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5
Safety Culture
Specific to self-escape, a safety management system can be thought of as consisting two
broad domains: prevention and preparation. Prevention focuses on the policies, programs, and
activities that seek to prevent adverse events and injuries from occurring. Actions within this
domain generally follow the traditional hazard control hierarchy, which places primary emphasis
on eliminating or controlling hazards in the work environment. Given the potentially catastrophic
consequences of underground coal mine fires and explosions, priority should be placed on
prevention through the use of redundant controls or what is sometimes referred to as defenses in
depth (Rasmussen, 1997; Reason, 1997; Saleh and Cummings, 2011).
Preparation involves actions directed at avoiding or minimizing the adverse consequences
of system failures once they occur or begin to occur. Escape training, personal protective
equipment and communication technologies, equipment caches, refuge facilities, suppression
systems, and lifelines and other wayfinding aids are all part of preparation. The goals here are to
make self-escape unnecessary, or failing that, as safe and as simple as possible.
Discussions of safety management systems often invoke the concept of safety culture.
The term safety culture first gained prominence in the aftermath of the Chernobyl disaster
(Pidgeon and O’Leary, 2000). Indeed, a string of subsequent high-profile disasters served to
focus both public and scientific attention on the role that a safety culture and other organizational
factors play in the history and unfolding of such events (Weick et al., 1999).
Safety culture has been defined a number of ways, (see e.g., Wiegmann et al., 2004;
DeJoy, 2005), but most definitions highlight the shared norms, values, and assumptions pertinent
to safety that exist within an organization and that serve to shape relevant attitudes and behaviors
within the organization. At the very heart of safety culture is the relative importance of safety in
comparison with other organizational priorities, such as production and cost control.
Safety culture forms the organizational context in which all safety-related actions take
place. It provides the subtle and sometimes not so subtle cues about the importance of safety, the
safety-related behaviors that are expected, the resources available to support safety, and the steps
taken to identify eliminate or control hazards. As depicted in Figure 5-1, safety culture has
general or global effects on how people in an organization receive and process information and
think about safety-related matters. It also affects how the organization embraces and utilizes
available hazard control technologies (i.e., operational hardware) and implements specific safety-
related policies and procedures to minimize risks and maximize safety performance (operational
software).
Safety cultures develop over time as organizations operate and adapt to local conditions,
respond to events, and as a function of their leadership. In one more concise formulation (Shein,
2010), cultures evolve as organizations learn to cope with problems of external adaptation and
internal integration. The safety culture of an organization can vary in terms of valence (positive
to negative) and strength (strong to weak).
A positive safety culture assigns high importance to safety, makes needed investments,
takes appropriate actions, and closely monitors its performance with respect to safety. In a
negative safety culture, safety has a relatively low priority and is often most likely to receive
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attention only after some type of adverse event has occurred. Such organizations frequently cut
corners when it comes to safety and seek quick and inexpensive solutions.
Helps shape
expectations;
mental models:
may increase
probability of
certain types of
Culture
Adoption, revision,
biases and errors compliance: SOPs,
training, fitness for
Adoption/use of duties standards,
equipment and admin. practices
technologies
Operational Operational
Hardware Software
Performance
FIGURE 5-1 General model of safety culture influences on system performance.
SOURCE: DeJoy et al. (2008).
Safety culture is defined above as involving shared norms, values, and assumptions. It is
this shared notion that brings forth the idea of culture strength. A strong safety culture is one in
which there is a high level of agreement about the importance of safety within and between work
groups and other organizational divisions or units – from top to bottom. Where consensus is
weak, absent, or highly variable across units, the safety culture is weak. Various attempts have
been made to identify the core characteristics of a positive safety culture: see Box 5-1.
BOX 5-1
Characteristics of a Positive Safety Culture
There would be general agreement throughout the organization that:
safety is a clearly recognized value in the organization,
accountability for safety within the organization is clear,
safety is integrated into all activities in the organization,
a safety leadership process exists within the organization, and
safety culture is learning driven in the organization.
SOURCE: Adapted from International Atomic Energy Agency (2006, pp. 9-10).
