Safety Science 44 (2006) 551562

www.elsevier.com/locate/ssci

A framework for understanding the development

of organisational safety culture
Dianne Parker
a

a,

, Matthew Lawrie a, Patrick Hudson

Department of Psychology, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
b
Faculty of Social Sciences, Leiden University, 2300 RB Leiden, The Netherlands
Received 11 February 2005; received in revised form 28 September 2005; accepted 10 October 2005

Abstract
A framework for the development and maturation of organisational safety culture was formulated. The content of the framework was informed by 26 semi-structured interviews with oil and gas
company executives, each very experienced in the industry. The form of the framework was based on
Westrums [Westrum, R., 1996. Human factors experts beginning to focus on organizational factors
in safety. ICAO Journal] typology of organisational cultures, which was adapted and extended as
proposed by Reason [Reason, J., 1997. Managing the Risks of Organisational Accidents. Ashgate,
Aldershot]. The product was a set of short descriptions of each of a number of aspects of organisational safety at each of Wve levels of safety culture advancement. The framework was assessed for face
validity. Theoretical implications and possible applications of the framework are discussed.
2005 Elsevier Ltd. All rights reserved.
Keywords: Safety culture; Organisations

1. Introduction
Organisational culture has been deWned as a complex framework of national, organisational and professional attitudes and values within which groups and individuals function
(Helmreich and Merritt, 1998). Part of that culture in hazardous industries relates to
*

Corresponding author. Tel.: +44 161 275 2570; fax: +44 161 275 2588.
E-mail address: dianne.parker@manchester.ac.uk (D. Parker).

0925-7535/$ - see front matter 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2005.10.004

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D. Parker et al. / Safety Science 44 (2006) 551562

safety, which was deWned by Reason (2000) as the ability of individuals or organisations
to deal with risks and hazards so as to avoid damage or losses and yet still achieve their
goals. The beliefs and values that refer speciWcally to health and safety form the subset of
organisational culture referred to as safety culture (Clarke, 1999). Important early work
on safety culture includes Zohar (1980) study assessing the shared perceptions guiding
appropriate and adaptive safety related behaviour based on cues in the environment, and
a later study by Cox and Cox (1991) studying the attitudes that employees share in relation to safety.
Since then, the concept of safety culture has attracted a great deal of research attention
from a range of academic disciplines. Inevitably, the perspectives taken and points of
emphasis vary, and there are several ongoing debates in the literature, for example about
the distinction between culture and climate (Neal et al., 2000), and about the scope of the
concept (Flin et al., 2000). It is not within the scope of this paper to oVer a systematic
review of that literature. Several excellent reviews have already been published (Cooper,
2000; Guldenmund, 2000; HSE, 2005).
In terms of its application to the issue of accident reduction in high risk industry, the
safety culture approach to accident reduction emphasises the role played by social forces
within an organisation that act upon its members with respect to safety (Clarke, 1999). It
has been suggested that culture reaches equally into all parts of the organisational system
and exerts a consistent eVect (for good or ill). For this reason its improvement is more
eVective than increased supervision or more rigorous procedures in enhancing safety performance (Reason, 1998). Reason (2000) proposed that an organisations safety culture
takes on a profound signiWcance at the point where accident rates reach a plateau, i.e.
where negative outcome data bottom out at some asymptotic value. In order to go
beyond this low but (seemingly) unassailable plateau and to continue improvement in
safety performance, it is necessary to address the hearts and minds of the management
and workers (Lee, 1998). This plateau is often reached after requirements for safety
hardware and software (i.e. barriers and procedures) have been met (Cox and Cox,
1991).
In describing how to engineer a safety culture, Reason (1997) identiWed the main elements of such a culture, which was conceptualised as the engine that drives the organisation towards the goal of maximum operational safety. The power of this engine relies
heavily on a continuing respect for the potential hazards associated with the organisations
activitiesnot forgetting to be afraid, termed chronic unease. Reason proposed that an
organisation with an eVective safety culture:
has 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;
has a reporting culture where people are prepared to report their errors, mistakes and
violations;
has a culture of trust where people are encouraged and even rewarded to provide essential safety-related information, but also in which it is clear where the line between
acceptable and unacceptable behaviour is drawn;
is Xexible, in terms of the ability to reconWgure the organisational structure in the face of
a dynamic and demanding task environment;
has the willingness and competence to draw the right conclusions from its safety system,
and is willing to implement reform when it is required.

