Safety Performance Improvement

using Cultural Change

Lessons Learned

© 2018 ABS Group of Companies, Inc. All rights reserved.

Safety Moment - Recent UK Fatalities

• 144 workers killed

• Mainly from being hit

by stored potential energy

• Mainly in construction

& agriculture

WHO WE ARE

ABS Group provides a range of technical solutions to support safe,

reliable and high performance assets and operations. ABS Group is an

affiliated company of ABS, a leading classification society with over 150

years of service.

INDUSTRIES WE SERVE

• Power

• Oil & Gas

• Maritime

• Government

• Manufacturing

HEADQUARTERS

ABS Group

16855 Northchase Drive

Texas, USA

+1-281-673-2800

www.abs-group.com

HOW WE SUPPORT OUR CLIENTS

ABS Group At A Glance

1500+Employees

30+Countries

40+Years

ABS Group

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Introduction

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• ABSG has been conducting cultural surveys > 10 years

• We have completed cultural projects for over 40 companies globally.

• This experience has indicated a practical relationships between safety culture and actual

performance. This presentation summaries the findings relating to:

• Measuring safety culture

• Correlating Safety Cultural findings to Process Safety incidents

• How to make cultural change and performance improvement programmes sustainable

Where does Safety Culture sit?

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Accident

Near Miss

Process Control Issues

Management System Issues

Organizational Culture Issues

Loss of Containment

Fatalities / Injuries / Pollution

Loss of Containment

Near Miss

Operating Envelope Excursions, Activated

Shutdown Systems, Relief Valves etc

Poor Operational Discipline – failure to

follow procedures, close actions etc

Cultural Issues Affecting

the Tiers above

How do we Improve PSM Performance?

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Accident

Near Miss

Process Control Issues

Management System Issues

Organizational Culture Issues

RCA / II identifies

issues to correct in the

lower levels (PSPIs)

Leading PSPIs and

Audits to correct

same level issues

Issue Detection and

Remedy ?

Three key aspects of PSM

1) Become a Learning Organisation

2) Implement Robust Safety

Management and Assurance

Systems

3) Embed an Appropriate Safety

Culture

Cultural Essential Features (CCPS/ABS Group Model)

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No Essential Feature Symptom that feature is absent

1Establish safety as a core

value

Units restart before the Pre Start-Up Safety Reviews (PSSRs) are fully signed off.

Awards and praise for high production, but none for safe behaviour.

2 Provide strong leadershipWhen the CEO comes on-site, discussions are only with the site leadership team.

Managers don’t perform weekly safety visits, or reinforce safety messages

3Establish and enforce high

standards of performance

Normalisation of deviance: individuals not following Standard Operating Procedures; this

behaviour is “accepted”, goes unnoticed and is not commented on.

Site procedures not updated within specified time frame.

Individuals not using all required PPE all the time.

Incomplete attendance of refresher training (and no follow-up).

4Formalise safety culture

emphasis/approach

No formal discussions on process safety culture.

Process safety not mentioned on internal and external company web pages.

No recent in-house training on process safety.

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No Essential Feature Symptom that feature is absent

5Maintain a sense of

vulnerability

No "chronic unease".

Individuals cannot answer “what is the worst case scenario for your area?” and what

would be the consequences? “We’ve done it this way for 30 years and nothing has

happened”.

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Empower individuals to

successfully fulfil their

safety responsibilities

No-one on the leadership teams (board/senior management team/site leadership team)

"owns" process safety issues.

No-one has hit the “big red button” in the last three years.

7 Defer to expertiseBurden of proof demanded on safety statements and comments.

Changes implemented without asking “the guru”.

8Ensure open and effective

communications

Town Hall meetings aren’t held or get postponed regularly.

Minimal reporting of near misses and minor accidents.

Front line staff not asked for their opinions.

People stop reporting safety issues because they won’t get feedback.

Cultural Essential Features (CCPS/ABS Group Model)

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No Essential Feature Symptom that feature is absent

9Establish a questioning and

learning environment

"I just do what I'm told". No challenging of instructions.

Operators can’t remember the topic of the last Safety Standstill/meeting.

Reasons for most recent incident not understood by all operators.

10 Foster mutual trustNear misses not reported for fear of being blamed.

Reporting a near miss perceived negatively.

11Provide timely responses to

safety issues and concerns

Reported safety issues just added to an ever-growing list and disappear in to a black hole.

Slow progress on resolving safety actions from RCAs after safety incidents.

Status of progress on safety actions from RCAs not shared with all.

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Provide continuous

monitoring of safety

performance

Process Safety KPIs not collected and shared with all on site.

No structured management review of (process) safety performance

Cultural Essential Features (CCPS/ABS Group Model)

Traditional Survey Results

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All companies had PSM issues

which initiated the Surveys.

“Strong leadership” and

“Enforcing High Standards”

scored poorly.

“Formal Approach” and “Sense of

Vulnerability” scored well, but

other areas for the same

companies scored poorly.

Based on these findings - what

changes to make, and how to

measure effectiveness?