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HIGH-RELIABILITY ORGANIZATIONS
Considerable attention within the safety literature has been given to so-called high
reliability organizations. These are organizations that routinely operate in dangerous, high-hazard
environments but that maintain remarkably good safety records. Commercial aviation, aircraft
carriers, and energy-generating facilities often qualify as high reliability organizations. Such
organizations are characterized by continuous and active engagement in safety that extends
beyond controlling or mitigating untoward events and includes actively anticipating and planning
for them (Roberts, 1990; Rochlin, 1999; LaPorte, 1996).
Box 5-2 summarizes the main attributes of high-reliability organizations. Many of these
attributes resemble the characteristics of a strong, positive safety culture noted above (leadership
and management support, learning orientation, etc.). Close attention to the attributes of high-
reliability organizations, however, reveals a very strong focus on communication. Two of the
attributes deal directly with communication: having open and candid communications about
safety matters, and having openness about safety problems and reporting. A third attribute, safety
mindfulness, implies that a very high priority is assigned to emergency preparedness and plays
out through communication.
High-reliability organizations are often described as being preoccupied with the idea that
things could go seriously wrong at any moment; that risk and safety must always be uppermost
in one’s thinking; and that error will seek out and find the complacent (Rochlin, 1993). High-
reliability organizations can be described as having a continuous type of safety chatter that serves
the important functions of keeping everyone in the organization alert and updated on system
status and unfolding activities. This type of free flow of information is especially apparent during
complex or critical operations. To a very considerable extent, maintaining a high level of safety
performance is a social-communicative process.
BOX 5-2
Attributes of High-Reliability Organizations
• Management commitment to safety
• Safety resources and incentives
• Open and candid communications
• Migration of authority based on functional skill
• Low frequency of unsafe behavior, even under production pressures
• Priority of safety, even at expense of production or efficiency
• Continuous safety mindfulness
• Openness about errors and problems; errors reported
• Organizational learning
SOURCE: Adapted from Rochlin (1999) and Singer et al. (2003).
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SAFETY VOICE
The importance of communication has also been noted within the safety culture literature.
For example, Reason (1997, p. 195) emphasizes the importance of “creating a safety information
system that collects, analyses, and disseminates information from incidents and near-misses as
well as from regular proactive checks on the system’s vital signs.” He also argues for the
importance of free and open communication, especially the freedom to report safety problems
without fear of blame or retribution.
More recent research has referred to this as “safety voice,” defined as behaviors that seek
to improve safety by identifying shortcoming and possibilities for improved performance (Barton
and Sutcliffe, 2009; Conchie et al., 2012). Having a learning orientation is a key element of a
positive safety culture and high-reliability organizations. And having a learning orientation
requires having timely access to relevant information and this involves free and open, two-way
communication. This emphasis on learning was also highlighted by Galvin (2005) in an analysis
of cultural maturity in the coal industry in Australia: see Figure 5-2.
FIGURE 5-2 Australian mining: Changing OHS behavioral culture
Note: The acronym OH&S refers to occupational health and safety.
SOURCE: Galvin (2005, Figure 6) Reprinted with permission.
Some high-hazard industries, such as firefighting and commercial aviation, have
implemented near-miss reporting to expand the flow of information that might prove useful in
preventing serious or deadly events in the future. Near misses are incidents or events that have
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the potential to result in injuries or other losses but do not (see Phimister et al., 2003). These
incidents or events are reported voluntarily, and there are immunity policies for reporters. The
reporting system is administered by a neutral party: for example the Aviation Near-Miss
Reporting System for the U.S. Federal Aviation Administration (FAA) is administered by the
National Aeronautics and Space Administration. Reports are kept confidential. Most near misses
represent errors or system failures or degradations that could have produced losses and may be
predictive of more serious outcomes in the future. Near misses are generally considered to be
much more frequent than actual loss-producing incidents and thus represent potentially important
learning opportunities. Near-miss reporting systems may be particularly useful in work
situations in which timely safety-related communications are logistically difficult or adversely
sanctioned. The FAA’s near-miss reporting system is probably the best established near-miss
reporting system in the United States.