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553

From this brief description of some key studies and concepts, it is clear that a desirable
safety culture does not just emerge, fully-formed, within an organisation. Given the size
and complexity of many modern organisations, within one speciWc organisation it is likely
that there are areas in which the safety culture is less well developed than in others. Moreover a desirable safety culture would take time to establish, and development may proceed more quickly in some areas than in others. This being the case it can be argued that
general measures of safety culture yielding one overall index or score, provide at best a
crude indication of this complex phenomenon. A more useful way of conceptualising the
safety culture must acknowledge that it is likely to vary within a single organisation. A
recent empirical demonstration of this came in Zohars (2000) study of 53 work groups in a
single manufacturing company, demonstrating both within-group homogeneity and
between-group variation in safety-related perceptions within the organisation. These
groups, operating at the level of supervisory units, diVered in terms of their perceptions of
safety over a range of facets, or aspects, of the organisation. Moreover, safety-related perceptions were predictive of behaviour, in terms of accidents at work requiring Wrst aid or
more over a Wve-month period.
At the same time, research has indicated that safety culture is best considered as a multidimensional concept. For example, studies of safety culture invariably stress the importance
of safety-related attitudes and actions among management (e.g. Clarke, 1998). Zohar
(1980) and Cox and Cox (1991) both discuss the importance of commitment to safety by
top management. It is crucial that the workforce sees that managers have the attitudes and
enact the behaviours that support safety. Perceptions of senior managers attitudes and
behaviours in relation to safety will form the basis for the safety behaviour of workers, and
hence the safety performance of the organisation (Clarke, 1999). Negative perceptions of
management commitment to safety can erode employees safe behaviours (Clarke, 1998).
While positive safety attitudes at the senior management level are essential for positive
safety culture (GriYths, 1985), it cannot be assumed that such attitudes will cascade
through the organisation. There is a need to regulate how these attitudes are transmitted to
subordinates to ensure that managerial commitment to safety is accurately perceived
(Clarke, 1999).
The importance of communication, including the reporting of hazards, incidents and
accidents, in the development of safety culture is well established. In his classic study,
Zohar (1980) found that frequent and open contact between managers and workers was
related to good safety performance. More recently, Clarke (1999) has advised that the role
of supervisors in staV-management communications needs more careful attention, as
supervisors are often the intermediaries between management and workforce. Clarke suggested that negative stereotyping of senior management attitudes and actions may be
reXective not only of a lack of direct contact, but also of a more fundamental lack of conWdence in management commitment to safety. At the heart of a safety culture is the way in
which organisational intelligence and collective imagination regarding safety issues are
deployed (Pidgeon and OLeary, 1994), i.e. the safety information system of an organisation, which is an essential aspect of an informed culture (Reason, 1997).
Some studies have taken the use of, and conWdence in, an incident reporting system as
an indicator of employees perceptions of management commitment to safety: as a dimension of safety culture (Zohar, 1980; Mearns et al., 2001a); as a direct inXuence on employees perceptions in relation to safety (Rundmo, 1992), and as an inXuence on
safety behaviours (Clarke, 1998). The willing participation of the workforce in a safety

