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CORESafety Safety Culture Enhancement
Toolbox
Defining Safety Culture
Getting Started
Identifying Improvements
Rio Tinto Minerals
Safety Culture in context
Launching the Survey
Walking the Talk
Alpha Natural Resources
Changing Safety Culture
Interviews & Workshops
Making a Difference
Luminant
Enablers & Disablers
Analysis & Conclusions
Opening Minds
NASA
Safety Culture & SHMS
Feedback & The
Way Forward
Learning to Learn
FAQ
Re-assessing
Day-to-day Safety Culture
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
return
Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
Culture has been called
“the way of life for an entire society”
Defining Culture
Culture includes behavior, values, manners, dress, language,
religion, rituals, games, norms of behavior such as law and
morality, and systems of belief as well as aesthetic values,
that are shared by a population and typically passed down
from generation to generation.
Organizational Culture
Every organization has a culture, whether you recognize it
or not. Your organizational culture (aka, company culture)
plays a big role in determining what’s important and how
you conduct business. It determines whether your
workplace is casual/informal or conservative. It influences
the tolerance for business risk. It affects the kind of people
who are promoted. Have you ever known an employee
who was truly out of step with the company culture?
Organizational Culture & Behavior
People behave the way they do because they interpret and
make sense of their situation, define their own goals to
serve their group or personal interests, and act accordingly.
When the situation, goals and reinforcement mechanisms
are shared, behaviors tend to be similar. As such, you could
say: behavior is a function of culture, and in turn leadership
What is a “Good”
Safety Culture?
What Safety
Culture is Not
behavior and established systems influence culture. This is
important, since it means that culture can be modified,
though such change can take a long time and require
continuous effort and strong leadership.
Culture strongly influences collective behavior. Much of
our behavior and thinking is shaped by culture. This
becomes very clear when one travels to a distant country
and culture. People who opt to live in a different culture
usually experience ‘culture shock’. Yet to the local
people, everything is understandable and ‘normal’. It is
just ‘the way it is’.
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
Safety culture is the way that safety is perceived,
valued & prioritized In an organization.
Overview
This section aims at defining the concept of safety culture
and its origins.
What is a “Good”
Safety Culture?
What Safety
Culture is Not
The term safely culture was first applied in the aftermath
of the Chernobyl nuclear reactor disaster in 1986. This
nuclear power plant had safety management processes
and trained operatives using clear procedures, but
deficiencies in the attitudes to safety in the organization
led to the world’s worst nuclear disaster.
Safety Culture
The essence of safety culture resides in people’s beliefs
about the Importance of safety, including what they think
their co-workers, supervisors and leaders really believe
about safety’s value.
It is demonstrated through attitudes, accepted norms and
behaviors. It is about how things work and “the way things
are done around here.”
Safety culture represents the priority given to
safety at all levels of your organization and
reflects the real commitment to safety.
Since then, the use of the safety culture concept has
spread to other industries including oil and gas, chemical,
rail, aviation, medical, and now mining.
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety culture reflects the value of safety at all levels
in the organization and therefore influences
the everyday management of safety.
Overview
Safety culture can range dramatically, some components
positive and others less desirable. This section introduces
some characteristics of ‘good’ and ‘not so good’ safety
cultures.
• Employees are reluctant to report incidents & injuries.
• No one is held accountable for their safety
responsibilities.
• Safety management representation is kept out of key
decision-making processes.
What might you see people doing in a positive culture?
• All employees identifying and resolving safety issues
• People looking for opportunities to help others and
intervene when needed
• Reinforcement of safer, healthier behaviors by everyone
• Employees accepting accountability for their own safety
as well as the safety of others.
• Employee openness to coaching and feedback
• Desire to provide resources to improve safety & health
• Willingness to share, communicate and learn
• People are encouraged to raise issues and suggestions
Some traits of such a less desirable safety culture could
include:
• Concerns about safety are consistently not addressed.
• No learning is achieved from safety incidents.
Sub-Cultures
What happens if managers, staff and workers do not share
the same beliefs about safety, or where their behaviors are
in opposition? These sub-cultures create concerns if
management is out of touch with the culture of the
workforce, or if employee behaviors change when
supervision is diminished (do weekends or night shifts
have a different feel?)
• This is normally a symptom of another issue:
• Is the culture one of compliance and penalty?
• Are behaviors inconsistently reinforced?
• Are management focused on outcomes rather than the
process used to achieve those outcomes?
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
Safety culture is not something you can buy.
Overview
Culture is something an organization has, and will improve
or damage depending on its actions. Organizational culture is
like a company’s personality traits concerning hazards, risk
and controls.
What Safety Culture is Not
• It is not something that people can easily “see” from
inside an organization. It can be assessed, but this will take
some organized effort, skills and methodology.
• It is not a silver bullet for safety. If there are problems with
safety, it’s not simply that people just have a bad mindset
(negative ideas or attitudes towards safety), which they could
be persuaded to change through appropriate communication
or training. If there are problems with safety, it is also
because the work environment and conditions trigger and
reinforce the mindsets, attitudes and behaviors producing
the safety problems.
A Model for Mining S&H Excellence
Culture is part of a broader picture of how safety excellence
can happen. It one of 3 key components: culture, leadership
and systems. It is important for mining companies to
understand that each of these factors can be measured and
managed.
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety culture is generated through the interactions between
people and their environment, while conversely it influences
these interactions. The primary interaction is between
leaders and their staff.
Safety culture improvement cannot be made independently
of the work environment. Something will need to be
simultaneously improved in the real environment as well, if
safety and culture are to be successfully improved.
Systems
Culture
Leadership
Management is charged with establishing the right direction,
vision and systems, which in turn will be reflected in the
culture.
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
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Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Culture: “The collective programming of the mind which
distinguishes the members of one group from another.”
Hofstede, 1980
Overview
National, organizational and professional cultures
significantly impact many aspects of work performance,
including our attitudes and behavior regarding safety and
health. This section focuses on national culture.
National Culture
National culture is influenced by many factors, including:
history, religion, language, climate, geography, immigration,
and cultural blending.
When considering what organizational culture your wish to
develop, it is crucial to consider the broader cultural
customs of your population
It is generally believed that Americans, tend to be
independent thinkers, place a very high value on freedom,
are heterogeneous in many respects (melting pot effect),
believe in hard work, and are able to ‘get things done’,
among many other attributes.
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Hofstede’s research found that typically AngloWestern cultures tend to be high in individualism,
with less distinction between hierarchy, while many
Asian and Latin cultures are collectivist and place
much greater emphasis on rank and title.
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Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
“The culture of an organization guides how its employees
work, dress, make decisions, think, communicate and behave.”
Hofstede, 1980
Overview
Organizational (or company or corporate) culture significantly
impacts work, including our beliefs, attitudes and behaviors.
This is true of safety and health and especially true when
an employee’s personal needs (for identity, power, money,
satisfying relationships, meaningful work) are aligned with
the company. This section addresses organizational culture.
People do not always simply do what they are told, e.g., “work
safely or don’t do the task.” They behave the way they do
because of the perceived consequences that will occur for
behaving that way.
Organizations are perfectly designed to continue with the way
that things are normally done in the local culture. If there are
problems with safety(or any type of work performance) it may
be because the behaviors producing the problem are continually
reinforced, whether overtly or not.
Managers and supervisors influence the behavior of others
through their own actions (on inaction…). They can increase
certain kinds of behavior (through positive & negative
reinforcement) or reduce behaviors (through punishment or
extinction) by the examples they set and the way they respond
to worker concerns and suggestions.
Organizational Culture
Corporate culture is defined as the reflection of shared
behaviors, beliefs and values regarding organizational goals,
functions and procedures (Cooper, 2000).
The best efforts to build safety and health systems and
processes in an organization may be wasted if the corporate
culture reflect a positive safety culture and lacks the cultural
beliefs and behaviors to make them last.
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Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety culture is prerequisite for good safety
performance in a number of industries
and mining is no exception.
Overview
When assessing total injury rates, the U.S. mining industry
is safer than many other industries including construction,
agriculture, forestry, manufacturing; however, the industry
continues to experience high severity incidents and disasters
resulting in an above-average fatality rate. This section
covers mining culture.
Mining Culture
Miners are special people. It takes a strong and in some
ways audacious person to develop and work in a mine.
Anecdotally, many characteristics have been offered to
describe U.S. mining culture. Miners are: dependable, hard
working, tough, self-assured, family-centered, outdoororiented, and risk-accepting, among other traits.
Safety Culture in
Mining
A Model for Safety
Culture in Mining
We are all tolerant to risk, miners (both managers and
workers) tend to be comfortable, to one degree or another
with the risks associated with mining. Much of this can be
attributed to mining history, the nature of mining hazards
and more importantly because of their ability to work safely
with these risks on a daily basis. Their experience of success
creates a confidence in being able to do it again (people
learn best from their direct experience). In addition, the
sense of overcoming these challenges is reinforcing, building
camaraderie amongst the team and ‘miners pride’.
This can be a double-edged sword. It enables the industry to
continue to produce the raw materials our country requires
to grow and maintain our standard of living. However,
comfort with, or acceptance of, risk can lead to negative
outcomes the industry is trying hard to prevent.
Our industry needs to understand how aspects of culture can
be a threat and how they can be managed. It also needs to
know the power of a strong and positive safety culture. Just
as the focus of incident investigation is moving from worker
error to systematic failure , the concept of safety culture
considers the critical importance of management and
individual actions regarding safety, based on their collective
values, beliefs and behaviors.
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Safety Culture &
National Culture
Safety Culture in Context
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Researchers and safety practitioners have proposed numerous safety culture models in recent years. The following
contains 14 dimensions on which a mining company can be defined and evaluated.
“Everyone is accountable
for their safety responsibilities”
“Don’t trust good performance”
Vigilance
Accountability
“I trust my supervisor,
my supervisor trusts me”
“No autopilot here.
I think about change”
Trust
Adaptability
“I report everything.
It’s the right thing to do”
Systems
“Mind on task,
but thinking ahead”
Reporting
Awareness
Culture
Leadership
Communication
Leadership
“Safety lives in conversation.
We are our brother’s keeper”
“We always walk the talk,
even under pressure”
Competency
Learning
“Properly trained, always retained”
“We learn from all incidents.
Avoid second errors”
Discipline
“Consequences for
intentional unsafe acts”
Justice
Empowerment
“I can change things here.”
Engagement
“I’m treated consistently fairly”
“I like what were doing.
I’m a team member”
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
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Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
It is easy to manage change
when management changes…
Steps for change
Enablers &
Disablers
its initial state, just like a spring. So it is difficult to get a 4person family to change, what about an organization of 400 or
4000?
Overview
This section illustrates the difficulty of changing habits and
values, drawing from a life example.
Jones’ Case Study
Consider the Jones family. Every day, Mr. Jones drives his 4WD
truck to work . Mrs. Jones takes the kids to school in her V6
Why People Resist Change
sedan, and they leave the light and appliances on at home.
Habits: Some people have established patterns of behavior
They need to change, but they are not prepared for change. that make their job efficient and easier.
Self-interest: Some people are mainly concerned with the
Why? Because the Jones family has compelling reasons for
implication of change on their own interests.
behaving the way they do. It is easy, comfortable, imageMisunderstanding: Inadequate communication/information
enhancing, consistent with their dreams, conforming with
about the objectives of change.
what their neighbors are doing. Over the years, they have
Different perception of the situation: Some employees may
established patterns of behavior, as well as a vision of life
disagree on the pros and cons of the change.
(values) in line with these behaviors.
Low tolerance to change: Certain people are very focused on
stability in their work.
Their life conditions and their beliefs generate these
Low capacity for change: People would like to see change, but
behaviors. Conversely, their behaviors (and those of their
don’t believe it will ever happen. Other changes have failed.
neighbors) carry on their life conditions and confirm their
vision of life.
This is a very stable circle: if you try and change one
component, say, a behavior, the other ones will pull it back to
Click here to read more about how you can successfully
manage change.
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Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
It is easy to manage change
when management changes…
Overview
This section addresses way to improve change in your
organization.
1. Realize that organizations don't change, people do -- or
they don't. If employees don't trust your leadership, don't
buy the organization's vision, don't buy the rationale for
Percentage of People Who Resist Change
change, and aren't involved in the planning, successful
Every mining company is different, but research suggests that a
change will be difficult, regardless of the brilliant strategy.
relatively large percentage of employees in any company resist
2. Large-scale organizational change usually triggers
change to one extent of another.
emotional reactions: denial, negativity, choice, tentative
acceptance, commitment. Leadership should facilitate this
emotional process to ensure the best chance of success.
3. Communication: openness and transparency go a long way
in helping to generate trust. Go beyond telling the truth
when it's advantageous. Be proactive, share as much as
possible: opportunities, risks, mistakes, potentials, failures.
Invite people to work on these challenges together.
4. Incremental change is linear and fairly predictable as it’s
based on prior performance. Conversely, transformation is
a redefinition of who you are and what you do. It's often
unpredictable, illogical (demanding people and
organizations change when they are the most successful),
Understanding Resistance to Change
and not a valid indicator of future success. Past success
Knowing why your employees resist change will make you a
may be your greatest obstacle.
better ‘change agent’.
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Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Before you can get to where you want to go – you
need to know where you are.