SYSTEM FAILURES
Any unintended emergency in an underground coal mine, regardless of magnitude,
represents a systems-level (organizational) failure. This is especially so given the relative
probability of serious consequences to workers and the likely complexity of successful escape.
This characterization is a widely accepted premise of modern safety management.
Like other work systems, coal mines are not closed systems. Interactions within them
can be influenced by external factors such as economic or market conditions, political actions
and regulatory policies, scientific and technological advances, as well as various natural and
societal or cultural factors. From a systems perspective, effective safety performance requires
careful analysis of all possible interactions and the adoption of a multilevel perspective
(Rasmussen, 1997; Leveson, 2011). For example, difficult market conditions can increase the
likelihood of safety short-cuts or delay the purchasing of needed safety equipment. The sheer
size and uniqueness of an industry can affect the development of new safety technologies or even
the level of governmental oversight it receives. Regulatory requirements can serve to either
stimulate or discourage technological innovations that could improve safety. A group culture of
risk acceptance among workers can influence safe work practices and operational safety and
even discourage acceptance and adoption of available safety technologies. Unsafe working
conditions, a culture that does not put safety first, and other systems-level malfunctions may
predate an immediate emergency. In other words, it is not necessarily just one adverse event that
leads to a mine emergency, but a series of events that align to necessitate self-escape. Of course,
in some situations, the series of events that necessitate self-escape could not have been prevented
beforehand. However, in some circumstances, systems failures predated the emergency that led
to the need to self-escape.
This scenario follows the “Swiss cheese model” developed by Reason (1990): see Figure
5-3. In the figure, there are different levels represented to provide safety barriers for potential
hazards. The holes within each level represent weaknesses at different stages of the system and
vary in size and position. The system as a whole fails when multiple weaknesses in defenses line
up, allowing for (in Reason's words) a “trajectory of accident opportunity”.
Systems problems require systems solutions; they cannot be shifted or relegated to human
actions or heroics. As has been argued many times, workplaces and organizations are easier to
change than the minds of individual workers (see, e.g., Reason, 1997). As with other high-
hazard operational environments, first priority must be assigned to prevention. Error tolerance
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and resilience systems involve both humans and technology and equipment to enable systems to
withstand some part of the system failing without complete failure. Much, but certainly not all
of tolerance and resilience, focuses on pre-escape, prevention, and damage control. Building
these qualities into the overall safety system should necessitate fewer escapes as well as more
timely, efficient, and effective escapes. Primary attention is given to preventing such situations
from occurring in the first place. There must also be continued safety mindfulness – conscious
awareness that things can go very wrong at any time. This mindfulness is a key attribute of high-
reliability organizations. Mindfulness also implies that a very high priority is assigned to
emergency preparedness.
FIGURE 5-3 James Reason’s Swiss Cheese model
SOURCE: Adapted from Reason (1990, Figure 7.8)
Miners are really the last line of defense in terms of promoting successful self-escape.
Instead, factors in the system (e.g., communication systems, training, environmental support for
escape, safety culture, external pressures) influence the likelihood of self-escape long before a
miner or group of miners must act in the event of a mine emergency. When there is an alignment
of deficiencies (or holes) in several different aspects of the system, successful self-escape is most
at risk (Reason et al., 2001).
IDENTIFYING SAFETY PRACTICES
In a strong and positive organizational culture, safety is a clearly recognized value and
there is a drive to increase learning to continuously enhance safety. Many unsafe work practices
develop through preference, habit, or adherence to the status quo. It is important to have a
systematic study of practices that will lead to the safest work environment possible and ensure
these practices are consistently implemented throughout the workplace. Integrating safe practices
into all activities will help to mitigate potential emergencies that might necessitate self-escape
and will help ensure the optimal self-escape practices once it is determined that a mining
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emergency has occurred and miners have to travel to a place of safety. Such practices of
organizations with successful safety records include:
Safety Culture: Creating a strong, positive safety culture that pervades an entire organization
begins with senior management through actions more than words. Safety must be shown to be a
key business and operational value; one that is adequately staffed and resourced. Safety
performance goals extend beyond simple compliance with external standards and regulations.