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D. Parker et al. / Safety Science 44 (2006) 551562

information system was one of Reason (1997) critical subcomponents of safety culture, as
applied to limiting organisational accidents.
The organisational safety literature supports the inclusion of several aspects of an organisation to describe the components of safety culture (Zohar, 1980; Reason, 1997; Hale,
2000; Mearns et al., 2001a). In addition to these studies, Cox and Cox (1996) stated that
few studies have been designed to capture multiple components (i.e. aspects) of safety culture as it has been deWned in the literature; they typically look at a few in detail and
acknowledge the need to research the remainder (Sorensen, 2002). In a similar vein,
Mearns et al. (2001b) proposed that an organisations eVorts to develop a safety culture
should involve identifying areas of strength and weakness.
A third issue of relevance to research on safety culture is the extent to which it is amenable to change. While some aspects of culture may be relatively static, there are nevertheless
some levers for change and development. For example, a change in the top leadership, or
the introduction of a revised safety management system might be expected to have an eVect
on the culture of an organisation. Thus it can be argued that a useful framework ought to
include developmental aspects of safety culture. The thinking of sociologist Ron Westrum
(1993, 1996, 2004) is pertinent here. He suggested that one way to distinguish between
organisational cultures was according to the sophistication of the way that safety-related
information was handled in the organisation. He developed a typology of cultures, each
reXecting a characteristic way of handling information Xow, and representing increasing
levels of advancement. The three types he identiWed were labelled pathological, bureaucratic and generative (see Fig. 1).
It is noticeable that many of the characteristics of the generative organisation suggested
by Westrum echo the characteristics of the high reliability organisation (HRO) as
described by Karl Weick (1987). HROs are those few organisations (e.g. air traYc control,
aircraft carriers) with high risk technologies which nevertheless cope well with the associated hazards and have good safety performance records. Weick proposed that the key element of HROs was simultaneous centralisation and decentralisation. Compliance is
ensured without surveillance, because members of the organisation are intrinsically motivated for safe working behaviour. This can only be achieved through a highly developed,
mature safety culture. Hale (2000) stated his belief that the essence of safety culture lies
in issues dealt with by Westrum (1993), Reason (1997) and Hudson (1999), and that an

Pathological

Bureaucratic

Generative

Information is hidden

Information may be

Information is actively

ignored

sought

Messengers are shot

Messengers are tolerated

Messengers are trained

Responsibilities are

Responsibility is

Responsibilities are shared

shirked

compartmentalised

Bridging is discouraged

Bridging is allowed but

Bridging is rewarded

neglected
Failure is covered up

Organisation is just and

Failure causes inquiry

merciful
New ideas are actively

New ideas create problems

New ideas are welcomed

crushed

Fig. 1. How diVerent organisations respond to information concerning safety (from Westrum, 1996).

D. Parker et al. / Safety Science 44 (2006) 551562

555

organisation has only achieved a true safety culture when it has attained the generative
level of culture put forward in the Westrum typology.
Westrums thinking about levels of safety culture advancement has not, to our knowledge, previously been directly used in an organisational setting. His idea of diVerent levels
of safety culture provides the basis for developing a framework of safety culture that takes
into consideration both a range of areas in which safety culture might manifest itself, and a
range of levels of sophistication. In the study reported here a framework of safety culture
was developed that was adapted from Westrums three levels and covered several of the
aspects of safety culture shown to be key in previous studies. The key objective of the study
was to develop a theory-based tool that could be used by organisations in the oil industry
to self-assess their current level of safety culture advancement.
Building on the three levels originally suggested by Westrum (1993), Wve levels of safety
culture were included and characterised in the following phrases:

Pathological; Who cares about safety as long as we are not caught?

Reactive; Safety is important: we do a lot every time we have an accident.
Calculative; We have systems in place to manage all hazards.
Proactive; We try to anticipate safety problems before they arise.
Generative; HSE is how we do business round here.