Overview
This section addresses ways to improve identify culture in your
organization.
Current Culture
There are many ways to sample and establish you
organizational culture. This is a key part of the process to
determine how best to facilitate a successful and sustainable
culture change.
Confidential employee perception surveys are the subject of an
entire section of this toolbox (See Section B)
What Is The Culture That Awaits?
Equally important as knowing where you are is knowing where
you are aiming to get to. What does your ideal culture look
like? What would you see people doing, what would people be
saying, how would issues be identified and resolved?
What that culture looks like and how it should be defined is
something that everyone can be involved with. Having the
discussion alone might even be the catalyst for change.
Taking Control
In the past, many people in the mining industry
believed that a strong, positive safety culture was
desirable but not something that was within the realm
of management to change . Today, we know that
company culture’s can be improved, but to do so you
must focus on the right management behaviors and
have an intent and plan to enhance your organization’s
culture.
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Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Managing any significant change within an organization,
and all the more so a cultural change, indicates a need
to follow certain steps.
Overview
This section addresses ways to improve change in your
organization.
Leading Change:
• Developing a clear vision, showing the direction of the
change and the underlying values.
• Create a climate of change: establish a need or sense of
purpose and urgency.
• Share the vision with employee using clear communication.
• Avoid roadblocks to the vision.
• Empower employees to act and clear obstacles. Employees
should feel trusted by management.
• Wherever possible, involve employees in the process.
Organizing Change:
• Build a coalition of driving forces.
• Set the relevant human resources – people need time and
space to work on the changes.
• Set a plan and agenda, including short-term wins.
• Coordinate activities.
Implement Change:
• Implement intentions. Make visible change occur in
operations as soon as possible.
• This requires behavior change at all levels of the organization.
Steps for change
Enablers &
Disablers
• Start at the top and ensure employees below see it and feel it.
Consolidate Change:
• Intentions are implemented and transformed with time.
Allow enough of it. Be urgent, but patient.
• Provide frequent updates about the change program.
• Consolidate first outcomes and keep moving.
• Don’t declare success with change until you are certain.
• Secure short-term wins.
• Anchor the change. If in doubt, look at senior leadership’s
behavior. Did it change permanently?
• Have follow-up program to ensure back sliding is minimized.
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Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Safety culture enablers are pervasive and enduring
company characteristics that exert a positive influence on
safety culture.
• Respect (enough said…).
•Confidence that management knows what it’s doing.
• A personal safety vision communicated by supervisors.
• Open door policy (bring it, good or bad).
• Making good decisions in difficult times (pressure’s on).
• Holding everyone accountable for his/her responsibilities.
• Making the connection between leadership and culture.
• Employees feel uncomfortable not being competent.
• Safe producers get promoted.
• Always thinking about what might go wrong.
Steps for change
Enablers &
Disablers
Safety culture disablers are pre-existing and often immutable
(short-term) company factors that hinder the maintenance or
enhancement of a safety culture.
•Inadequate organizational communication (are we ok?).
• Inadequate interpersonal communication (don’t bother me).
• Excessive change (personnel, frequent business initiatives).
• Mergers or acquisitions without culture integration planning.
• Excessive command and control management style.
• Inconsistent approach to S&H management (flavor of month).
• Labor-management unrest (work stoppages).
• Inadequate resource parity between production and safety.
• Fear of retribution (report and be damned).
• No involvement of workers in S&H management policy.
Enablers & disablers that are harder to influence: National culture, professional culture, local social culture, etc.
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
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Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Under just culture conditions, individuals are not blamed
for honest errors, but held accountable for willful
violations and gross negligence.
Summary
In a just organizational culture, individuals are not
blamed for 'honest errors', but are held accountable
for willful violations and gross negligence. Discipline is fair
and equitable.
People are less willing to report their own errors and other
safely problems or hazards if they are afraid of being
punished or prosecuted. Employees’ perception of
punishment prevents the management from being property
informed of the actual risks. Managers are unable to make
the right decisions in order to improve safely.
However, a totally no-blame culture is neither feasible
nor desirable. Most people desire some level of accountability
when an incident occurs.
In the mining industry, a ‘just culture’ is an atmosphere of trust
and fairness in which people are encouraged, and even
acknowledged for providing essential safety-related
information, but in which they are also clear about where the
line must be drawn between acceptable and unacceptable
behavior. Consequences are consistent for a behavior
regardless of the outcome observed.
Therefore, a just culture supports learning about incidents,
unsafe acts, and near miss incidents, in order to improve safety
and health management through the improved recognition of
safety situations and helps with the sharing of safety
information.
Consequently, a just culture can be regarded as an enabler and
an indicator of (a good) safety culture.
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Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
mistake, I think others can learn from my mistake”.
The influence of national culture on safety attitudes
and behaviors can be positive and negative.
Summary
The Influence of national culture on safety attitudes and
behaviors can be both positive and negative.
National culture does influence the attitudes and behaviors
of individual’s work. Corporate culture and professional
habits cannot supersede entirely national cultural traits.
Consequently, some features of a national culture can play a
positive role towards safety culture, and some can play a
rather negative role.
According to G. Hofstede, a national culture can be
characterized by the following dimensions:
• Power distance and relationship to authority.
• Management of uncertainty and relationship to rules.
• Degree of individualism and group power on individuals.
• Degree of macho attitude and the importance of ‘face’.
Communication with management can be influenced by
‘power distance’. In countries characterized by a high power
distance, it may be more difficult for a miner to speak up and
voice concerns about the impact of a decision on safety, or to
advise his/her supervisor that "I just made an interesting
In countries with a high level of ‘uncertainty avoidance’,
adherence to rules and procedures is a natural way of life.
Employees will then lend to request comprehensive and
detailed procedures and will be keen on following them. In
countries with high uncertainty acceptance features, it may be
difficult to get people to exactly follow the written procedures.
Developing a just culture may be influenced significantly by
aspects of national culture such as social attitudes toward
blame and punishment in response to human error.
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Enablers & Disablers
Just Culture
National Culture
A mining company’s financial circumstances are an
important influence on the way resources are devoted
to safety, and thus operate as an enabler (or disabler)
for safety culture.
Summary
All organizations have limited resources to devote to
safety and must deal continually with the conflicting goals
of safety versus productivity and efficiency objectives, which
ultimately determine profitability.
Financial health in any business will be influenced not only
by good management and internal efficiency, but by the
external economic environment. A stated commitment to
safety is necessary, but not sufficient to enable safety
improvements. The commitment must be supported by
appropriate resources of technology, equipment, training
and expertise, policies and systems that promote
operational safely.
One indicator of a positive safety culture is the extent to
which these resources for safety are immune from an
organization's financial situation, the commitment to
safety should be consistent and visible regardless of any
financial pressures facing the organization, whether
internally or externally generated.
The Cost of Safety
Is Safety a Priority or is Safety a Value?
•What budgetary changes affecting safety are made when times
are tough? For example, is some safety-related training seen as
dispensable and is cut or postponed?
• To what extent are productivity or efficiency pressures
increased at these times? For example, is 'cutting corners'
encouraged or condoned more often?
•Do management priorities, messages and most importantly
their actions change from a focus on safety to other
organizational goals, such as the 'bottom line'?
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Defining Safety Culture
What is a Culture?
What is Safety
Culture?
What is a “Good”
Safety Culture?
What Safety
Culture is Not
Safety Culture in Context
Safety Culture &
National Culture
Safety Culture &
Corporate Culture
Safety Culture in
Mining
A Model for Safety
Culture in Mining
Changing Safety Culture
Why it’s Difficult to
Change Culture
Current Culture vs.
Future Culture
Steps for change
Enablers &
Disablers
Enablers & Disablers
Just Culture
National Culture
The Cost of Safety
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
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Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
A strong safety culture is a strong enabler to ensure the SHMS
works in practice. The reverse can also be true: implementing
a good SHMS can be an enabler for safety culture.
1986
Overview
This section emphasizes the importance of having a positive
safety culture as well as an effective SHMS.
Safety & Health Management System (SHMS)
Safety management implies a systematic approach to managing
safety, including the risk management, necessary organizational
structure, competencies, accountabilities, policies and
procedures. For more information on developing an effective
SHMS, see the NMA S&H Management System Toolbox.
Is a SHMS implementation enough to guarantee Safety?
It is recognized that an effective SHMS is necessary for
maintaining and improving safety in U.S. mining operations.
However, it may not be adequate to guarantee adequate safety
performance.
We need only look outside our own industry to see examples of
high-risk organizations with very good management systems
who experienced spectacular losses owing to failures of the
organizational culture or the leadership that drives the culture:
2003
“NASA organizational culture had as much to do with this
accident as the foam.” Columbia Investigation Report
Similar losses can been experienced by British Petroleum:
2005
2010
“Absent a healthy safety culture, even the best safety
management systems will be largely ineffective…” Baker
Commission Report.
NASA Challenger & Columbia Disasters
return
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
SHMS works in practice. The reverse can also be true:
implementing a good SHMS can be an enabler for safety
culture.
investigations can be conducted to understand where a failure
1986
in the system occurred (e.g., behavior,
accountability,
procedures, training, etc?). However, employees are less likely
to report incidents if they fear there will be personal
Implementing an SHMS & Culture: Which one First?
repercussions. If your organization has fair and equitable safety
There is no right answer to the question: “Which comes first?” rules and disciplinary procedures, and you have let it be known
that you are interested in fact-finding and not fault-finding
relative to incidents, then employees are much more likely to
report things that occur.
An alternative approach is to retain some distance between
The strength of treating safety culture and safety
the two areas. This still allows feedback on where a SHMS may
2005
management in tandem is that the approach can sometimes not actually be working in practice (e.g., technical problem in
translate or focus safety culture improvement needs into
the incident and error reporting systems that stops people
tangible improvements to the SHMS.
from bothering to report incidents), while allowing an albeit
fuzzier focus on deeper cultural issues that can be unearthed
2010
An example of this is the parallel between the SHMS
during safety culture surveys, e.g., regional differences in
elements of incident reporting & investigation and safety
safety attitudes, or problems of mistrust between different
culture attribute of organizational justice.
mines or different layers in the organization (e.g.,
organizational staff believing an SHMS is just ‘for show’ or ‘to
You need your employees to report all incidents that occur so protect’ managers).
return
Safety Culture & SHMS
Is Having an
SHMS Enough?
Which Comes First?
Hand & Glove:
Safety Culture &
SHMS
1986
In Core Safety, the NMA SHMS, leadership and safety culture
components are fully integrated , i.e., there are three
elements within the SHMS – hand and glove.
Overview
This section describes the interdependency between safety
and health management systems, culture and leadership.
Linking the SHSM, Culture & Leadership
The safety and health of any mining organization is the product
of three elements:
1. The quality and effectiveness of the management systems
implemented to systematically address risk and S&Hrelated information. See the NMA S&H Management
Systems Toolbox for more information.
2. The safety culture which includes people’s shared values,
attitudes, beliefs and behaviors about safety and health.
3. Leadership , which is the driving force for
developing/enhancing safety culture and a prerequisite for
establishing the authority, accountability, resources and
goals associated with and importance of safety and health
management. See the NMA Leadership Toolbox for more
information.
The Three Fit Together Like Hand & Glove.
The SHMS, culture and leadership are interdependent .
Leadership creates the initiatives, drive and urgency to
reach safety excellence. The systems supports the process
to achieve safety excellence. The culture embodies the
commitment to achieve safety excellence.
Systems
Culture
2005
Leadership
2010
return
CORESafety Safety Culture Enhancement
Toolbox
Defining Safety Culture
Getting Started
Identifying Improvements
Rio Tinto Minerals
Safety Culture in context
Launching the Survey
Walking the Talk
Alpha Natural Resources
Changing Safety Culture
Interviews & Workshops
Making a Difference
Luminant
Enablers & Disablers
Analysis & Conclusions
Opening Minds
NASA
Safety Culture & SHMS
Feedback & The
Way Forward
Learning to Learn
FAQ
Re-assessing
Day-to-day Safety Culture
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
What gets measured, gets managed, even culture
Pre-launch of safety
culture assessment
Overview
This section describes the overall purpose for conducting a
safety culture assessment.
Process
The aim of the NMA Core Safety culture assessment tool is to
describe how to measure an organization’s safety culture and
identify the culture’s strengths and weaknesses to determine
whether cultural changes are needed. The process involves:
1. A pre-launch phase to prepare senior managers and
employees for the assessment and obtain their support.
2. Data collection phases, involving both questionnaire
surveys (quantitative processes) and interviews,
workshops, etc. (qualitative processes) depending on time
and employee accessibility .
3. Safety culture analysis phase.
4. Diagnosis, feedback and way forward phase.
Preparing the
Launch
Survey kickoff
Familiarization
visits
Distribution of
questionnaires
Additional data
collection
Initial safety culture analysis & development
of interview/workshop agenda
Interviews with
management
Workshops and/or interviews
with staff & workers
Safety culture analysis
Safety culture diagnosis
Feedback & way forward
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Safety culture assessment is a collaborative process between
culture assessment experts and company management.
Overview
•
Since an organization’s safety culture is deeply rooted in its
history and collective experience, attempts to measure and
change it are difficult and require considerable time, efforts and
resources. This section describes the overall purpose for
conducting a safety culture assessment.
