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1. Introduction
Some companies wonder why they keep experiencing the same process safety problems. Others
wonder why they seem to have plateaued in process safety performance. Culture has also been
recognized as a contributor to major accidents; these have been termed organizational accidents.
Understanding and improving Culture is KEY. Culture is the individual and organizational
DNA that represents our tendency to want to do (1) the right thing in (2) the right way at (3)
the right time, (4) ALL the time even when if no one is looking. The safety culture that exists
in a plant or company is the result of all the actions - and inactions - in institutional/workforce
memory.1 Many facilities use management systems to help control risks of hazardous processes.
These management systems are operated by people people whose inherent attitudes about
safety can affect the choices they make in operating these systems and, thus, the overall safety
performance of the facility.
This paper presents lessons learned from companies implementing process safety/HSE culture
improvements involving the following steps: education, planning, workforce involvement, and
providing remedies for culture weaknesses.
The Center for Chemical Process Safety (CCPS) has created a framework for understanding,
evaluating, and improving culture (Table 1)2,3. Using that framework, we have created a unique
analysis process for determining culture weaknesses by comparing workforce opinions gained
via survey and interviews with HSE performance deficiencies.4 This Performance Assurance
Review (PAR) approach was presented at the May 2008 1st Latin American Process Safety
Conference in Buenos Aires. This novel approach highlights the culture weaknesses in a plant or
a company that give rise to HSE performance deficiencies.
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Table 1 Essential Features of a Good Process Safety/HSE Culture
Once weaknesses are determined, culture improvements can be focused to generate the best,
sustainable process safety/HSE performance improvement.
When pursuing any goal, it is often helpful to keep in mind a picture of what a better condition
would look like. The same can be said for pursuing culture improvements. Using the CCPS 12
Essential Culture Features, the following is a paradigm of what a really good process safety/HSE
culture would be like.
People at a plant or a company possess shared values about the importance of process safety and
HSE. These values give rise to commitment and a pride in the way that the organization
approaches process safety and HSE issues. Performance tends to be good and improving.
Everyone says that "you can stop production without killing the messenger", and there is
evidence to demonstrate that the plant has shut down a process or not started a process in order to
be certain that it is safe. If it cost them a lot of money, they still praised the individual who took
the action. The following are some typical survey questions used to determine the status of this
culture feature at a plant or a company.
This feature is marked by people throughout the organization that lead by example. They do not
simply talk about the importance of process safety/HSE; their daily actions show that they
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believe it. For example, management provides sufficient resources to support safety programs.
Plant manager and operations managers are frequent visitors, they ask questions, and people feel
comfortable telling them what they think. Supervisors and hourly workers speak up in safety
meetings and voice their concerns or praise for those that have acted in supported of the
company safety goals. The following are some example survey questions for this feature.
The feature is marked by evidence that an organization holds itself accountable for the
requirements and standards of care that it accepts. Documentation (procedures, records, etc.) are
kept up-to-date. If you ask someone or observe work, you notice that the practices they use are
always consistent with procedures. Shortcuts are not encouraged and if someone does, their
peers call them out on it. Typically, the plant has excellent housekeeping. Personal safety
equipment is ALWAYS used and employees take action (and contractors) if they don't use it.
The following are some typical survey questions for this feature.
Process safety procedures are mandatory here anyone who ignores them is disciplined.
I fully understand what the company expects of me when it comes to process safety and
my job.
My coworkers always follow the correct work procedures.
We have good routines for housekeeping and equipment maintenance at this site.
For this feature, the plant/company has taken action to understand and improve its process
safety/HSE culture. Company web sites, policies, and communication refer to the importance of
process safety/HSE and the company has a plan for periodically evaluating culture. For
example, they have done a culture survey or have sponsored some seminars/training on safety
culture. The following are some typical survey questions for this feature.
The companys process safety policies are clearly understood by all employees.
I have attended one or more meetings/classes on the importance of good safety attitudes
and behaviors.
I have participated one or more safety-improvement activities (such as doing work
observations in a behavior-based safety program).
This feature is marked by a pervasive awareness of the hazards of the plants they operate and the
activities undertaken. Everyone has an idea of what the worst case scenario is. People
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remember notable incidents at the site or in the company/industry and what was important about
them to prevent recurrence. The following are some example survey questions.
Everyone at this site is strongly aware of the consequences (injuries, fires, etc.) of unsafe
actions or conditions.
We do a good job of sharing the lessons learned from near-misses and hazard studies.
Before starting any work, our standard routine is to make sure it is safe to proceed.
Company management provides the training, tools, resources, and - most importantly the time
for people to do their job safely. Everyone says that "you can stop production if you think there
is a safety problem without retribution". There is evidence that people have used company
resources to improve safety. Safety/HSE training is taken seriously and is up-to-date. The
following are some survey questions for this feature.
I would feel comfortable shutting down a process or equipment for safety reasons.
I have the resources I need (equipment, tools, procedures) to do my job safely.
I have the training I need to do my job safely.
I have the time I need to do my job safely.