The two additional levels, reactive and proactive, were initially proposed by Reason
(1997) as extensions of Westrums original typology. They were thought to add depth to
the framework, allowing for more subtle classiWcation and increasing the accessibility of
the framework to industry employees by including terms they would be familiar with, and
so clarifying the idea that organisations would be expected to progress through the levels
of safety culture with increasing maturity.
Organisational safety research has not generally focused on an integrative framework
that includes both formal safety management systems, and the safety-related behaviour of
individuals, including managers and frontline workers. For example, the eVects of the
content of safety management systems on safety performance have largely been ignored
(Cooper, 2000). Mearns et al. (2000) stated that auditing was a key requirement in any
eVective safety management system, and Isla Daz and Daz Cabrera (1997) found company policies towards safety to be critical, e.g. compliance with safety standards, feedback
on performance, assignations of funds and resources to safety areas, importance of safety
training. Other inXuences on safety culture that have been suggested are the status
within the organisation of safety oYcers (Zohar, 1980), the extent and quality of safety
training and the demonstrable impact of safe behaviour on promotion (Cooper and Phillips, 1994).
The aim of this exploratory study was to generate a theory-based framework that could
be used by organisations to understand their own safety culture. The framework was
designed to reXect the multidimensional, dynamic nature of safety culture by providing
descriptions of an organisation with respect to a range of key aspects of safety culture, at
each of Wve levels of safety culture advancement developed from Westrums initial ideas
(1993). The aspects of safety culture included were chosen to reXect the key features of
safety identiWed in the organisational safety culture literature. It was anticipated that the
resulting framework would be meaningful and useful to those working in the petrochemical industry who are concerned to improve the safety culture of their organisation.

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D. Parker et al. / Safety Science 44 (2006) 551562

2. Method
In depth interviews were carried out with a purposive sample of 26 senior oil and gas
company executives, working at a range of multinational oil companies and contracting
companies each of which had oYces in Houston, Texas. The aim was to interview very
senior employees who had extensive Wrst hand experience of how HSE systems work in the
oil industry at all hierarchical levels of an organisation. Although all the interviewees were
senior executives at the time of interview, they had all worked their way up through the
industry from much lower levels through their careers. They therefore had all had the
opportunity to see HSE from a number of diVerent perspectives.
The interviews lasted between 60 and 90 min, and were tape recorded with the permission of the interviewee. A second researcher simultaneously made a written summary of
the interviewees key responses. This summary was read back to them to check that the
scribe had captured the essence of what the interviewee wanted to convey. Interviewees
were asked to consider in turn several aspects of a large, worldleading organisations HSE
safety culture. These aspects were grouped under headings, which were the elements of the
organisations documented HSE management system (HSE-MS). This strategy was
adopted because the elements of an HSE-MS are familiar and meaningful to the interviewees, ensuring their engagement with the interview process. Although one speciWc organisations HSE-MS was used to frame the interviews, the elements it contained were familiar
to all those interviewed, and were present in the management systems of all the companies
involved.
Following a distinction pointed out by Zohar, both concrete and abstract aspects of
safety culture were investigated. Tangible, or concrete, aspects included the system for
benchmarking and auditing safety performance, and the way in which work is formally
planned. These were the elements of the HSE management system with which the interviewees were all familiar. Less tangible, or abstract, aspects involving the perceptions of
the workforce, thought to be important by Zohar (2000) were also considered, as they
are likely to be crucial indicators of organisational safety culture. The interviews covered
11 tangible and seven less tangible aspects of safety culture, as shown in Figs. 2 and 3.
Interviewees were asked to describe how an oil company would function in terms of
each of the aspects covered at each of the Wve levels of safety culture, from pathological
through to generative. Once it had been explained to them, Westrums framework for levels of safety culture was quickly understood by the interviewees, and they had little diYculty in relating an organisations aspects to safety culture at all levels.
3. Results
Over the course of the interviews, a consensus quickly emerged in terms of the descriptions oVered by the interviewees, and saturation was achieved in that new and diVerent
descriptions ceased to emerge from the interviews. Each interviewee gave broadly similar
descriptions in relation to each of the Wve levels. The descriptions provided by participants
were typically two or three sentences long. At this point the researchers were satisWed that
they had carried out a suYcient number of interviews to ensure that a consensus description could be generated. It was thus relatively simple for the researchers to develop a grid

D. Parker et al. / Safety Science 44 (2006) 551562

557

containing brief descriptions of a company in the oil industry at each of the Wve stages of
safety culture advancement, for each of the aspects of safety culture investigated. After all
the interviews had been completed, the researchers collated the responses relating to each
of the organisational aspects in turn. The views of all those interviewed were therefore
incorporated into each description of safety culture. The Wnal output is shown in Figs. 2
and 3, which contain the descriptions of each level of safety culture for the concrete (i.e. the
management systems in place) and abstract (i.e. attitudes and behaviours) organisational
aspects respectively.