Internal Buy-in
Preparing the
Launch
values and beliefs underlying day-to-day behaviors,
appreciate past and present culture and challenge individual
and organizational safety behaviors.
Providing expertise and experience necessary for conducting
an effective assessment process, identifying strengths and
weaknesses, and working with your company’s,
management to identify the path forward base don the
assessment results.
Two Assessment Approaches
There are two different approaches to conducting a culture
assessment:
1. A mining company can conduct their own assessment;
however, given the expertise required to develop an
Company Personnel Are Useful For:
appropriate questionnaire and the need for confidentiality • Providing the ‘inside’ information to measure the
and objectivity, this approach may impose hurdles that
organization’s culture (e.g., opinions and experiences on risk
undermine the utility of the assessment
awareness, safety behavior, and commitment to and
2. Retain an external expert to assist management in
involvement in safety).
conducting the assessment. While this approach requires • Assisting the assessment team in data collection and
more resources, it will very likely yield much better results.
validation (e.g., providing access to information and
workshop participants).
External Experts Are Useful For:
• Establishing a viable way forward.
• Contributing outside perspective. It is often easier for
• Ensuring ‘ownership’ by company management of the
outsiders rather than insiders to identify subtle but
process, findings and outcomes.
important aspects of organizational culture, investigate the
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
An internal champion ensures a successful safety
assessment process.
• Acting as an interface between the external assessment team
and company management, board of directors (as required)
Overview
unions, staff and other stakeholders.
The presence and commitment of an ‘internal champion’, an
• Setting the scene for the assessment campaign and assisting it
enthusiastic supporter and defender of the safety culture
assessment process and objectives , is desirable for ensuring a along the way until the implementation of the action plan., and
later with the re-assessment process.
successful result.
• Assisting the assessment team by making them aware of
relevant information, such as recent incidents, re-organizations,
or SHMS implementation.
• Promoting the safety culture assessment campaign internally,
in order to get as much ‘buy-in’ as possible from managers and
staff.
The Champion’s Role
The champion plays an important role in supporting and
promoting the assessment process by:
Selecting a Champion
The champion can be selected from among the members of the
safety team, human resources, or senior management. The
champion should be well informed about the process, expected
outputs, time scales and other critical aspects of the
assessment.
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Prior to launch of the assessment process, company
management and the external assessment team should
discuss and agree on details of the assessment process.
An internal champion ensures a successful safety
assessment process.
Scope
The scope of involvement in the assessment process will be
dependent on factors such as the project timeframe and the
availability of company management. At a minimum, the
assessment should include representatives of the management
group and line management and staff for each staff undergoing
an assessment. Collecting a wide, representative range of views
from all areas and levels of the company is important in order
to:
•Ensure that the assessment is an organizational safety culture
assessment.
• Enable the assessment team to compare and contrast the
perceptions of different groups or sub-cultures, for example, to
test whether managers do what they say they do, in the eyes of
their workers.
• Minimize any potential bias effects that may result when
characteristics of an organization are being assessed through a
sample of individuals nominated to interact with the
assessment team.
Internal Buy-in
Preparing the
Launch
Timeframe
• The assessment team should define, with company
management, an adequate time period in which to launch the
assessment process, to avoid the impact of external and other
factors, such as busy periods, overlap with other activities.
Confidentiality
An important aspect of preparation is to determine how
confidentiality will be preserved. For example, how materials
will be stored, used and reported, and who will participate in
the data collection phase. It is important to determine:
• All collected materials will be kept confidential and used only
by the assessment team.
• Collected information from the interviews and workshops will
be summarized and reported in a way that does not identify any
individual.
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
return
Launching The Survey
Survey Kickoff
Questionnaire
The survey kickoff marks the beginning of the safety
culture assessment process.
Familiarization
visits
Additional data
collection
to 'sell' the project to those who will be giving their time to
participate. It is thus important to promote the benefits to
employees of a good Safety Culture, and to alleviate any
concerns ('threats') they may perceive.
The launch starts with a presentation of the entire process
to senior and middle managers, operational staff (either
separately or jointly), and other stakeholders if required (e.g.,
unions). Further presentations to separate working groups can
also be planned if necessary to motivate staff and ensure
their active participation.
The kickoff presentations should introduce the
assessment team to company management and personnel
and should cover:
• The purpose and intended outcomes of the assessment.
• The process involved, including how information will be
collected, analyzed and used.
• The requirements of survey participants and the
importance of their contributions.
• Confidentiality terms. These must be explained to all
participants who will be involved in the data gathering
phase.
• Any questions or concerns raised by personnel.
The presentation must capture the interest of the
participants to ensure their commitment. It is an opportunity
The survey kickoff is followed by the distribution of the
safety culture questionnaire and other data gathering
processes, as discussed in the following sections.
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Launching The Survey
Survey Kickoff
Questionnaire
Data Collection: The Safety Culture Questionnaire
Design
The safety culture questionnaire is a set of statements
that respondents are asked to agree or disagree with by
marking their choice on a pre-determined scale (e.g., 5-point
scale, Yes/No, etc.).
The questionnaire can contain as few as 10 and as many as
100 statements, normally in random order. The format may
vary depending on which expert is designing the survey. The
questionnaire should be designed to elicit responses on a
variety of topics that indicate how the company approaches
and manages safety, leadership and culture.
Language
The questionnaire should be available in English, but can be
translated into the local language of the company if
necessary. If this option is chosen, it is recommended that
the questionnaire then be translated back into English to
ensure the translation is as accurate as possible.
Distribution
The questionnaire can be distributed either by dissemination
of hard-copies in person (preferred method) or by electronic
Familiarization
visits
Additional data
collection
means. In-person distribution and completion is preferred to
minimize the potential for comparison of answers among
respondents. The questionnaire should only be completed once
by each individual in the organization and personnel should
have access to only those sections that concern them.
Promotion & Sample Size
To ensure the validity of the questionnaire data it is important
to have a representative sample size (at least 30% of the
identified target groups, and ideally 50 - 90%.). Therefore, the
launch of the questionnaire should be combined with the
familiarization visits to the different mines and support facilities
(by the external assessment team) to explain the purpose of the
survey and promote it. The 'champion' should also help
distribute the questionnaires and help oversee completion and
collection. Management support and encouragement are
extremely valuable during this phase.
Collection
Once completed, the questionnaire are returned directly to the
assessment team.
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Launching The Survey
Survey Kickoff
Questionnaire
Data Collection: Familiarization Visits
Familiarization
visits
Additional data
collection
improvement, the assessment team should visit different mines
(plus mills, prep plants, refineries, smelters, etc.) of the
company.
While extensive observations may be useful for determining
safety behaviors and investigating the way an organization
manages safety, it is often costly and time-consuming to
conduct this activity. Still, visits with company mines and
related operations facilities are very useful.
Objectives
The main objectives of familiarization visits are to:
• provide the assessment team with a general impression
of the climate and operational environment of the company;
and,
• enable the assessment team to interact with mining
company personnel during their day-to-day activities.
This process helps, the assessment team to become
familiar with the working environment of the company and
make observations that can be followed up on and explored
further in interviews and workshops. It also allows the team
to establish a rapport with company personnel, which is of
general benefit in subsequent information sharing stages.
Locations
In order to gather information on a range of safety culture
issues, enablers, constraints and opportunities for
Expertise
Familiarization visits are generally conducted by a mixed team,
consisting of:
• those with operational expertise - to assist with understanding
the technical aspects of the observed activity; and
• external experts from the assessment learn – who contribute
an 'outsider' perspective and the experience and expertise to
assess observed behaviors in terms of safety culture elements.
return
Launching The Survey
Survey Kickoff
Questionnaire
Data Collection: Additional Sources of Information
Broader Cultural Factors
When assessing a mining company’s safety culture, the
assessment learn must have an understanding of, and empathy
with, the entire local environment in which the company
operates. As Hofstede notes, “ .. people in other countries may
think, feel, and act very differently from yourself, even when
confronted with basic problems of safety...” The assessment
team can conduct external literature and document reviews
and website reviews, for instance, to access relevant
information. Reading about the historical background of the
company may also assist in understanding the culture.
Safety Culture Information
Specific information about a company’s safety culture can be
gained from a number of sources to complement data
obtained through the questionnaires and familiarization visits:
• The company website. The content and the way the
Information is presented conveys information about where
the company's areas of interest lie.
• Safety programs and initiatives in place at the company,
indicating the level of commitment to safety.
• Documented policies and procedures.
• Internal publications outlining details of the organizational
structure, mission statement, etc.
Familiarization
visits
Additional data
collection
• Incident reports, incident summary and other safety
indicators. While the culture questionnaire identifies whether
the company has tools in place to learn (e.g., reporting systems.
incident analysis, feedback and communication channels), the
quality and effectiveness of this learning process is difficult to
assess without observing the outcomes.
An examination of the process and related documents (incident
reports, documentation of resulting action and feedback. etc.)
provides important information on organizational learning by
considering issues such as:
• How often voluntary reporting processes are used.
• The quality and scope of incident reports, and whether
important issues are covered appropriately.
• Whether reports are acted on, how feedback is communicated,
and what the process for responding to reports entails.
•How trends in incident data are collected and acted on.
This information assists the assessment team in understanding
the reporting processes in place, people's involvement in the
processes and the quality of the feedback and outcomes.
These details can be collected prior to the launch of the survey
or during the site visits. The subsequent interviews and
workshops provide additional opportunities to collect
information about the organizational structure and context,
social environment and financial health.
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
return
Interviews & Workshops
Objectives
Interview & Workshops: Speaking to the People
Overview
This section outlines the objectives of the safety culture
interviews and workshops.
The objectives of the workshops and interviews are to:
• Supplement information from the safety culture
questionnaires by accessing additional qualitative data.
These qualitative data help achieve greater insight into
safety-related activities, actions and behavior shown by
mining company personnel and to enrich the safety culture
picture of the company.
• Assist in interpreting the questionnaire results.
Preparation
Facilitation
Who Should Be
involved?
Structured collective workshops or focus groups
supplement the questionnaire and individual interviews by
gathering additional insight about safety-related activities,
actions and behavior exhibited by company employees.
Further focus groups could involve staff of other departments
such as Human Resources and Security. All these discussions
are intended to collect useful and complementary information to
support the company safety culture diagnosis.
Note that it is important to run multiple workshops, since
different workshop groups may not always say the same things.
The workshops and interviews are designed to elicit views from
managers, staff and workers on a range of issues, including the
prevailing culture through its impacts on safe behavior, reporting
of errors and incidents, and communication about safety
priorities.
The enablers and motivators, and barriers and disincentives to
safety culture, emerging from these activities, provide insight into
the safety culture dynamics of the organization.
Safety culture centered interviews gather first-hand
information about people's behavior as well as subjective
perceptions of the company safety culture from senior and
middle management. An alternative option, when possible,
is for managers to participate in a dedicated focus group.
The final goal is to integrate the information from the workshops
and interviews with the findings of the safely culture
questionnaire to highlight the full range of safely culture issues
within the organization.
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Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should Be
involved?
middle managers, etc.)
Workshops & Interviews: Get Prepared
Overview
This section explains how to prepare for the safety culture
interviews and workshops, and describes the content of these
data collection activities.
Preparation
The workshop and interview preparation starts with the
pre-analysis of questionnaire results and other pertinent
documents to identify key safety culture issues. The
assessment team groups these data into areas of interest
and uses these key safety culture issues to structure the
workshops with the operational and technical personnel and
interviews with managers.
During the pre-analysis, the assessment team also establishes
what complementary information is needed to make sense of
the questionnaire results, so that these topics can be explored
in the workshops and interviews.
The presence of members of the company safety/management
team is undesirable in workshops, as this may prevent the
participants from speaking freely. The safety team members are
generally interviewed separately to complement information
gathered during the workshops.
Scope
Investigating safety culture issues starts with the summarized
questionnaire results, and ensures that the assessment team's
interpretation of responses is correct. Other issues not captured
by the survey may also be raised during the workshops.
The issues covered should also integrate the informal safety
system, which refers to the unwritten rules pertaining to safety
behavior, such as accountability, authority (authorization and
employee involvement in safety decision making) and employee
professionalism (e.g., peer-culture, employee-group norms
pertaining to safe and unsafe behavior).
The assessment team should also distinguish between safety
culture in the organization and in the mine. Possible differences
In arranging the visit agenda, the assessment team works
can be explored to identify the system weaknesses. The output of
closely with, and is supported by, local safety personnel, to
ensure minimal disruption to the activities of the units involved. the workshops should be a refined set of issues, and in some
During the workshops and interviews; however, the assessment cases potential solutions or ways forward to improve safety
culture in the organization as a whole.
team needs to be seen as independent of the champion and
other local management (safety and line managers and
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Interviews & Workshops
Objectives
Preparation
Workshops & Interviews: Facilitation
Overview
This section explains some basic principles for facilitating
safety culture interviews and workshops.
Individual interview can take between 1 hour and 90 minutes.
Workshops typically run for between 2 and 3 hours. At the
beginning, the interviewer or workshop facilitator must
provide an overview to describe:
• the purpose of the interview or workshop.
• the intended uses of the collected data; and,
• the measures taken to protect confidentiality
and anonymity.
For the workshops, the agenda should be arranged in a
way that allows a break half-way through the workshop.
