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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 Prepublication Copy – Uncorrected Proofs 5-1
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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). Prepublication Copy – Uncorrected Proofs 5-2
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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). Prepublication Copy – Uncorrected Proofs 5-3
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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 Prepublication Copy – Uncorrected Proofs 5-4
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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 Prepublication Copy – Uncorrected Proofs 5-5
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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 Prepublication Copy – Uncorrected Proofs 5-6
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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 Prepublication Copy – Uncorrected Proofs 5-7
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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. Prepublication Copy – Uncorrected Proofs 5-8