Fig. 2. Descriptions of levels of safety culture for concrete organisational aspects.

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D. Parker et al. / Safety Science 44 (2006) 551562

Fig. 2 (continued)

After all the descriptions were compiled into a document as set out in Figs. 2 and 3, they
were presented to 12 employees of the same organisation who had not previously been
interviewed. This was to ensure that the framework and its descriptions of the levels of
safety culture developed by the researchers following the interviews made sense to those
people who would be using the framework. Several line managers from an operational unit
of the organisation were consulted on the face validity of the framework, along with key
members of the corporate HSE department of the global parent company of the multinational. All of those consulted agreed that the framework was coherent and the descriptions
of the levels of safety culture were accurate.
4. Discussion
The study reported here sought to develop a theoretically based framework for considering the safety culture of large multinational oil companies that acknowledged the multi-

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559

Fig. 3. Descriptions of levels of safety culture for abstract organisational aspects.

dimensional and dynamic nature of safety culture. This approach was complementary to
that taken in Zohars (2000) study, in that it considered a broader range of organisational

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D. Parker et al. / Safety Science 44 (2006) 551562

aspects, both concrete and abstract, and developed a framework capable of reXecting
development of safety culture over time.
The extension to and application of Westrums typology of organisational communication proved to be well suited to the context of the oil and gas industry. When it was
explained to them, the interviewees found the idea of Wve stages of safety culture advancement applicable and useful to the industry. Moreover, the Wnal framework was approved
by a diVerent sample of employees. Notably, the addition of two more levels of safety culture to the three-level original typology was approved by participants in the study, who
perceived the additional levels to be indispensable in the transition from the pathological,
through calculative, to the generative level of organisational safety culture.
The use of in-depth interviews as a method for eliciting descriptions of each of the levels
of safety culture advancement for the organisational aspects was very successful. Consensus about the descriptions emerged readily, even though those interviewed were employed
by a range of organisations, and when shown the Wnal descriptions, all interviewees were
satisWed. These descriptions were then assembled into a brochure which was produced by
one of the collaborating organisations as a self-assessment tool to aid employees at all job
levels of that organisation, to locate themselves in terms of safety culture advancement at
their work-site.
In terms of practical application, the safety culture brochure had two aims. The Wrst of
these was to help employees recognise and understand the safety culture of the organisation. It was intended to be used in safety meetings and workshops to provide participants
with a clear and detailed view of how they perceived their present safety culture. The second aim of the brochure was to demonstrate how the participants company or division
could be moved forward in terms of safety culture, as set out in the framework derived
from the study, to a more advanced level of maturity.
Consideration of the framework by employees would generate a proWle, by considering
the level of safety culture for each of the organisational aspects in turn. This would allow
for the identiWcation of comparative strengths and weaknesses within the organisation.
The brochure could also be used with diVerent work groups, to investigate diVerences in
perception of the safety culture between these groups, for example between managers,
supervisors and operations staV, between work sites, and also as a before and after measure
to self-assess the change in level of safety culture following an intervention.
From the organisations perspective, the use of the safety culture brochure complemented the self-assessment of the HSE management system. The intangible abstract
aspects of safety culture were seen as augmenting the tangible concrete aspects of a fully
implemented safety management system, thus ensuring safe operations for the organisation. Cox and Cheynes (2000) study described a similar strategy, which involved the development and testing of an assessment technique which provided both a practical tool for
the assessment of safety climate and simultaneously aided the promotion of a positive
safety culture.
Notwithstanding the organisations enthusiasm for the tool, at this point its validity
rested on the comments of the participants in the study and those expected to use it. The
tool was developed from interview data collected from a relatively small sample (n D 26)
and then commented on by 12 employees from a single organisation, none of whom had
taken part in the interviews. There clearly remained a need to assess more systematically
whether the content of the descriptions was internally consistent in terms of the levels of
safety culture, and to investigate the underlying structure of the perceptions of the frame-

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561

work. In order to address these issues, a second study was carried out and is reported in a
companion publication.
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