The break is useful to evaluate the outcome of the discussion
and see if there are any conclusions to be drawn or If there are
still gaps in the resulting picture.
The types of issues that should be addressed in the workshop
include, but is not limited to:
Facilitation
Who Should Be
involved?
• Determining if the opinions of the workshop participants align
with the overall trends form the questionnaire data.
• Getting specific examples of concerns from the questionnaire
data.
• Ensuring the questionnaire data is current and not a reflection
of the perceived culture from previous years.
• Determining if there are opinions about the safety culture of the
mine/company based on the workshop participant’s impression
of culture.
• Attempting to gauge the degree of response (triangulation)
between different participants.
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Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should Be
involved?
Workshops & Interviews: Who Should Be Involved?
Overview
This section lists the personnel who are typically involved in
safety culture interviews and workshops.
During interviews and workshops, A company members usually
serve as informants, who interact with the assessment team
using their own terms and concepts to express their point of
view.
Interviews
Interviews are normally conducted with one person at a
time. Personnel typically involved in the safety culture
interviews include:
• Company senior management, (e.g., CEO, COO, etc.)
operations director, technical staff, financial officer.
• Company middle management, including line, supervisors,
maintenance supervisors, trainers.
•Subcontractors (if possible)
In general, individual interviews are carried out with company
senior and middle managers to collect in-depth information
about safety culture.
However, additional interviews company management can help
to gain a wider overview of how safety is valued by all
stakeholders dealing with safety within the mining company.
Workshops
Each workshop should be conducted with members of the
same employee group. The ideal number of participants
should not exceed 7 to 10 people. Ideally, participants will
tie members of different teams or shifts and of different ages.
experience, etc., so that a variety of perspectives and experiences
can be discussed. It can be useful to have one workshop aimed at
the executive management of the company (the CEO may be
interviewed separately).
Another workshop might comprise personnel who do not work
on the front line, such as human resources and security.
Remaining workshops would than comprise groups of 4·6
company workers, engineers and shift supervisors. Each
workshop requires two facilitators one of whom will take detailed
notes.
return
Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
return
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Analysis & Conclusions: Triangulation
Overview
This section focuses on the analysis and conclusions
stage of the assessment process. The first step in this stage is
triangulating and analyzing the collected data.
Triangulation
The triangulation of all collected data enables the assessment
team to build a picture of the organization's management of
and commitment to safely. During the analysis phase, all
collected raw data are analyzed and interpreted, and the results
collated into a report resulting from a collaborative process
between the assessment team and company representatives.
In assessing the collected data, it is important to note that
the opinions and perspectives accessed during a safety
culture assessment are generally obtained from only those
personnel who interact directly or indirectly with the
assessment team and may not, therefore, be representative of
the views of all employees. An essential step towards presenting
an accurate assessment of an organization's safety culture is
therefore to compare and 'triangulate', or cross-check,
information collected from a variety of different sources:
• Safely culture questionnaire survey .
• Analysis of documents (manuals, policies, etc.).
• Interviews with management .
• Workshops l focus groups.
• Site visits (e.g., observations. informal discussions, etc.).
Interviews
Focus
Groups
Site visits
Document
Review
Interpret
& Analyze
Survey
Data
return
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Analysis & Conclusions: The Big Picture
Overview
Following data triangulation and analysis, an overall
safety culture picture is derived from the analysis
results.
In order to build an overall picture of the assessed safety
culture, there is a need for a theoretical model to help
understanding the observational data. The results of the
analysis of collected data are therefore clustered according
to the particular safety culture model used as a framework
by the assessment team (e.g., see figure).
Each safely culture attribute is investigated by compiling all the
available evidence exploring the shared values and behaviors,
as well as mismatches in responses and thus in beliefs. These
mismatches occur, for example, when management and
operational staff or controllers and engineers I technical staff
present conflicting opinions on a given safety culture topic. For
instance, managers and operational staff may present opposing
opinions on whether concerns about safety are acted upon, the
effectiveness of team meetings for improving safety or
whether changes are communicated to staff effectively.
Such mismatches indicate disparity within the organization
regarding commitment to, and management of safety, and
are useful for identifying areas for improvement,
 Accountability
 Adaptability
 Awareness
 Communication
 Competency
 Discipline
 Empowerment
 Engagement
 Justice
 Leadership
 Learning
 Reporting
 Trust
 Vigilance
Systems
Culture
Leadership
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Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Analysis & Conclusions: Expert Perspective
Overview
Specific safety culture assessment expertise and
experience are required to make sense of the analysis
outcomes.
Need for Expertise in Analyzing the Data
The analysis of all collected data enables the assessment
team to investigate safety culture attributes and to identify
local organizational and external enablers and disablers
which influence the safety culture either directly or
indirectly.
However, making sense of all this information is not an easy
and straightforward task. It is largely the expertise of the
assessment team and their previous experience with
the safety culture of other organizations (in the same industry
or from other industries) that allow them to draw major
insights about the assessed safety culture and to identify
its strengths and areas for improvement, with discussion of
causes and potential improvement measures.
This insight is based primarily on the appraisal of the observable
and analyzed issues in the actual context of the organization,
that is, company safety performance, and the organizational
and national culture and the commercial and social environment
in which the company operates.
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Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Analysis & Conclusions: Strengths & Weaknesses
Overview
The final part of the ‘Analysis & Conclusions' stage is identifying
safety culture strengths and weaknesses.
The outcomes of the analysis are used to identify and summarize
strengths and weaknesses or 'opportunities for improvement’ in
the organization's safety culture to help company leaders and
staff understand their safety culture and how they might
improve it.
This process is described in the following section:
Feedback & The Way Forward.
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Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
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Feedback & Way Forward
Reporting The
Findings
Diagnosis Feedback
‘Digesting’ Period
Way Forward
findings in the report are presented along with practical
Feedback & Way Forward: Reporting the Findings
Overview
In the final stage of the safety culture assessment process,
'Feedback and way forward', each mining company is
provided with a customized, confidential report of the
findings.
The safety culture assessment report provides a detailed
outline of the assessment process and sets out the findings
and conclusions of the assessment, including:
• Key observations about the organization's safety culture;
• Safety culture strengths, and;
• Safety culture weaknesses, or potential areas for improvement.
An important limitation of the information provided in these
reports, and presented in the feedback sessions (described in the
next section), is that it represents only a 'snapshot' of the
prevailing organizational and safety culture issues.
Furthermore, observations and conclusions can only be based on
the information made available to the assessment team (e.g.,
what was reported in questionnaires, said in workshops and
interviews, and observed by the team). Where possible,
examples to support the conclusions drawn, and give a 'flavor' of
the raw data that was collected.
Appendices to the reports give full access to statistics
and the summaries for each question answered in the
questionnaire, both generally and broken down by different
groupings. These summaries and observations are reported in a
way that does not identify any individual.
As important as the written report, companies should expect
their assessment expert to provide a verbal presentation so
questions can be asked and answered.
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Feedback & Way Forward
Reporting The
Findings
Diagnosis Feedback
Feedback & Way Forward: Reporting the Findings
Overview
In addition to receiving a written report of the findings,
the safety culture assessment team presents feedback
to company leadership on the assessment findings.
‘Digesting’ Period
Way Forward
and if possible through additional presentations with middle
management, operational staff, or regional personnel, for
example.
The findings and conclusions presented at this point are not
intended to be taken as absolute or prescriptive, but as
ideas to be tested, validated and accepted (or otherwise)
within the company through further discussion, reflection and
detailed analysis.
The aim is to raise awareness of areas in which action might
be taken to further enhance the company’s safely culture.
The measurement phase helps to uncover the safety
culture aspects present in the core values and beliefs as
well as in the behaviors of the company employees.
The diagnosis often shows differences between core values and
beliefs or different subcultures within the organization. The
insight given through the feedback event can enlighten
company management about their safety culture 'reality', that is,
their strengths and weaknesses.
In the feedback stage, the analysis team presents findings
back to the company - usually to the senior management group
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Feedback & Way Forward
Reporting The
Findings
Diagnosis Feedback
Feedback & Way Forward: Digesting Period
Overview
The safety culture diagnosis and feedback phase is
followed by a 'digesting' period to interpret and accept
the findings.
Following the 'discovery' phase during the feedback of the
safety culture diagnosis outcomes (see Section “Which Comes
First?”), company senior management and staff need time to
'digest'
the information they have received, so that they can
interpret the findings properly and examine how they fit
with existing perceptions about the culture.
‘Digesting’ Period
Way Forward
Shock  Anger  Resignation  Acceptance  Help
It is important that key stakeholders in the company culture have
time to go through these digestion stages before moving on to
actions.
Once relevant safety culture strengths and weaknesses have
been understood and accepted, the next step is to plan how to
address these weaknesses, and to decide which safety culture
change strategies are most relevant.
Typically, three to five or so major areas for improvement
are identified. Within these areas there are usually some
‘quick 'wins' related to communication and safety strategy,
Sometimes this information can be a shock to company
for example, or incident learning practices. Other issues
management. Normally, this occur because senior management may be more 'long hand'. In all cases, it is up to the company
has one idea about how employees view the company and its
to decide which to tackle, or indeed to consider other options.
culture and the employees have a very different view. In other The resultant 'strategy' needs to be 'owned' and driven by the
cases, management may think they have really tried to improve company, as discussed next.
culture, and convinced themselves that everything was good.
There is a predictable response in people for whom this is more
than just bad news: they go through a somewhat predictable
digestion process abbreviated as ‘S.A.R.A.H.’
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Feedback & Way Forward
Reporting The
Findings
Diagnosis Feedback
Feedback & Way Forward: Way Forward
Overview
The final stage of the safety culture assessment is a
collaborative process to determine the way forward.
Commitment to improve safety culture once weaknesses
have been identified is of great importance. In fact, a lack
of action can reduce staffs trust in the management and
compromise future activities relating to safety culture
improvement.
After the 'discovery' phase of the safety culture diagnosis
(see Section “Which Comes First?”) , the company needs to
identity its own safely culture change objectives. The outcomes of
the safety culture assessment can be used to identify goals for
change and identify a safety culture improvement action plan.
These steps cannot be completed by the external assessment
experts alone. It is essential that senior management take
ownership of these goals and develops improvement strategies
that are realistic and practical, given the organization's constraints
and resources, as imposed by both the organization and national
regional or professional culture.
Thus, there is a need for a collaborative approach to translate the
‘Digesting’ Period
Way Forward
identified challenges into action plans and solutions. This can be
achieved through a facilitated workshop involving the decisionmakers who can assure the implementation of the agreed actions.
This workshop (or series of workshops) will:
• Prepare senior management for their role in culture change.
• help interpret the diagnosis and reconcile evidence with reality.
• Help the company describe a target culture level and attributes.
• Support them in gaining deep insights or setting priorities.
• Build a coherent and realistic action plan.
• Identify appropriate/realistic interventions to initiate change.
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Getting Started
How Do You
Measure Culture?
Who Should
Measure?
Internal Buy-in
Preparing the
Launch
Launching the Survey
Survey Kickoff
Questionnaire
Familiarization
Visits
Additional Data
Collection
Interviews & Workshops
Objectives
Preparation
Facilitation
Who Should be
Involved
Analysis & Conclusions
Data Triangulation
& Analysis
Safety Culture
Overall Picture
Making Sense of
Analysis Outcomes
Strengths &
Weaknesses
Feedback & Way Forward
Reporting the
Findings
Diagnosis Feedback
‘Digesting’ period
Way Forward
Re-assessing
When to Re-Assess
Who Should
Re-assess
How Should You
Re-assess
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Re-assessing
When to Re-assess
Re-assessing the Culture: When to Re-assess
Overview
This section explains why it is important to undertake
a re-assessment of the safety culture some time after
the initial assessment.
Following the completion of a safety culture assessment
and implementation of the improvement plan, it is
recommended that re-assessment is conducted to:
• evaluate the effectiveness of the improvement strategies;
• promote continuous improvement by addressing chronic
weaknesses;
• fine-tune improvement efforts to reflect changes in safety
culture strengths and weaknesses;
• reaffirm commitment to culture improvement; and,
• defend against other projects being given priority.
Who Should
Re-assess
Timeframe
The safety culture assessment campaign, from the launch to the
decisions for change by the mining company management, can
take about a year. Somewhat more time will be required before
an organization can implement the change strategies and see the
early outcomes of any improvements. Therefore, a re-assessment
campaign will be relevant only after two to three years.
Mid-term review
Actions & Improvement
Analysis/report
Interviews/workshops
Pre-analysis
Launch
Pre-launch
How to Re-assess
time
Re-assess
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Re-assessing
When to Re-assess
Who Should
Re-assess
Re-assessing the Culture: Who Should Re-assess
Overview
The re-assessment should be conducted by external
experts and internal company representatives as a
collaborative process.
Inside vs Outside
As for the first safety culture assessment campaign, it is
recommended that external evaluators be called in to reassess the safety culture, identify Improvements and
determine areas where changes are still needed. In fact,
'outsiders' (typically the same assessment team
involved in the first campaign) are better able to
re-organize the improvements from the previous safety
culture level than personnel working within the system.
Alternatively, the company can allocate the re-assessment
task to a different group of experts in order to challenge the first
assessment outcomes by the use of different assessment
methodologies and perhaps identifying other strengths and
weaknesses.
