaders' eyes, and transit systems are very political with little accountability. The readers must understand occupying a leadership position is not the same as leading. To lead, one must connect, motivate, and inspire a sense of ownership of shared objectives with the essential workers by making them visible.
Transit leaders’ role is to develop, implement, and sustain a positive transit system culture. Transit leaders do this by always being on the lookout for signs that transit culture has become psychologically coercive. Transit leaders should ask themselves, do employees believe in the transit vision because they understand and agree with it or because that is what they are supposed to do? The acid test of transit leaders is their ability to unlock employees' potential to get the best out of them, not to create a culture that enslaves them (Ketes, 2020).
Safety culture must begin with transit leadership's commitment to safety. Transit leadership must understand some of the many challenges in developing and implementing a safety culture: 1) determine the level at which the safety culture currently functions; 2) decide where they wish to take the culture; and 3) chart and navigate a path from here to there by developing creative and strategic strategies; 4) define safety culture values that will help shape employee’s beliefs, attitudes, behaviors, and values and 5) create accurate and appropriate measures that measure the attitudes, behaviors, and values, in addition to the number of miles traveled. Additionally, leadership must further identify safety as a core value and embed safety in the transit systems' purpose, vision, mission, and priority. Transit leadership must identify and commit the resource and the personnel to define and implement a transit safety culture.
Why Is Safety Culture Important?
To understand why safety culture is essential, let us begin by discussing organizational culture. Each organization has its own culture—the values and norms that define what is and is not appropriate for the organization. Culture guides how you work. A healthy one enables organizations to attract and retain highly motivated employees and unites them around a common goal, purpose, or cause to pursue sustainable performance. Healthy cultures can quickly turn into cults or toxic, whether leaders intend for it to happen or not. Healthy safety culture builds a sense of community, shared purpose, and collaboration among employees across the multiple sub-systems found in the transit system. Safety cultures give people space to be individuals and encourage life.
Transit/transportation systems serve the nation as a critical component of the national infrastructure mission. That is, these systems are a requirement for day-to-day mobility and critical during an emergency crisis. Secondly, the quality of life is at stake for millions of transit riders. Public transportation connects to school, job opportunities, health care, housing, and social mobility. According to the American Public Transit Association (APTA) ridership data, the transit industry transported 10.1 billion passengers in 2017. Thirdly, according to APTA, the transit industry has a $90 Billion State of Good Repair needs. Why is safety culture influential?
Transit essential workers have not been primarily engaged and inspired by transit leadership. Therefore, many transit workers fall into the category of “satisfied workers or paycheck workers” and may choose to ignore safety policies and procedures at all transit systems levels. Why? As stated, many frontline workers are African Americans and people of color. These employees’ perception is that these systems do not care about them, and they do not care about the system. Safety is a perception! This perception is real. If workers do not perceive themselves as being safe, they are not safe. Transit leaders must understand this perception and must work to dispel the perception held by frontline workers
Accidents and incidents will continue to plague the industry, which will continue to create massive lawsuits and cost the American taxpayer millions of dollars in tremendous payouts. These payouts will have a direct impact on transit system bottom lines and will impact effective service delivery. Transit systems will continue to have high turnover rates in employment, absenteeism, given the current toxic safety culture, and transit essential workers will continue to feel invisible. Yet, transit leaders have largely failed to embrace the theoretical concept and move forward with an industry approach to developing and implement sustainable transit safety.
Path Forward
Crises are ideal for transit leaders to make significant changes to create a better and brighter transit safety future for essential workers. According to Korn Ferry, "experts say instead of trying to return to pre-pandemic operations, leaders must shift their mentality toward envisioning a whole new future for their firms. For the transit industry, this new envisioning must become developing and implementing a sustainable transit safety culture that will move toward making frontline (essential) workers' visible, rather invisible.
Transit leaders at all levels must reexamine current models and paradigms being used in the transit industry. They should review how CEOs are hired. For decades, transit leaders have been hired through political connections. CEOs are also hired for their ability to focus on financial results, leaving the human experience absent. They should reexamine the use of the same transit recruiting agencies. And they should write CEO job descriptions that attract candidates with vision. For example, transit boards and the Secretary of Transportation should interview candidates whose values align with the system's purpose; it becomes a win-win. For the first time, many corporate American organizations have started talking about systemic racism in how companies hire, train people, and sell their goods (Korn Ferry, 2020).
Greater accountability is needed in transit to address systemic racism, poor leadership, sexual behavior, and unacceptable practices. Frontline employees are hurting, stressed, suffering from anxiety, and working from a place of pain. The public execution of George Floyd and COVID-19 has awakened the nation to the inequities and iniquities of systemic racism. Much work is to be done by transit industry leaders to eradicate these social injustices that have plagued the transit industry for decades. Transit leaders to include transit CEO, Board Members, Elected Officials at all levels, must take immediate actions on these injustices and must become vocal regarding racism in service delivery and diversity and inclusion.