Linking Culture with Performance

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Increasing

Significance

Accident

Near Miss

Process Control Issues

Management System Issues

Organizational Culture Issues

• Containment integrity issue allowed to exist

• Unsafe work practice

• Action item not completed or late

• Safety hazard situation is allowed to exist

• Inadequate inspection, testing, maintenance

• Inadequate management practice/ system / procedure

• Inadequate hazard, risk, root cause analysis

• Inadequate monitoring or auditing

• Inadequate training

• Inadequate recordkeeping and documentation

• Inadequate communication or signage

Threat

Threat

Threat

Top

Event

Consequence

Consequence

Consequence

Pro

tection S

yste

ms

Em

erg

ency

Response

Trip S

yste

ms

Ala

rm &

Op.

Resp

on

se

Cross correlating Culture Survey data with PSPIs

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Cultural Survey ResultsP

SP

Is

Cross Correlation of Cultural Feature Low Scores with Observed PS

Performance

Increasing

Significance

Case Study – Example for one facility

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This give prioritised Cultural

Features to work on.

• Sharing lessons learned from

previous incidents

• Conduct “What-if” sessions

• Sharing PSPIs trends

Performance to be measured by

the following PSPIs:

• Safety hazards allowed to

exist

• Action items left undone

Case Study – Group of Facilities

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A B C D E F G H J

Normalization of deviance 1 1 4 2 1 2 7 1 2

Non-responsiveness to safety concerns 3 8 3 3 7 1 3 3 3

Lack of a questioning/learning environment 4 5 7 5 3 3 2 4 5

Lack of trust – unsafe reporting environment 6 1 10 5 5 7 6

Lack of personal responsibility for safety 8 9 9 8 9

Not listening to technical experts 10 6 9 8 1 6 4

No performance monitoring or pursuit of improvement 2 9 9 1 2 4 4 2 11

Lack of sense of vulnerability 5 2 5 4 8 7 8 5 7

Ineffective communications 11 2 11 6 6 11 10

Process safety is NOT a core value 6 3 12 6 5 10 10 9 8

Lack of strong PS leadership 7 7 11 7 6 11 11 10 1

No formalization of culture process 12 10 12 12 12 12 12

Process Safety Culture ProblemCompanyAll companies had PSM issues

which initiated the Surveys.

“Formal Approach” and

“Leadership” were found to be

a lower priority.

“Normalisation of Deviation”,

“Non-Responsiveness to

Safety Concerns” and “Lack of

Questioning/Learning

environment” came out top.

Focused Cultural “Fixes”

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Certain Cultural elements are

more closely linked to Tiers

in the PSM Triangle than

others.

If PSPIs are measured for

each Tier then our

experience indicates that:

1) Targeted “fixes” can be

introduced

2) Early detection of cultural

degradation is possible

3) Effectiveness of Cultural

Change programmes can

be monitored.

Hierarchy of Cultural Issues

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Level 1 Performance Action Issue

Level 2 Situational Awareness Issue

Level 3 Adoption of Leadership Values by Organisational Issues

Level 4 – Values Expressed by Leadership

Continuous Improvement and

Monitoring Issue

Responsiveness to Concerns

Issue

Deference to Expertise

Issue

Safe Questioning and Learning

Environment Issue

Normalisation of Deviation

Issue

Cultural

Cultivation

Issue

Effective

Communication

Issue

Empowerment

Issue

Sense of

Vulnerability

Issue

Mutual Trust

Issue

Leadership Issue Core Value Issue

Application of Cultural Cause Analysis™

CCA methodology and Cultural Cause Map™ can be applied to

any RCA methodology.

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Example

Front-line Personnel Issue

Company Personnel Issue

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3

126

Procedure Issue

122

Correct Procedure Not Used

Procedure Use Discouraged

Company Standards, Policies and Administrative Controls (SPAC) Not Used

SPAC Enforcement Issue

123

233

230

BP Texas City

Causal Factor – Blowdown

drum overfilled

An intermediate cause-

operator started unit with

exit valve closed - Technical

Finding was an employee

failed to follow the startup

procedure because the

procedure use was not

encouraged

Leadership Issues

Questioning and

Learning Environment

Issue

Responsiveness to

Concerns Issue

Ineffective management

demonstration of commitment

Support for programs and objectives issue

Mismatch between practices and

procedures not resolved in timely

mannerC15

Known management system issue uncorrected

Empowerment Issue

Resources available to fulfill health, safety, and

environment roles and responsibilities issue

C3

C11

C21

C45

C47

C61

C63 C64

Questioning and Learning Environment Issue

Inadequate Critical Thinking

Summary

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Cultural change programmes are more effective if linked to performance

If the right PSPIs are measured at each level of the Process Safety Triangle

then performance issues can be associated with specific cultural features

and then treated

It is more practical and effective to perform cultural surveys periodically, and

manage based on the links to the Cultural Features

The Cultural Causal Analysis (CCA) methodology is a new reactive approach

that supplements and extends RCAs into underlying cultural issues

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