As before, however, the assistance of ‘internal champions’
(see Section “Internal Buy-In”) is necessary to assist the
How to Re-assess
assessment team in accessing the data, provide information on
changes and relevant events that have taken place, and promote
re-assessment activities. Therefore, a collaborative approach is
recommended in order to obtain the benefits of both 'insider' and
'outsider’ perspectives in assessing changes to the organization's
safety culture.
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Re-assessing
When to Re-assess
Who Should
Re-assess
How to Re-assess
workers interpreting the question(s) differently.
Re-assessing the Culture: How to Re-assess
Overview
The re-assessment process depends on the level of analysis
required.
The company can choose to apply the whole assessment
process as followed in the first assessment campaign, or
to use parts of the assessment tool, e.g., the questionnaire
alone or interviews of collective workshops.
Follow-up interviews can be more relevant for mid-term
review, whereas a re-distribution of the questionnaire can
help to establish a more objective and quantitative internal
'benchmark' as a point of comparison between the results of
earlier and later assessment.
In addition, the re-assessment can be tailored to focus on
one or more specific safety culture issues at a time, or can be
designed to consider all aspects of the company safety culture.
However, to ensure that the data is comparable between the
initial assessment and the re-assessment it‘s important to use the
same questions to ensure continuity, i.e., compare apples with
apples. If you change the wording of the questions, you risk
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CORESafety Safety Culture Enhancement
Toolbox
Defining Safety Culture
Getting Started
Identifying Improvements
Rio Tinto Minerals
Safety Culture in context
Launching the Survey
Walking the Talk
Alpha Natural Resources
Changing Safety Culture
Interviews & Workshops
Making a Difference
Luminant
Enablers & Disablers
Analysis & Conclusions
Opening Minds
NASA
Safety Culture & SHMS
Feedback & The
Way Forward
Learning to Learn
FAQ
Re-assessing
Day-to-day Safety Culture
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Identifying Improvements: Making Sense of the
Safety Culture Assessment
Overview
Observations reported in the safety culture
assessment should be ‘tested' by company management,
reviewed and evaluated critically, before being used
to plan future improvement activities.
As described In Section B, the tangible outcome from a
safety culture assessment is a written report to management.
This diagnosis of safety culture strengths and weaknesses
should not be taken at face value, but critically evaluated.
There are a number of reasons for this:
• The assessment is a snapshot in time, based on observations
made over only a number of days.
• The information collected typically comes from a selection of
company personnel.
• The data has been processed through a number of stages
before being reported, recorded, collated, and integrated from
diverse sources and summarized before being presented; and
finally, safety culture is a complex and 'fuzzy' concept, that is
open to personal interpretation.
Planning for Culture
Change
Making Sense of the Culture Assessment
• Keep an open mind and be positive. Constructive feedback
is sometimes interpreted as criticism - this is not the intention of
the assessment.
• Review the report as a group, listening to different opinions and
responses to the ideas presented.
• Take key observations one by one and ask “does this fit with my
intuitive understanding about our company and our culture?” "If
not, why not?“
• Having agreed to what is accurate and useful to learn from, be
prepared to take ownership of the diagnosis, and the safety
culture improvement strategy that will flow from it.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Identifying Improvements: Identifying
Opportunities & Limitations
Overview
The safety culture assessment will suggest many opportunities
for improvement. A process is required to establish the priority
areas for action, and to consider limitations in what can be
achieved in practice and reality.
The Company’s goal should be to identify:
• The most important safety culture improvements required
(effectiveness or benefit), based on their interpretation of the
diagnosis?
• How easy or feasible it will be to make meaningful change?
That is, which of the improvements will be easy to achieve,
and which will be more difficult (their feasibility)?
The process for making these distinctions is referred to as an
‘effectiveness/feasibility evaluation’.
This can be undertaken via management meetings, or as a
workshop actually, run by a facilitator who understands the
process, and with participation from a range of stakeholders
in the safety culture improvement project.
Effectiveness /Feasibility Evaluation
Step 1: Determine the likely effectiveness of the change, through
discussion of the following questions:
• What is the expected effect /benefit on safety management?
• What would be the extent and depth of the effect?
• How durable or lasting would the effects be: long-term or
temporary?
• Is there any 'downside', that is, potential risk or adverse
collateral effect from the change (e.g., risk transfer or creation of
new risks)?
Step 2: How feasible is the action, in terms of factors such as
cost, practicality and difficulty:
• What is the financial cost?
• What operating constraints or limitations apply?
• How will the target population be affected by and respond to
the intervention?
• How complex and widespread will the impact be on the
organization as a whole; on policies, procedures and practices; on
structures; on MSHA or OSHA regulatory compliance; and on
socio-political systems (power, status, corporate interests)?
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Identifying Improvements
Understanding the
Culture Assessment
Identifying Improvements: Planning For
Safety Culture Change
Priorities &
Limitations
Planning for Culture
Change
It is important to allow for the possibility that unforeseen events
will disrupt the way the project is carried out:
Overview
As with any project, safety culture enhancement
activities need to be properly planned, resourced and
monitored to ensure that they achieve the intended
objectives.
1. Expect that not everything will go according to plan.
2. Clarify exactly what has changed and what needs to be done.
3. Be flexible in adjusting plans, main objectives and timeframes
4. Communicate what has changed and why to stakeholders,
and document these.
Steps in Planning & Managing Cultural Change
Remember that cultural change projects are somewhat intangible,
in that the desired changes in altitudes may be hard to see, and
the behavioral effects may be gradual and subtle. This means
momentum for the project may fall away unless commitment and
project controls are actively maintained, and the project is given
ongoing prominence in the organization - through regular
reporting and communication of progress.
1.
2.
3.
4.
5.
6.
7.
8.
Establish commitment to the project.
Clearly defined scope, objectives and timeframe.
Identify and allocate funding.
Agree in advance the measures of success.
Prepare a project plan (summarizing issues above).
Identify risks and ways to manage them.
Assign responsibilities for activities.
Develop monitoring processes (for resources, objectives,
outputs and timeliness).
9. Report progress and communicate achievements.
10. Celebrate success!
Flexibility is required to deal with unforeseen events
and complications along the way.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
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Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Walking The Talk: Senior Management Commitment
To begin changing behavior, identify exactly what it is that
Overview
distinguishes managers who are highly committed to safety from
those who are not interested in, or only pay lip-service to safety.
These leadership competencies enable managers to 'walk the
talk', for example, by:
A commitment to safety by the organization's senior
management group is essential to the existence of a
positive safety culture.
• Promoting safety and communicating the right messages.
• Leading or participating in safety meetings, workshops, forums.
• Encouraging people to report hazards, near misses and errors.
• Listening to and addressing employee concerns.
• Treating people justly when they report normal errors.
• Being 'visible' In the workplace; and,
Two preliminary steps are important:
1. Become informed about the organization and its risks: about • Maintaining safety standards, e.g., correcting unsafe behavior.
and the nature of safety culture; and about the impact of
(collective) decisions and actions on safety. This information
can come from the formal culture assessment activities,
research, and informal information gathering.
2. Develop integrated strategy and supporting plans for safety
improvement that recognize the importance of culture and
guarantee the necessary resources, regardless of financial
pressures.
The assessment process described in Part B (see Section “How
Do You Measure Culture”) of this toolkit should highlight
actions and behaviors by senior managers that would Indicate
a greater level of commitment.
The simplest way for managers to show commitment is
through their behavior – the things they say and do.
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Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Walking The Talk: Just Culture
Overview
This section contains a brief 'checklist' for establishing a ‘just
culture'.
Organizational Justice
As indicated in Part A (see Section “Just Culture”), a just culture
is not only an ethically responsible way of dealing with inevitable
human errors – it’s a prerequisite for open reporting that enable
your company to learn about employee errors, near misses,
hazards and risks inherent in its operations.
The items shown opposite are the key features of a just culture.
Fair and equitable means rules and expectations have been
designed so they are understandable, reasonable and as
objective as possible (not open-ended and subjective);
expectations are communicated and acknowledges by those
affected by the rule/expectation; there is a consistent (applied
evenly to all employees including managers) investigation
procedure; negative consequences associated with errors and
violations are consistent (no favoritism, nepotism, chronyism).
Understood standards of acceptable behavior.
 Fair & equitable safety rules.
 Fair & equitable discipline for rule violations/errors.
 Encouragement of error reporting.
 Management review of gray area violations.
 Action taken to address error-causing conditions.
 Employee input on disciplinary procedures.
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Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
personal communications.
Walking The Talk: Communication
Overview
Communication is a fundamental and essential process
through which people cooperate to achieve any mutual
goal. This section explains the particular communication
competencies that organizational leaders can use to
support safety culture enhancement.
At one level, a form of 'technical' communication will occur in
a mining company to present the findings from the safety
culture assessment and to explain the improvement plans.
At a second level, communication is a behavior that, like
other actions, reflects collective attitudes and beliefs, and
thus the organization’s safety culture. For example,
what people say about safety, how often they say it and who
they say it to, are clear indicators of safety culture, failing to
speak up (e.g., at meetings), also sends (negative) signal about
safely culture.
An organization's leaders include not only the senior
management team, but anyone in a position where they can
influence others, e.g., team leaders, supervisors,
S&H pros, etc. These people have a manifest opportunity to
influence safety culture through the content and style of their
Communicating for Safety
An effective leader would support a safety culture by:
• Promoting safety: as a personal value, reporting related
activities and highlighting achievements.
• Clarifying safety goals: explaining the safety vision and
expressing clear expectations about safe behavior.
• Interacting with miners ‘at the face’ ,‘shovel pit’, etc. Be visible.
• Have a personal safety vision and share it openly.
• Listening: to safety concerns, seeking feedback, asking about
problems.
• Closing the loop: asking how incidents occur, communicating
lessons from safety occurrences, notifying improvements made.
• Shaping behavior: acknowledging and rewarding good behavior,
challenging and correcting inappropriate actions.
• Being just: communicating an understanding that people are
fallible and will make errors, applying principles of just culture
accordingly.
• Exercise caution to avoid sending mixed signals: “Be safe but we
need to do whatever is necessary to meet our numbers today...”
• Be credible: when you tell an employee you will do something,
be sure to keep to your word.
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Walking the Talk
Sr Management
Commitment
‘Just Culture’
Walking The Talk: Symbolic Behavior Change
Overview
Symbolic behavioral change is an important catalyst for
change to safety culture.
When demonstrators want to warn their fellow citizens about
a threat against freedom, they may occasionally chain
themselves up to the gate of the governor’s palace. Such an
action has no practical effect in itself. But it may well have a
lot of impact because of its symbolic power.
Politicians, managers and leaders also use symbols intensively.
Most of the time they do it intentionally. They show themselves
at the scene of the accident or natural disaster soon after the
Event wearing a black tie and say the right things about the
victims. Sometimes they do it unintentionally, e.g., a politician
is photographed by the paparazzi in a luxury vacation resort
immediately after announcing severe austerity measures tor the
country.
Crises, conflicts, or simply periods of change, are times in
which symbols are particularly sensitive issues. This is why
any project to change safety culture and behavior‘s will
have to handle symbols with caution. Managers will need to
Communication
Symbolic Behavior
Change
be very careful about the potential implicit meaning of what
they say or do. In one organization, a safety promotion
campaign had started to encourage the staff to voice their
concerns about safety, and complaints had been collected about
the unreliable in-house telephone system.
However, management rejected requests to replace it due to
argued budget constraints. At the same time, the administration
building was entirely renovated at considerable cost.
An implicit but devastating message about safety priority was
conveyed. Symbols can be used to facilitate changes. For
example, an unusual decision to close a sector or reduce
operational hours for safety reasons due to a momentary lack of
staff may send a strong signal that something has changed
about priorities. This message may then lead to a corresponding
symbolic change elsewhere.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Making a Difference: Improving the SHMS
Overview
A properly implemented safety and health management
system (SHMS) is complementary and interdependent with
the safety culture to create a safer organization. The SHMS
must be continuously improved.
A SHMS represents an organization's competence in the area
of safety and health management, and it is important to have
an SHMS and competent safety staff to execute it.
Safety culture can be summarized as the degree of commitment
to safety evident throughout the organization. This includes a
commitment to use the SHMS as intended (see Section “Is Having
an SHMS Enough?”).
As explained in Part A of this Toolbox, culture and behavior
are interdependent (see Section “What is a Culture?”), so they
may need to evolve simultaneously to reinforce each other.
Therefore, improving the normalized process of safety
management (the SHMS) should not only generate safer
practices, but also progressively generate values consistent
with these practices, i.e., improve the safety culture.
How to Improve an SHMS to Improve
Culture:
• Ensure your SHMS is owned by senior
management and that it is integrated into
other company systems, e.g., mining
planning, operations , maintenance, HR, IT.
• Distribute formal responsibilities for
execution of the SHMS among as wide a
group as possible and hold people
accountable for those responsibilities.
• Ensure everyone who is touched by the
SHMS has been educated in its form,
function, and fallibilities. Don’t let ignorance
prevent people from making the SHMS work.
• Conduct a gap analysis and collect root
cause analysis data to identify areas where
the SHMS needs improvement. These often
issues like competence, accountability,
communication, leadership, etc.