These goals should be continually monitored and updated as necessary. Monitoring and
assessment feature both leading indicators (safety culture, safe work practices, hazard audits,
near-misses, etc) and lagging indicators (accidents, injuries, other losses). Nothing short of
continuous improvement is accepted.
Hazard Identification and Control: A fundamental element in successful safety management
involves having a systematic program for identifying and assessing work-related hazards and for
implementing and evaluating appropriate controls and other mitigation strategies on an ongoing
basis. The primary emphasis is with preventing adverse events from occurring that might make
mine escape necessary. However, this basic analytic process also can used to make mine escape
and other emergency actions safer and more efficient.
Emergency Preparedness: An organization actively plans for and rehearses the actions that
will be taken in emergency situations. Both managers and workers are involved in planning and
executing practice activities. The formal emergency response plan is detailed, current, and
customized to the specific characteristics of the workplace. It is a proactive document, a
“playbook” that is readily available and used, and reflects a human-systems perspective that
carries over into the design of safety-related training and adoption and use of available safety
equipment and technologies.
Information Flow: Organizations are made up of individuals who must function together
through effective communication. As with other organizational priorities, good communication
is crucial to achieving safety goals and maximizing worker safety. All people in the organization
have a “voice” and can speak up about safety issues without fear of retribution. Communication
is central to successful emergency response, but it also has a crucial role in prevention and
preparation activities.
Learning Orientation: In the most general sense, organizations with a learning orientation are
open to new information, technologies, and ways of thinking and doing things. They realize the
need to question, revise, and improve shared mental models that have become outdated,
distorted, or inadequate based on new knowledge, emergent technologies, and/or the changing
demands of the work situation.
Training Engagement: The term “engagement” reflects the fact that safe organizations,
especially those in high-hazard industries, are committed to training excellence and the use of
best practices. Training efforts extend beyond the passive and perfunctory transfer of
information. Training experiences are provided that are experiential and competency-based.
Employees at all levels of the organization are involved in the design, implementation, and
evaluation of safety training programs. Specific safety-related training might also be directed at
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senior managers to help them keep pace with overall safety needs and to help them be more
knowledgeable and effective leaders of the entire safety effort.
RECOMMENDATIONS
A safety culture forms the organizational context in which all safety-related actions take
place. It provides the subtle and sometimes not so subtle cues about the importance of safety, the
safety-related behaviors that are expected, the resources available to support safety, and the steps
taken to identify, eliminate, or control hazards. Safety cultures develop over time as
organizations operate and adapt to local conditions and respond to events and as a function of
organizational leadership. It is understood that mine operators have an obligation to comply with
the law. However, to enhance self-escape capabilities, mine operators should also pursue efforts
that create a strong, positive culture of safety. Safety needs to be recognized as a core value
throughout the industry. There is a repository of information on safety cultures from other
industries. The National Institute of Occupational Safety and Health is to be recognized for
recently initiating research on safety culture specific to underground coal mining.
RECOMMENDATION 6:
A. The National Institute of Occupational Safety and Health (NIOSH), in coordination
with mining stakeholders, should compile the existing research and recommendations
on safety culture from other high hazard and process industries and disseminate them
to the mining industry. Such information would provide a useful resource that mine
stakeholders could use to examine their own safety cultures and identify strengths and
weaknesses specific to their organizations.
B. The National Institute of Occupational Safety and Health should expand its safety
culture research efforts to include a larger and more generalizable sample of mining
organizations as well as to examine linkages between cultural attributes and safety
performance, ideally using longitudinal data on safe work practices and accident and
injury outcomes. NIOSH’s current data base of qualitative and questionnaire data
would appear to provide a strong basis for this expansion. Ultimately, the results from
this research effort could be used to produce a set of safety culture tools that could be
used by the entire mining community. This compilation of data collected using these
tools could then be used for further analyses and benchmarking activities.
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