To unlock employees' potential, transit leaders are required to encourage critical thinking, use prize sound judgment, value individuality, radiate authenticity, and tap into employees' unique strengths and knowledge. One of many failures of transit CEOs is to believe frontline workers have nothing to offer. A great culture involves learning from the past, agreeing on core values, finding people who both complement and challenge one another, engaging in open communication, having fun, and working as a team, and creating healthy debate—in which people can debate individual values and norms and differ in their opinions. When a culture ceases to embrace diversity and dissent, it will become toxic and a cult.
Summary
Transit essential workers are heroes even though they remain invisible in the eyes of the networks, social media, and many transit leaders. Transit frontline workers work hard each day, even though many workers died from the COVID-19 pandemic across the industry, and many contracted the virus. They came to work and sacrifice their lives for their families and to see that other essential workers and community people got to their destination. They are not famous, and there will be no television series that reflects their daily challenges, like healthcare workers. However, they will remain my heroes, because I too, was once a frontline worker.
Transit leadership's failure to develop and implement a sustainable safety culture is a true reflection of transit leadership culture—the values, behaviors, norms that define what is and what is not appropriate behavior for the transit industry. To begin addressing these safety culture gaps and the crucibles of leadership, transit leaders should adopt a change model and begin to measure appropriate small wins. This approach focuses on setting and achieving narrow, attainable safety goals to produce a sense of success that will build momentum for more considerable gains and systemic transformation (Denend, Yock, Azagury, 2020).
Safety culture is based on upon shared values, beliefs and perception that determines what comes to be regarded as the norm for the transit system. If the transit leaders feel strongly about a particular behavior, there will be little tolerance for deviation (diversity and inclusion), and there will be strong leadership pressure for conformance. Everyone in the transit system has a role in reinforcing the behavior norms, and many will feel excited about their involvement.
Accidents and incidents will continue to plague the industry, transit systems will continue to have high turnover rates in employment given the current toxic safety culture, and transit essential workers will continue to feel invisible. The failure to develop and implement a sustainable safety culture in the transit industry is a testimony to the fact that essential workers are invisible. And transit leaders lack compassion and wisdom to change the paradigm.
Transit systems are in crisis. Economies are unwinding with little income from ridership, jobs are and will disappear—and employees’ spirit is being tested. Considering this, it is imperative for transit leaders to demonstrate compassion and wisdom and begin developing and implementing a sustainable transit safety culture.
REFERENCE
ABS Group (2020), Safety Management, https://www.abs-group.com/what-we-do/safety-risk-andcompliance/safety-management
American Public Transit Association, 2017, Public Transportation Ridership Report, Fourth Quarter, 2017 www.apta.gov
America Public Transit Association, 2017, Report Prepared for the Asian Railway International Study Mission
Bennis, W. and Thomas, R. J. (2002) Crucibles of Leadership, Harvard Business Review, https://www.hbr.org
Bukowski, T. J. (2014) Safety Culture In Transportation, https: www.safetyandhealthmagazine.com/articles/print/9676-safety-culture-in-transportation
Denend, L. Yock, P. and Azagury, D. (2020) Research: Small Wins Can Make a Big Impact on Gender Equality, https://www.hbr.org
Dow Chemical Company, https://corporate.dow.com/en-us/science-and-sustainability/innovation/safety-at-dow.html
Fuller, J. Raman, M. Sage-Gavin, E. and Davarzani, L. (2020), How Businesses Can Find “Hidden Workers,” Harvard Business Review, https://www.hbr.org
Ingram, P. 2021), The Forgotten Dimension of Diversity, Harvard Business Review Magazine (January-February 2021), https://www.hbr.org
Invisible Man/Kirkus Reviews, https://www.kirkusreviews.com/book-review/ralphellison/invisible-man
Kets de Vries, M. (2019) Is Your Corporate Culture Cultish? Harvard Business Review https://www.hbr.org
Korn Ferry Institute, 4 Ways to Leverage “Hope”, https://[email protected]
National Transportation Safety Board, (2010) Investigation Report for the WMATA Red Line Accident June 22, 2009
Nawaz, S. (2020), In Times of Crisis, a Little Thanks Goes a Long Way, May 22, 2020, https://www.hbr.org.
Nuclear Regulatory Commission, https://www.nrc.gov/about-nrc/safety-culture.html
Ralph Ellison’s Quotes, https://www.goodreads.com/quotes/7471802-i-am-a-man-of-substance-of-flesh-and-bone
Safety Culture: “What Is At Stake”
Conducting An Organizational Culture Workshop up Incident Summary: Columbia Case History ?
Science Daily (2020), https://www.sciencedaily.com/releases/2019/05/190531100558.htm
Time Magazine, Dec. 21/ Dec. 28, 202
U.K. Health and Safety Executive, Safety Culture: A Review of the Literature, HSL/2002/25