• Make sure there is a central focus on risk
management associated with critical mining
hazards (mobile equipment, ground support,
explosives, proximity detection, etc.)
Known to contribute to the majority of
incidents. You must go beyond MSHA
requirements.
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Making a Difference
Improving the
HSMS
Empowering
Employees
Making a Difference: Improving the SHMS
Overview
This section explains the importance of empowerment
as a desirable, if not essential element in the process
of improving operational safety through cultural
change.
The misperception is sometimes held that safety
management should be based on formalized processes,
detailed, prescriptive procedures and strict hierarchical
control over work practices and decisions.
In reality, this is impossible. Even well-written, detailed
procedures cannot prescribe people's behavior in every
work situation. Neither can workers be constantly supervised,
to ensure they do the right thing. Moreover, operational goals
(e.g., productivity, etc.) inadvertently or intentionally encourage
inappropriate action, e.g., cut corners to save time and money.
It is therefore better to share responsibility for operational
safety decisions. In practice this means involving company’s
employees in making important decisions about the dynamic,
and sometimes unpredictable, operational environment that
is typical of mining. These decisions are of course limited by
Upward Feedback
Building Trust
clearly established guidelines and based on a known level of
professional competence.
Empowerment
The term empowerment is often used to describe this
involvement. It simply means giving employees the necessary
skills, knowledge, information and authority to act with a high
degree of independence in achieving work objectives in the most
effective, safe and efficient manner.
Empowerment also has significant additional benefits to safety.
Employees gain a sense of independence and healthy selfimportance when given responsibility, This is likely to encourage
them to report problems and operational threats more readily, to
represent safety concerns assertively, and to express higher
expectations about their organization's safety and health
management practices.
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Making a Difference
Improving the
HSMS
Making a Difference: Upward Feedback
Overview
A key factor in safety management is the level of
knowledge managers have about what really goes on in
the field. Feedback processes are essential to a positive
Safety culture, so that managers can understand where
to make improvements to safety practices.
Upward communication channels generally exist in any
organization. These include face-to-face activities such as
meetings, briefings and debriefs, as well as written
processes, such as incident reporting and hazard
notification. All of these communication channels
provide the opportunity for frontline operators to pass
relevant information to their supervisors or managers.
In addition, line supervisors/managers are supposed to
observe and talk to their staff, and report to their managers.
As with many aspects of organizational functioning, there
is a distinction between policy - what should happen, and
practice - what actually occurs.
Often upward communication and feedback are ineffective.
There are many possible reasons for this. They include
Empowering
Employees
Upward Feedback
Building Trust
what might be called 'barriers' to effective communication.
Some of these are listed below, with suggestions for
how they can be overcome.
For senior managers a difficulty is that people often tell them
what they think they want to hear. A senior manager may have to
probe a little. For example, asking 'is everything okay?' will often
result in a bland response. Asking for somebody’s top 3 safety
concerns should elicit more concrete information.
Improving Upward Feedback
Feedback Barriers
Example Solutions
Organizational: time pressures,
inadequate resources (people,
etc).
Schedule time for one-on-one
contacts, be prepared to listen,
discuss issues.
Interpersonal: Authority, trust,
personal dislikes, confidence,
respect, language.
Reduce formality, develop
rapport with workers, work at
listening better.
Physical: busy, noisy
environment, lack of suitable
meeting rooms, distance from
other person(s).
Identify informal opportunities
to meet – coffee breaks, etc. Sit
next to the other person, not in
front of them.
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Making a Difference
Improving the
HSMS
Making a Difference: Building Trust
Overview
Trust can be defined as a belief or expectation that
someone will do what they say they will. Because
safety is dependent on cooperation between people
and the open sharing of sensitive information, a
positive safety culture cannot survive without trust.
Trust is necessary in each of the following relationships:
• Employees' trust of their managers, created for example
by managers encouraging people to speak up and
report safety problems without fear of being blamed.
• Employees' trust of their colleagues. This will be evident
from a work environment that allows everyone to do their
job with a reasonable level of confidence that things will
go well: where stress levels are manageable; and where
people display appropriateness about hazards and risk.
• Managers' trust of employees. This is evident, for
example, when they empower employees to make or
inform local safety decisions. So building trust is pivotal
for a strong safety culture.
Empowering
Employees
Upward Feedback
Building Trust
How to Build Trust
• Tell the truth.
• Be open, honest and direct.
• Do what you say you will do.
• Know the policies and procedures so
you can follow them.
• Treat people the way they expect to
be treated.
• Be supportive, e.g., address
employees; concerns, complaints and
criticisms.
• Follow-up on actions you commit to
address.
• Be willing to explain your actions
and decisions.
• Be willing to be challenged.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Opening Minds: Educating Senior Management
Overview
To carry out their safety responsibilities effectively,
senior managers require specialist education in safety,
leadership and culture.
All senior managers have an implicit (if not explicit}
accountability for the safety performance of their
organization, but their professional training and
background rarely provides the specific knowledge and
skills necessary to meet this responsibility.
Education is often required in subjects such as the
principles of safety, safety and health management systems,
organizational reliability, leadership development, among others.
This education does not require months or weeks of
classroom instruction. The important concepts and
principles can be mastered in short workshops.
Examples of educational subjects for company senior managers
Behavior
Enhancement
Leadership
Development
Change
Management
Effective
SHMS
Senior
Manager
Education
Culture
Enhancement
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Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Frontline Supervisor Leadership Competencies
Opening Minds: Developing Frontline Managers
Overview
It can be argued that the most important position for good safety is
the frontline manager. First level supervisors in any organization have
an important influence on safe behavior in the workplace, executed
through the variety of responsibilities or 'sub-roles' they perform.
The competence to perform effectively in these different roles
needs to be actively developed.
Supervisors require skills to influence safety in the following roles:
• As a leader, to promote safety as a high priority.
• As a trainer/coach to ensure operational personnel possess
appropriate non-technical skills.
• As a role model, to set an example in acting safely, reporting
incidents, and being just and fair.
• As an auditor/assessor, observing performance, setting and
maintaining standards and ensuring compliance with policies and
procedures.
• As a risk and resource manager, managing workload,
staffing, balancing productivity targets with safety goals.
• As an information channel, providing information, feedback
and keeping managers informed about safety issues and
concerns of operators.
• Remind others why standard operating procedures are important.
• Set a good example.
• Be regularly seen around the workplace. Management by walk around.
• Be available and ready to listen to people.
• Ask questions about what isIwas happening. Know what’s going on.
• Check to ensure that tasks are conducted as planned and trained.
• Look for conditions that make errors more likely and take action.
• Give regular advice and performance feedback.
• Recognize and praise safe practices. Catch people doing things right.
• Correct unsafe behavior.
• Remove pressures or other conditions that promote violations.
• Stop routine violations that occur and become accepted practice.
• Have "bad" rules and procedures changed.
See the NMA Leadership Development Toolkit for more information.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Learning to Learn
Safety Observation
Confidential
Reporting
Learning to Learn: Safety Observation
Overview
Direct observation of miners and mining-related workers
performing their everyday work is useful technique for
understanding better the nature of hazards, risks, errors and
safety-related risks in the mining industry.
Historically, operational fallibility in complex systems a mine and
mining-related facilities (prep plants, smelters, refineries, etc.) has
been brought to light by serious incidents involving fatal injuries
and near misses alike.
These are then investigated thoroughly, with a view to changing
the conditions, behaviors or inadequate barriers that contributed
to the event. Incidents and other safety occurrences are, however,
only the 'tip of the iceberg' in regard to understanding the
reliability of mining processes.
Relatively common everyday situations and reactions to these
(errors, adaptations, improvisations etc.) can provide valuable
insight into inherent weaknesses, even though no reportable
incident occurs. Safety observation schemes have been developed
recently to capture: information about the normaI operations and
everyday operator behavior.
Incident
Investigation
Post-Incident
Communication
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Learning to Learn
Safety Observation
Confidential
Reporting
Learning to Learn: Reporting
Overview
A reporting system can be a useful way to reinforce the safety
culture. Such systems complement mandatory reporting
processes, and allow safety lessons to be learned from
occurrences that may otherwise remain unreported. It is
sometime necessary to make reporting confidential to ensure
everything that should be reported is actually reported.
Transparency
Unless workers who experience or witness incidents (property
damage, injuries, fires, near miss, error, unsafe behavior, etc.), are
willing to report them to their management, mining companies
won’t have information necessary to understand how well their
systems are working (trailing indicators) and to learn how to get
better. Effective reporting, investigation and learning are core
competencies of effective safety and health management.
To be effective, confidential reporting systems must:
• Be non-punitive, where 'normal error' is involved
• Protect the identity of the reporter (confidentiality, not
necessarily anonymity); and ,
• Be based on trust. One breach of trust will inhibit
reporting and seriously disadvantage safety.
Incident
Investigation
Post-Incident
Communication
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Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
failures in the company SHMS.
Learning to Learn: Incident investigation
Overview
Although safety occurrences are unfortunate and costly, they
are a valuable opportunity for an company to learn about its
vulnerabilities. The amount learned from an event is
dependent on the quality of the investigation process used,
and the investigation team resources.
Examples of poor occurrence investigation practice :
• Reporting forms and requirements are not clear.
• No standard investigation methodology used.
• Tendency to focus on individual error.
• 'Blame' approach rather than a just culture philosophy.
• Little emphasis on understanding human factors.
• Systemic causes not property investigated or identified.
• Recommendations not followed-up.
• Lessons from occurrences not shared or communicated.
• Investigators not trained in formal investigation methods.
• Insufficient resources to look for trends in incident patterns.
It is important that every NMA CORESafety company have its
own approach to incident investigation (root cause analysis)
process. Optimally, the root cause analysis will focus on
Post-Incident
Communication
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Learning to Learn
Safety Observation
Confidential
Reporting
Learning to Learn: Incident Debriefings
Overview
The debriefing after a safety incident is another opportunity for an a
company to learn about its safety weaknesses. It may also be that a
'near miss' has caused some distress to those involved (or perhaps
even people only indirectly associated), which needs to be addressed.
For these reasons it is desirable that a team debriefing becomes a
routine event after an incident.
Aim of the Debrief
The primary aims of the incident debriefing are to understand what
happened, to learn from this, and implement actions of learning at
the team level, designed to prevent it from happening again. Lessons,
for the company or even the industry may emerge from the
debriefing, and should be communicated through appropriate
channels.
Approach
It is important that the debriefing be conducted as an open and 'blamefree' discussion, consistent with a just culture. Each team member
should be allowed and encouraged to express their point of view.
The team debriefing after an incident is another important way to learn
from the event, at the local and organizational levels. Feedback to
individuals should be constructive - "what would you do differently next
time" - not critical or directive ("don't make that mistake again").
Incident
Investigation
Post-Incident
Communication
The nature of work in the mining industry is such that people are both a
threat to safety, through their errors, and a safety barrier through their
error management skills and behavior. Non-technical skills like
communication, decision making and situational awareness, provide a
practical framework for discussing what happened, deciding how this
can be corrected, and communicating the lessons learned.
Emotional Responses after an Incident
When someone is involved in or witness to an extremely stressful event,
e.g., an incident involving a life-threatening of serious injury, they may
experience traumatic stress. Personnel who have been seriously
affected by an event should not be required to take part in a team
debriefing. Instead, they should be referred to a trained mental health
professional who is able to conduct a formal stress debriefing (e.g.
using critical incident stress management.
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Identifying Improvements
Understanding the
Culture Assessment
Priorities &
Limitations
Planning for Culture
Change
Walking the Talk
Sr Management
Commitment
‘Just Culture’
Communication
Symbolic Behavior
Change
Making a Difference
Improving the
HSMS
Empowering
Employees
Upward Feedback
Building Trust
Opening Minds
Educating Senior
Managers
Developing
Frontline Leaders
Learning to Learn
Safety Observation
Confidential
Reporting
Incident
Investigation
Post-Incident
Communication
Day-to-day Culture
Safety
Communication
Staying Vigilant
return
Day-to-day Culture
Safety
Communication
Staying Vigilant
Day-to-Day Culture: Safety Communication
Overview
Safety culture is not a static entity. It changes and morphs based on
changing in leadership, behaviors, priorities, and many other factors.
Consistent and positive communication is one way to ensure safety
culture is maintains its equilibrium.
Types of Safety Communication
There are a number of communication mechanisms that can be used
to maintain and enhance your safety culture:
• Tailgate meeting: Usually conducted at the start of the work shift,
this short (5 – 15 minute) is a chance for managers to ensure crews
and workers understand the work for the day, any safety-related
issues , check the readiness of their workers, etc.
• E-mail & memos: Never as effective as verbal communication,
email and memos serve an important means to provide safety
communication as often deemed appropriate, provided your
audience has access.
• General safety meetings: Normally conducted on a monthly or
quarterly basis, this all hands approach allows management to reach
a broad audience. The more involvement from workers in organizing
and conducting these meetings, the better.
• One-on-one contacts: Arguably the most effective form of safety
communication. This allows leaders to share their safety vision,
provide performance feedback, say thanks, develop relationships,
give direction and receive feedback.