7. Defer to expertise
Employee involvement in planning, preparing and executing process safety/HSE activities is the
norm. Workers say that their opinions matter. If a labor union is on site, its leadership is
engaged with management. When important decisions are made, people always take the time to
seek out evidence or experienced people to provide their input. The following are some typical
survey questions for this feature.
There are multiple, active lines of communication frequently used up and down the
organization and across departments. Workers say that their supervisors and management
frequently ask for their opinions. There are frequent, effective town hall meetings. Here are
some typical questions used to elicit insight into this feature at a company.
Our reporting processes work well all near-misses, accidents and injuries are fully
reported.
My manager/supervisor encourages our feedback on safety issues.
Overall, we do a good job here on communicating about work and safety issues.
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9. Establish a questioning/learning environment
Workers are not afraid to ask their supervisors for reasons why they take decisions or perform
certain actions. They speak up often and are engaged in process hazard review meetings. Safety
meetings where incident lessons are discussed are remembered by the workforce. Executives
and senior management respond to tough questions about their decisions in a non-defensive
manner. This feature can be investigated in a survey using the following questions.
In my work area, our safety training keeps us very aware of potential hazards and how to
prevent them.
We have a good process for routinely reviewing hazards and risks.
We do a good job of investigating process safety incidents and near-misses.
There is a strong spirit of teamwork in place at the plant. The constructive discipline process is
implemented in a just way. Workers say they trust each other and their supervision and
management. The following are some typical survey questions dealing with trust.
I trust site management to do the right thing when it comes to process safety.
Honest safety mistakes are treated fairly by site management.
I trust my coworkers to do the right thing when it comes to safety.
We all feel comfortable raising process safety issues with management, with no fear of
reprisal.
When you look around the work site, it is apparent that housekeeping is important. Backlogs of
work requests and corrective actions are low. Process safety metrics relating to inspections are
"in the green". Audit findings are taken seriously and responses are completed quickly, not
waiting for the last minute. This feature can be investigated using the following questions.
Metrics exist, are used throughout the departments and are visible to all employees. Employees
are aware of the HSE and process safety performance. Management reviews are frequently
conducted on-site and at corporate offices to encourage good performance and refocus on areas
that need improvement. The following are some example survey questions for this feature.
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We have a good process for noticing potential site process safety problems (e.g., frequent
safety walk-arounds).
Process safety performance indicators are routinely tracked (e.g., incomplete inspections,
number of injuries).
Our company takes appropriate action whenever process safety performance is poor (e.g.,
injury rates increase).
Frequently, it is convenient and necessary to develop process safety/HSE culture insights via the
use of targeted or layered interviews. This tactic can help reveal some of the reasons why
worker opinions exist. It is also easier to resolve questions behind the culture questions
regarding root causes of organizational dysfunction. Interviews can be formal or casual
conversations. In either case, it is important to have in mind the focus of the culture inquiry.
Typically, narrative answers are given that are reduced to the interviewer assessing whether the
interviewee exhibited the following overall response to a feature: Doing a Good Job, Needs
Improvement, or Do not know/not relevant.
Once your have determined the areas of process safety/HSE culture weakness, it is time to begin
the process of improvement. Usually, culture improvement activities will take many months or
years to have a deeply rooted effect. Regardless of the size of the plant or company, the
following activities and concerns are important to creating a last-lasting culture change.
Education
Planning
Workforce involvement
Education is given to all layers in a plant/company. Typically, three main audiences are
addressed with approximate initial awareness training durations given:
The following are some example topics used for reach layer of training.
Such training, whether for executives or hourly workers, is more effective is the delegates are
fully engaged and thinking about culture change. Their opinions matter and it is important that
we discover their ideas for culture change. Interactive, facilitated workshops provide an
effective means for dialogue, soliciting ideas, engagement, and learning. These workshops are
most effective if done using small groups that consider some of the following issues:
1. What can you do to assess the culture in your company and/or your facility?
2. What can you do to identify which of the process safety culture features will have the
greatest impact in your company; which is the weakest in your company?
3. Pick one of the culture areas and develop an action plan to address the following issue at
your company/site.
The following steps should be addressed in culture workshops at all levels of the plant/company.
Brainstorm what has happened in the past that could be in the memory of the work
force
Look at culture survey/interview results by feature.
What is going on the past year/recently that could affect this feature?
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2. Identify existing activities that could be used or amended to help correct the cultural
issues.
What things are going on now in the plant/company that could improve or adversely
affect this issue?
o Capital expansion/operations contraction
o Employee welfare
o Workforce changes
o Implementation of new safety programs (e.g., Behavior Based Safety)
See the list of potential remedial actions in the next section as a starting point.
Have small groups during culture awareness training develop company and personal
culture action plans using this list.
5. Develop an overall, integrated list of activities to help deal with the culture challenges.
Work the plan as you would any process safety/HSE action plan
Monitor implementation
Develop culture improvement metrics
Following the above approach will require that you eventually address what actions you should
take to improve culture. You will follow an interactive process that engages all levels of the
plant and company. At each occasion early on, you will seek peoples opinions about the root
cause of culture weaknesses, factors that contributed to the problems, conditions that the
company faces in the near-term as it purses culture improvements.