• Newsletters & mailings: Like email and memos, this form is less
personal, but can serve as a good platform to recognize employees,
ensure they understand what is going on in the company, talk about
progress or challenges
• Posters, banners, signs: Visual communication is an MSHA/OSHA
requirement in certain instances, is a behavior antecedent, but must
be managed -- Don’t let the poster sit unchanged for years on end.
• Safety share: An important culture builder used at the beginning of
all business meetings (not just safety meetings). A short (5 min)
opportunity to ask for a volunteer to talk about anything that will
help people work or live more safely. It doesn’t need to be planned.
• Talk: Safety lives in conversation. The more that miners talk
amongst themselves and with their managers about safety, the more
engrained it becomes in the culture.
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Day-to-day Culture
Safety
Communication
Staying Vigilant
Day-to-Day Culture: Staying Vigilant
Overview
Vigilance (aka, wariness) means being on guard or aware at all times.
Vigilance is critical to not losing focus Just as an organization can
demonstrate vigilance as a feature of its safety culture, teams and
individuals can display vigilance at a local level, through their alertness
to hazards, both seen and unseen.
What is Vigilance?
At a global level, vigilance refers to the way an organization remains
constantly aware of hazards, unsafe behavior, changing risk conditions,
and potential failures, and prepares for unexpected although unlikely
and rare events. It is perhaps one of the more subtle and obscure
characteristics of a safe mining company, yet one that clearly
distinguishes a positive safety culture from one that is less mature.
All employees have a role to play in being vigilant, since by definition,
safety culture is based on 'shared values and norms of behavior
articulated by senior management and translated with high
uniformity into effective work practices at the front line.
More importantly, all employees can practice vigilance when carrying
out their day-to-day work. The checklist opposite suggests some
behaviors at both the individual and organizational levels that
demonstrate vigilance.
Vigilance Checklist
Management
Miners &
Workers
Constant Assessment
What is the safety significance
of near misses & unsafe
behavior?
√
√
What level of attention or
action is required?
√
√
Accepting that failures, errors
and near misses and actively
anticipating them.
√
√
Considering unexpected events
“what if” occurrences.
√
√
Vigilance & Anticipation
Not Being Complacent About Safety Success
Focused on past incidents or
failures as reminders.
√
√
Don’t let safety awards or
recognition convince you to
ease off safety activities.
√
√
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CORESafety Safety Culture Enhancement
Toolbox
Defining Safety Culture
Getting Started
Identifying Improvements
Rio Tinto Minerals
Safety Culture in context
Launching the Survey
Walking the Talk
Alpha Natural Resources
Changing Safety Culture
Interviews & Workshops
Making a Difference
Luminant
Enablers & Disablers
Analysis & Conclusions
Opening Minds
NASA
Safety Culture & SHMS
Feedback & The
Way Forward
Learning to Learn
FAQ
Re-assessing
Day-to-day Safety Culture
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
return
Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
return
Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Vision & Values
Rio Tinto Minerals
Background
Rio Tinto Minerals (RTM) , a division of Rio Tinto Group employs
approximately 2000 globally and has operations in North and South
America, Europe and Asia. It is a leading supplier of refined borates
primarily mined at its U.S. Borax mine in Boron California.
The company has a deep history of innovation and leading health,
safety & environmental performance going back to the days of the
‘20 mule’ teams who hauled Borax from mines in Death Valley over
many miles of rough terrain and never lost a mule or wagon.
Today RTM focuses on innovation and leading practices in mine safety,
the approach of building and maintaining a desirable and sustainable
culture. Health, safety and environmental stewardship are values that
underpin their business objectives.
Focusing on Culture
Results
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Safety & Health Management
Overview
RTM’s approach to safety, health, environmental and quality (HSEQ)
management is captured in a simple seven point philosophy:
• Look for the motivators of behavior to understand and resolve issues
and reinforce desirable behaviors (consistent with values).
• Integrate HSEQ systems, tools, and sharing best practices.
• Promote HSEQ leadership at all levels of the organization.
• Generate understanding of regulations and improve systems to
motivate all to identify and resolve issues.
• All employees are responsible to take action when operations are out
of compliance or control.
• Drive open, transparent culture by finding fact, not fault, followed by
effective corrective actions and communications.
• Promote conscious risk awareness and judgment with effective
mitigation.
“Rio Tinto Minerals (RTM) Health Safety and
Environment strategy is based on the RTM
Sustainability Policy and outlines the activities that
support that policy. The strategy includes education,
interactions, integration of HSE and simplification
where possible, recognition of desired behaviors, risk
assessments, and sharing of information across the Rio
Tinto Diamonds and Minerals group. Year to year, we
build on our experiences and refine as we go to sustain
a workplace where people feel empowered to act on
behalf of the safety and health of the people around
them and the protection of the environment.”
Xiaoling Liu
CEO, Rio Tinto Minerals
Focusing on Culture
Results
HSEQ Management System
To optimize performance, RTM has developed and implemented an
integrated HSEQ management system that is operational at all RTM
sites worldwide.
• Foundation of leadership commitment and resources.
• Clear expectations.
• Consistent consequences to reinforce behavior.
• Integrated HSEQ.
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Managing Safety Culture
RTM strives for a culture of safety and ‘actively caring’. It is a culture
where all employees feel motivated and empowered to go beyond the
call of duty for the well being of others. All RTM leaders are educated
on the concepts of culture and how it is influenced, as well as the
science of behavior.
Sustainable culture teams have been established throughout the
organization with all employees encouraged to participate. These
teams are also trained on the science of behavior and the theories of
risk psychology so that they can be champions for improvement with
the understanding to make an impact. They also have specific
objectives such as:
• Facilitate the use of employee perception surveys
• Provide training on people-based safety and risk
• Extract, analyze publish behavioral data
• Form behavior improvement strategies and plans
• Remove barriers to the desired behaviors
• Recommend ideas for sites or departments
• Communicate to employees and promote cross communications
• Actively listen to employees
• Conduit for employee beliefs to management
• Coach other employees
Focusing on Culture
Former Paradigms
•Top-down control
•External enforcement
•Outcome focused
•Failure oriented
•Negative motivation
•Rugged individualism
•Individual fault-finding
•Safety as a priority
Results
More Effective Paradigms
•Bottom-up ownership
•Shared responsibility
•Process (behavior) focus
•Achievement oriented
•Positive motivation
•Interdependent teamwork
•Systems fact-finding
•Safety as a value
“It is the culture that defines us, and it is the function of
leadership. In my mind, the measure of effective leadership is the
ability to identify the hallmarks of a desirable culture and allow
all employees to be engaged in the journey to get there. Culture
is a complex mesh of perceptions that factor in emotion, logic
and experience, culminating in the shared beliefs of employees
which in turn translates into workplace behavior. Understanding
the concept of culture how it influences employee behavior is
key. Even more crucial is being conscious and deliberate in our
actions and system design that underpin and support the culture.
That is effective leadership.”
Matt Pedersen-Howard
Director, HSE, Rio Tinto Minerals
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
HSE Performance
Introduction of the performance standards
4
Introduction of people-based safety
All Injury Frequency Rate
Metrics
RTM had an all injury frequency rate (AIFR)
of 0.36 for 2011, representing 8 reportable
injuries for the year. Over 2700 near
hits (events that did not result in injury,
damage or loss) were reported, resolved
and communicated in 2011 at RTM
locations. Over 270,000 desirable
behaviors were observed and
documented in 2011 at RTM locations
In the first quarter of 2012 over 50% of
all documented behavior observations
we completed by operators and
maintenance personnel.
3
Revised & integrated HSEQ MS
2
1
0.36
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
RTM is one the safest mining companies in the U.S.
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
return
Alpha Natural Resources
ANR Overview
Running Right
Background
Alpha Natural Resources (ANR) is a mining company built on change.
Not that change was an intentional part of their strategy, but rather that
change has been the consequence of an aggressive growth strategy that
has seen ANR become one of America's premier coal suppliers with
affiliate coal production capacity of more than 90 million tons a year.
Alpha is the nation's leading supplier and exporter of metallurgical coal
used in the steel-making process and is a major supplier of thermal coal
to electric utilities and manufacturing industries across the country.
Alpha and its affiliates employ approximately 14,000 people and
operate more than 150 mines and 40 coal preparation and coal
handling facilities in the regions of Northern and Central Appalachia
and the Powder River Basin.
Kevin Crutchfield, CEO
“At Alpha, we believe that all injuries
are preventable. That's why safety is
integrated into every activity. If a task
cannot be completed safely, it will not
be performed. Every person has a
responsibility not only for their own
safety but for the safety of those around
them. You'll find every level of our
organization is proactive in
implementing safety processes that
promote a safe and healthy environment.
Together, we can achieve our goal of
a total health and safety culture.”
Focusing on
Behavior to Drive
the Culture
Results
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Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Results
Running Right Principles
• Everyone shall have a VOICE and a seat at the table.
Running Right
• Each functional area shall utilize a standard card by which every
Overview
employee can document safety observations and suggestions for
ANR believes that all injuries are preventable. They integrate safety
operational improvements, and comments shall be forwarded to
into every activity. If a task cannot be completed safely, it will not be
management in an open and unrestricted manner.
performed. Every person has a responsibility not only for their own
safety but for the safety of those around them. You'll find every level • Every safety observation and operational improvement suggestion
of our organization is proactive in implementing safety processes that shall be considered by an employee involvement group.
• Timely feedback shall be given to employees to facilitate transparency
promote a safe and healthy environment. The goal of ANR is a total
and trust in the process.
health and safety culture.
Running Right Characteristics
• Golden Rule: Treat all stakeholders as you wish to be treated.
• Servant Leadership: Act humbly and leave egos at the door.
• Deal honestly and treat everyone with respect and dignity.
• Listen without judgment to ideas.
• Respond in a timely and appropriate manner.
• Place the welfare of the company over personal desire.
• Work hard and work as a team.
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Alpha Natural Resources
ANR Overview
Running Right
Focusing on Behavior to Drive the Culture
Managing Safety Culture
ANR has always recognized that its employees are the individuals who
create and add value in the company. Focusing the collective energy of
all employees has tremendous power and potential to discover and
benefit from new opportunities. ANR’s management believes that
energy will power the engine that drives the organization forward.
Working collectively with complete alignment of contribution ensures
that team-based efforts continue to produce the greatest results.
Integration of Massey Energy
In June of 2011, Alpha acquired Massey Energy. Despite this very
significant integration, Alpha safety performance continues to improve
and influence heritage Massey mines and minds. Using an extensive
cultural and leadership transformation processes, Running Right and
Leading Right, Alpha’s management is creating a common culture with
respect for the welfare of the employee, their family, their communities
and their futures. To change safety, they are changing the culture.
Focusing on
Behavior to Drive
the Culture
Results
From
To
Reactive:
Pro-active:
Failure Oriented
Rewards for Outcomes
Top-Down Control
Rugged Individualism
Fault Finding (blame)
Quick Fix
A Priority
Achievement Oriented
Rewards for Behaviors
Bottom-up Involvement
Teamwork
Fact Finding (investigate)
Continuous Improvement
A Value
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Alpha Natural Resources
ANR Overview
Running Right
HSE Performance
Employees at 84 locations within the Alpha mining network completed
2011 without a lost-time injury . Alpha’s operations and the people
running them have won multiple awards for safety.
Focusing on
Behavior to Drive
the Culture
Results
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
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Luminant
Company Overview
Luminant Safety
Background
Luminant is a Texas-based electric utility, the largest power generator in
the state, and a subsidiary of Energy Future Holdings. Luminant
operates 15,400 MW of power generation fueled by a mixture of coal,
natural gas, and nuclear, and is also one of the largest purchasers of
wind energy in the country. A privately held company, Luminant
employs more than 4,000 with the majority of hourly workers
represented by the International Brotherhood of Electrical Workers
(IBEW). It operates eight surface lignite mines and produced 32 million
tons of coal in 2011.
Vision
Luminant’s vision is to be recognized as a leader in the energy industry
and an enabler of economic development and social progress by
providing safe, reliable, affordable and environmentally sustainable
power.
Philosophy
Safety – Always our first priority
Operational Excellence – The foundation of our success
Stewardship – Our commitment to the environment
and our Texas market
Community – Our dedication to our colleagues and
our neighbors
Focusing on Culture
Performance
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Luminant
Company Overview
Safety & Health Management
Luminant Safety
Focusing on Culture
Performance
This would prove to be very challenging given the diversity of the
cultures and associated regulatory structures (mining, fossil generation,
and nuclear). The company desired a consistent approach to safety and
was seeking to find the “Luminant Way” to manage safety. Thus,
company leaders elected to take two big steps forward:
Overview
Luminant’s historical approach to safety management was a
combination of MSHA and OSHA compliance, industry specific
initiatives based on benchmarking and a measure of company-specific
1) The adoption of a zero incident safety performance goal.
elements aimed at addressing injury trends and changing business
needs. Beyond regulatory compliance and a desire for a safe working
environment there was not a comprehensive management system.
A Need for Change
In the early-2000s, the company knew it wanted better safety
performance and recognized that its employees were capable of much
more, despite performing in the top 50% of companies in the industry.
Two business units, mining and generation, had reached a performance
2) Based on work done in the nuclear energy industry where
plateau. Each business unit would demonstrate strong performance
consistent safety performance and optimization of operator
one year, but neither was able to achieve a sustainable level of safety
behavior were critical to industry survival, the company elected to
excellence. The company needed a way to build a more robust safety
adopt and adapt ‘human performance improvement’ (HPI) with a
culture that would achieve and sustain superior performance to reach
focus on culture improvement that emphasized the pursuit of a
a goal of ZERO injuries.
‘just culture.’
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Luminant
Company Overview
Luminant Safety
Focusing on Culture
Human Performance Improvement (HPI) & Culture
HPI is a discipline that focuses on incident prevention and error
reduction by understanding the immediate causes and systemic
contributors to incidents and applying tools to prevent recurrence.
Luminant’s approach to HPI involves a strongly engaged leadership
team, applying new risk assessment tools, reducing human error and
improving the organization’s culture by improving organizational
“justice.”
Culture Change
The focus on justice is logical: to improve safety and operational
reliability, all incidents and near incidents must be reported and
investigated to determine root cause. Workers will report if they know
that management is looking for facts and not fault -- a sense of justice.
Justice is rooted in trust, fair and balanced rules and procedures, fair
and equitable discipline for all.
The Luminant Strategy
• Increased Executive Involvement: e.g., daily calls start with safety
status at each location; senior executives review all reportable injuries
and significant near misses.
•Adopted “Safety Zero” as a company goal: emphasize incident
reporting; improved cause analysis of each incident; better data analysis
and emphasis on sharing key learnings; adopted leading indicators to
emphasize leadership involvement and employee engagement in safety
processes.
Focusing on Culture
Performance
• Embraced Human Performance Improvement (HPI): used new
methods to identify risks, reduce human error, and pursue a
“just culture”; all leaders received two days of HPI
fundamentals training; hourly employees received two fourhour sessions on HPI fundamentals and additional training on
specific HPI tools.
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Luminant
Company Overview
Luminant Safety
Focusing on Culture
Luminant Recordable Injuries
HSE Performance
Generation HPI
20
S&H Management Metrics
Luminant is realizing substantial safety performance improvements
since the inception of their human performance improvement and
culture focus. The company’s 2011 total recordable incident rate
was 1.06, a 10% improvement from 2010. However, the last four
quarters have shown a strong and stable improvement trend and
2012 is shaping up to be record-setting year.
Success Factors
Luminant’s management ascribes their improved performance to
many factors including human performance improvement;
however, it involved and continues to require:
• Top down commitment both symbolic and practical such as:
budgetary support for acquiring/developing HPI experts;
commitment to train the whole organization;
senior managers modeling the desired behavior (willingness
to change).
• A well-developed and supported implementation plan.
• Knowledgeable and credible HPI subject matter experts.
• Strong communications plan.
• Patience. This is a culture change activity and requires time to take
root and prosper. It requires a commitment to the continued journey.
Advice to Other Mining Companies
Culture change is an “all-in” commitment that requires a good plan,
patience and a willingness by ALL to embrace change.
Performance
Mining HPI
18
16
14
12
10
8
6
4
2
0
1Q09
2Q09
3Q09
4Q09
1Q10
2Q10
3Q10
4Q10
Recordable Injuries
1Q11
2Q11
3Q11
4Q11
1Q12
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
return
NASA
World Class
Organization
Challenger
NASA
A World Class Organization
Not all insightful safety culture case studies come from the mining
industry. Take the example of NASA. At first, you might not think that
NASA and mining companies have much in common. However, when
you look at risk there are strong parallels. In NASA and in mining if you
don’t manage risk appropriately, you risk not having anything to
manage.
NASA is a globally iconic organization with the best minds,
engineering systems, resources, standards of excellence and
unlimited scientific ambition, i.e., they know that they must take risks
to advance the science. And like mining, there is a strong thread of
autonomy and confidence running through the respective cultures.
Managing Risk
In recent years NASA’s mission has been to "pioneer the future in
space exploration, scientific discovery and aeronautics research.” The
Space Shuttle program made space exploration almost pedestrian in
its ability to make the extremely complex look simple and totally
manageable. NASA has enormous expectations focused on its by
Congress and the general public, both in the U.S. and globally. NASA
has always had a can do attitude and an ambition to extend what was
believed to be possible all the while trying to meet the expectations of
the public. To quote a famous NASA manager; “Failure was not an
option.”
Columbia
Lessons Learned
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NASA
World Class
Organization
Challenger
Challenger
January 28, 1986
It was the most anticipated Shuttle mission in the history of the
program. A teacher was going into space and the world was watching
that cold Florida morning. Solid rocket engineers from Morton Thiokol
warned NASA managers that the O-rings in the solid rockets were not
designed for a cold weather launch. However, other shuttle launched
had experienced some O-ring damage and not negatively affected the
integrity of the shuttle. However, this time it did.
Investigation
The Challenger Investigation Board (Rogers Commission) took a deep
look at NASA and concluded that: NASA’s organizational culture and
decision-making processes about risk had been key contributing
factors to the accident.
Pressure to Launch & Filtered Warning Messages
The commission concluded that NASA senior management created
pressure where there need not to be as a result of their interest in
maintain the launch schedule. Previous launches had revealed near
failures of the same O-ring that failed catastrophically on Challenger.
Engineers with the solid rocket booster manufacturer warned their
management and NASA of the need to stay within the O-ring design
specification regarding ambient temperature. Those warning were
either filtered and over-ruled by NASA senior management. This is
‘normalization of deviance’ allowed small changes in safety design to
occur because previous changes did not result in losses.
Columbia
Lessons Learned
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NASA
World Class
Organization
Challenger
Columbia
Moving on After Challenger
As a result of the Challenger disaster, NASA lost the confidence of the
general public, caused Congress to question the value of the agency,. It
took many years as NASA redesigned the shuttles and regained its
funding and momentum. Shuttle began to be launched again, until a
lunch in January 2003 when foam form the rockets peeled off and
struck the leading edge of the shuttle . Concerned that re-entry would
cause destruction of the shuttle, NASA managers had two options:
stay in space and wait for the Russians to rescue the crew; 2) chance
re-entry. Upon re-entry, the shuttle disintegrated over Texas. How
could this have happened after Challenger?
Columbia Investigation
Yet another independent investigation revealed:
“For both accidents there were moments when management
definitions of risk might have been reversed were it not for the many
missing signals -- an absence of trend analysis, concerns not voiced,
information overlooked or dropped…“
“NASA organizational culture had as much to do with this accident as
the foam.”
Columbia Investigation Report
Columbia
Lessons Learned
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NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
NASA
Lessons Learned
Like British Petroleum, NASA seemed to be immune from disasters
owing to their long-term safety performance and their reputation for
doing the (nearly) impossible. But even for world class organizations,
catastrophic loss is a real possibility if sufficient risk is present.
Those Who Fail to Learn From History are Doomed to Repeat It
Great management systems make a big difference in a high risk
industry or organization, but they couldn’t save the Challenger crew
or the Columbia crews. The two disaster look like two train wrecks. In
hindsight, the risk looks obvious. How could these incidents happen in
an organization with so much power and influence? It is because no
matter how strong and effective a company’s management system
may be, no matter how much power and influence the organization is
in the community, if the system it isn’t based on a foundation of a
strong and positive safety culture that enables the SHSM to be an
effective tool.
Leadership & Culture
Given that leadership has a very strong influence on safety culture,
modern mining companies are focusing on having good systems, but
also in optimizing their leadership (focus on transformation), and
culture. They are both measureable and manageable. CORESafety
has been designed by NMA to help companies address all three
variables in an integrated manner.
Systems
Culture
Leadership
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Rio Tinto Minerals
Company Overview
RTM’s Approach to
S&H Management
Focusing on Culture
Results
Results
Alpha Natural Resources
ANR Overview
Running Right
Focusing on
Behavior to Drive
the Culture
Luminant
Company Overview
Luminant Safety
Focusing on Culture
Performance
NASA
World Class
Organization
Challenger
Columbia
Lessons Learned
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
return
Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
Can You Change Safety Culture?
New Views on Culture
For many decades in industry it was assumed that safety culture was
a conceptual state and it was treated as such by most companies. It
was something you could make reference to , e.g., “We have a good
safety culture”, without knowing if that was true from an objective
scientific perspective. Few companies thought about trying to
intentionally change their culture. Efforts were well-intentioned, but
random. That experience is starting to change.
Today, after many years of research and experimentation, we know
that there is a strong correlation between highly safe companies and
their safety cultures. That is, these companies generally have certain
organizational characteristics reflected in their organizational culture
that were not random. Examples of these characteristics include, but
are not limited to: organizational justice, open reporting of errors and
incidents, a strong need to learn from those errors and incidents, trust
between workers and management, a lack of complacency related to
performance (they generally don’t relax when S&H performance
continuously improves), a focus on behavior as a contributor to
incidents, to name a few.
Today, mining companies can change their culture without being
social scientists and without huge outlays of resources. These are
measureable and manageable processes that only require desire to
change, a little knowledge and determination. There is no one safety
culture. Each organization is different so what works for one may not
work for another. No one size fits all.
How Long Will it
Take?
Will it Last?
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Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it
Take?
Will it Last?
What’s the Process?
No One Right Way to Improve Culture
There are many different strategies and approaches to culture
enhancement. However, the basic approach that is integrated into
CORESafety is foundational to all other approaches:
• Determine what aspect(s) of the culture require change or
enhancement;
• Measure the current status of the culture using employee
confidential perception surveys;
• Assess the meaning of the perception data;
• Formulate the change strategy that will be effective and sustainable;
implement the strategy.
Define culture characteristics
Develop confidential perception survey
Conduct survey
Conduct survey analysis
While it is essential that senior management lead the process, and
ensure that they understand the current state of the culture, it is the
action plan that is most important. For example, if employee feedback
indicates that there are issues with trust between management and
workers, than management must have the objectivity and motivation
to know how to improve trust and then make it happen.
Many U.S. mining companies have had success in improving
organizational culture by focusing on behavioral issues. Behavioral
optimization directly involves employees, directly minimizes the
potential for safety-related incidents, and helps address key variable
in culture: culture is always expressed in employee behaviors – good
and bad.
Confirm strengths & weaknesses with sr management
Develop strategy to enhance weaknesses & reinforce strengths
Implement strategy
Repeat perception survey
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Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it Take?
How Long Will it
Take?
Will it Last?
• Prevention of all incidents is core company value
• Good performance, but no complacency. Never satisfied
• Many SH metrics, all process driven
• Management confident about system
• Employees trust management, Feel confident about safety
• Continuous improvement in hazard controls
Culture Sustainability
There are many different levels of organizational culture maturity.
The Hudson safety maturity model is the most commonly recognized.
Before you can estimate how long it will take to change a culture , it
must be known where it is on the maturity scale. If a culture is at the
• Majority of employees believe safety is critical to their job
bottom, it stands to reason that more time will be required. This may
• Frontline management accepts responsibility for safety
be measured in years not just months. Conversely, if a culture is
• Employees feel valued and believe they are treated fairly
• Significant effort invested in proactive safety measures
already fairly advanced, it has less change to undertake and will
• Primary cause for incident sis management decisions
therefore require less overall time. There is no science to indicate
• Proactive safety metrics used
how long it will take; however, companies will seriously committed
leaders will change faster than those in which the
• Frontline involvement viewed as critical to safety improvement
leaders are inactive in the change process. Keep
• Majority of employees accept personal responsibility for their safety
in mind, change efforts have the highest likelihood
• Management sees there are many causes to incidents, including their decisions
of success when driven by visible support from
• Systems are in place to manage hazards, but are mechanical
• Majority of employees willing to work with management to improve safety
leadership, when employees know what they
have to do to support the change, and when
adequate
Continually
• Safety defined by adherence to rules, procedures & engineering controls
resources are
• Managers perceive that most incidents caused by unsafe behavior
improving
• Management believes most incidents are preventable
dedicated to
• Safety is viewed as a business risk
Cooperating
the change.
• Management puts time into prevention, but personal involvement is reactive
•Technical & procedural safety solutions
• Primary focus: compliance with regulations
• Not seen as a key business risk
• Many incidents seen as unavoidable
• Safety dept responsible for safety performance
Involving
Managing
Emerging
Hudson Safety
Culture Maturity Model
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Frequently Asked
Questions
Can You Change
Safety Culture?
What’s the
Process?
How Long Will it Last?
As with the natural world, if a system has no ongoing support,
and it isn’t already self-sustaining, it will decline and decay in
time. The same is true for all man-made structures and systems.
If you do nothing your organization’s safety culture is more likely
to find and stay at the lowest safety culture maturity level.
Strong, positive safety cultures require ongoing maintenance
and support. With that support, there is no reason the culture
can’t be sustained many years. There are examples of sites and
companies who have sustained world-class performance (based
on a strong culture) for decades. Yes, it can last.
Temporary versus Permanent Change
Culture change involves a number of subtle variables and
change that may be obvious at first may fade because it didn’t
have sufficient time to become part of the organizational DNA.
Ways that safety culture change can be reinforced include, but
are not limited to:
• Senior and line management modeling the behaviors
necessary to maintain the improved culture;
• Involve workers in the culture change but empowering them
to make decisions and be involved in the change process.
Change is lead by senior management, but can only be
sustained if workers are directly involved.
How Long Will it
Take?
Will it Last?
•It is important to remember that is it much easy to sustain a
positive strong culture than it is to build the culture in the first
place.