Normally, a plant or company faces one or more culture issues at the same time. These issues
should be addressed together to avoid adverse interactions of improvement actions and to
increase efficiency. The following tables give some examples for each culture essential feature
of possible remedies that have been used by many companies to address culture weaknesses.
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1. Process Safety/HSE Is NOT a Core Value
Establish a process safety policy
Communicate the Business Case for Process Safety to senior executives; communicate the process
safety policy regularly
Hold training courses/workshops on the policy
Reinforce policy via company newsletters and meetings
Ask the workforce for feedback on whether they consider process safety to be a core value and
whether management is acting that way
Demonstrate that process safety is a core value by making decisions and taking visible action in
support of the policy
Celebrate workforce actions that demonstrate adherence to process safety being a core value
Encourage senior executives to participate in process safety functions/committees/symposia with
other respected executives
Widely share the CCPS Process Safety Beacon
Share significant incidents from similar facilities and relate the broader consequences of a process
safety incident
Help people at all levels in the organization to understand the importance of process safety
Appeal to the business case for process safety, the humanitarian case for process safety, and the legal
case for process safety
Find a process safety champion high in the organization that is willing to try to influence other senior
leadership
Provide ideas/input for annual reports and other visionary documents that are periodically published
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3. Normalization of Deviance Not Maintaining High Standards of Performance
Create reasonable, high standards of performance and communicate expectations
Create a dialogue within the company on the importance of operational discipline
Promote accountability throughout the organization
Institute a constructive discipline policy
Promote a safe reporting environment; if necessary, create an anonymous reporting system
Create metrics and communicate results
Consider a zero-tolerance policy for severe or willful transgressions and for chronic failures. Take
strong action when necessary to protect company performance standards
Appropriately communicate both positive and negative consequence situations to significant breaches
Highlight examples throughout the chain of command not just at the hourly worker level
Institute some fashion of pay-at-risk for performance failures and reward for performance successes
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Publish the CCPS Process Safety Beacon internally
8. Ineffective Communications
Encourage senior management in the facility to be in the plant frequently to be available to listen and
respond to employee concerns. Remember to seek input from professional staff as well as hourly
employees
Provide a mechanism for anonymous input to management so that those that have fear of reprisal
have an avenue to provide input
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Do not shoot the messenger
Praise bad-news messengers in visible, public ways
Provide frequent status of lengthy projects that are important to employees so they are aware that the
project is progressing
Help management include process safety messages in their periodic newsletters or other
communications
Establish process safety committees that include a vertical slice of the organization
Hold regular process safety management reviews
Provide communications training to everyone
Solicit workforce opinions on effective communication means and frequency
Create newsletters, increase safety meeting frequency and effectiveness
Emphasize communication throughout chain of command
Develop/improve communications response discipline for phone mail, email, and web responses
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Conduct refresher training about the progressive discipline system
Include an elapsed time at which previous violations no longer impact future discipline. For example,
incidents more than two years old do not impact the progressive discipline system
Make examples of supervisors and management who do things right and wrong
Establish/re-invigorate an employee/management safety committee
Include workforce representatives on a accident investigation committee
Provide human factors/behavioral safety training
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Hold management reviews to spotlight good performance and focus on weaknesses
Make improvement a part of the accountability and performance review system
Create ways to solicit and accept employee suggestions
6. Conclusions
If we want to have sustainable improvement in process safety and HSE performance, it is vital
that we address individual and organizational culture issues. Safety/HSE culture for an
individual is the complex product of a persons life experiences on and off the job. In order to
have a non-temporary impact on these lifetime-learned attitudes and habits, we must seek new
ways to re-map the process safety/HSE DNA in us.
Re-mapping requires that we know what the problems are to begin with. The CCPS Culture
Essential Features and the PAR approach provides a reliable, reproducible, and defensible way to
discern culture weaknesses and focus attention on those challenges that spark the greatest risk to
future process safety/HSE performance.
Once those weaknesses are identified, companies must courageously look in the mirror, be
vulnerable, and be willing to change. Such culture change will take time, but such journeys are
more likely to achieve the type of performance improvement that has always be promised by
applying quality principles except this time, we not only fix the system, but we fix the
human tendencies in we who operate the process safety/HSE systems.
References
1. Chapter 3 Process Safety Culture in Risk Based Process Safety, Center for Chemical
Process Safety, Wiley, March 2007.
2. Center for Chemical Process Safety, Building Process Safety Culture: Tools to Enhance
Process Safety Performance, http://www.aiche.org/CCPS/ PSCulture.aspx.
3. Frank, W. L., Essential Elements of a Sound Safety Culture, AIChE, Process Plant
Safety Symposium, Atlanta, GA, April 2005.
4. Arendt, J.S. et al, "Connecting Process Safety Performance Outcomes to Process Safety
Cultural Root Causes", 1st Latin American Process Safety Conference, 26-28 May 2008,
Buenos Aires.
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