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
 ABS Group At A Glance

WHO WE ARE

30+ 40+
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
1500+
Employees Countries Years
years of service.
HOW WE SUPPORT OUR CLIENTS

INDUSTRIES WE SERVE HEADQUARTERS

• Power ABS Group

• Oil & Gas 16855 Northchase Drive
• Maritime Texas, USA
• Government +1-281-673-2800
• Manufacturing www.abs-group.com
ABS Group

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Introduction

• 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

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Where does Safety Culture sit?

Loss of Containment
Accident
Fatalities / Injuries / Pollution

Loss of Containment Near Miss

Near Miss

Operating Envelope Excursions, Activated Process Control

Shutdown Systems, Relief Valves etc Issues

Poor Operational Discipline – failure to Management System

follow procedures, close actions etc Issues

Cultural Issues Affecting

Organizational Culture Issues
the Tiers above

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How do we Improve PSM Performance?

Three key aspects of PSM

RCA / II identifies
Accident issues to correct in the
1) Become a Learning Organisation lower levels (PSPIs)

Near Miss

Process Control
2) Implement Robust Safety Issues Leading PSPIs and
Management and Assurance Audits to correct
Systems Management System same level issues
Issues

3) Embed an Appropriate Safety Issue Detection and

Organizational Culture Issues
Culture Remedy ?

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 Cultural Essential Features (CCPS/ABS Group Model)

No Essential Feature Symptom that feature is absent

Establish safety as a core Units restart before the Pre Start-Up Safety Reviews (PSSRs) are fully signed off.
1
value Awards and praise for high production, but none for safe behaviour.

When the CEO comes on-site, discussions are only with the site leadership team.
2 Provide strong leadership
Managers don’t perform weekly safety visits, or reinforce safety messages

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

behaviour is “accepted”, goes unnoticed and is not commented on.
Establish and enforce high
3 Site procedures not updated within specified time frame.
standards of performance
Individuals not using all required PPE all the time.
Incomplete attendance of refresher training (and no follow-up).

No formal discussions on process safety culture.

Formalise safety culture
4 Process safety not mentioned on internal and external company web pages.
emphasis/approach
No recent in-house training on process safety.
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 Cultural Essential Features (CCPS/ABS Group Model)

No Essential Feature Symptom that feature is absent

No "chronic unease".
Maintain a sense of Individuals cannot answer “what is the worst case scenario for your area?” and what
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vulnerability would be the consequences? “We’ve done it this way for 30 years and nothing has
happened”.
Empower individuals to No-one on the leadership teams (board/senior management team/site leadership team)
6 successfully fulfil their "owns" process safety issues.
safety responsibilities No-one has hit the “big red button” in the last three years.

Burden of proof demanded on safety statements and comments.

7 Defer to expertise
Changes implemented without asking “the guru”.

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

Ensure open and effective Minimal reporting of near misses and minor accidents.
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communications Front line staff not asked for their opinions.
People stop reporting safety issues because they won’t get feedback.
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 Cultural Essential Features (CCPS/ABS Group Model)

No Essential Feature Symptom that feature is absent

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

Establish a questioning and
9 Operators can’t remember the topic of the last Safety Standstill/meeting.
learning environment
Reasons for most recent incident not understood by all operators.

Near misses not reported for fear of being blamed.

10 Foster mutual trust
Reporting a near miss perceived negatively.

Reported safety issues just added to an ever-growing list and disappear in to a black hole.
Provide timely responses to
11 Slow progress on resolving safety actions from RCAs after safety incidents.
safety issues and concerns
Status of progress on safety actions from RCAs not shared with all.

Provide continuous
Process Safety KPIs not collected and shared with all on site.
12 monitoring of safety
No structured management review of (process) safety performance
performance 10
 Traditional Survey
Results

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?

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 Linking Culture with Performance

Accident

• Containment integrity issue allowed to exist

Near Miss

• Unsafe work practice Process Control

Issues
Increasing • Action item not completed or late Management System
Significance Issues

• Safety hazard situation is allowed to exist Organizational Culture

Issues

• Inadequate inspection, testing, maintenance

• Inadequate management practice/ system / procedure
• Inadequate hazard, risk, root cause analysis Threat Consequence

Alarm & Op. Response

Emergency Response
Inadequate monitoring or auditing

Protection Systems
Trip Systems
Threat
Top Consequence
• Inadequate training Event

• Inadequate recordkeeping and documentation Threat Consequence

• Inadequate communication or signage

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 Cross correlating Culture Survey data with PSPIs

Cultural Survey Results

Increasing
Significance
PSPIs

Cross Correlation of Cultural Feature Low Scores with Observed PS

Performance
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Case Study – Example for one facility

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

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 Case Study – Group of Facilities

All companies had PSM issues Company

Process Safety Culture Problem A B C D E F G H J
which initiated the Surveys.
Normalization of deviance 1 1 4 2 1 2 7 1 2
“Formal Approach” and Non-responsiveness to safety concerns 3 8 3 3 7 1 3 3 3
“Leadership” were found to be Lack of a questioning/learning environment 4 5 7 5 3 3 2 4 5
a lower priority. Lack of trust – unsafe reporting environment 6 1 10 5 5 7 6
Lack of personal responsibility for safety 8 9 9 8 9
“Normalisation of Deviation”, Not listening to technical experts 10 6 9 8 1 6 4
“Non-Responsiveness to No performance monitoring or pursuit of improvement 2 9 9 1 2 4 4 2 11
Safety Concerns” and “Lack of Lack of sense of vulnerability 5 2 5 4 8 7 8 5 7
Questioning/Learning Ineffective communications 11 2 11 6 6 11 10
environment” came out top. 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

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Focused Cultural “Fixes”

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.
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 Hierarchy of Cultural Issues
Level 1 Performance Action Issue
Continuous Improvement and Responsiveness to Concerns
Monitoring Issue Issue

Level 2 Situational Awareness Issue

Deference to Expertise Safe Questioning and Learning Normalisation of Deviation
Issue Environment Issue Issue

Level 3 Adoption of Leadership Values by Organisational Issues

Cultural Effective Sense of
Empowerment Mutual Trust
Cultivation Communication Vulnerability
Issue Issue
Issue Issue Issue

Level 4 – Values Expressed by Leadership

Leadership Issue Core Value Issue

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Application of Cultural Cause Analysis™

CCA methodology and Cultural Cause Map™ can be applied to

any RCA methodology.
 Example
Front-line Personnel Known management
system issue
BP Texas City Issue 3 uncorrected C3

Causal Factor – Blowdown Company Personnel

Responsiveness to
Concerns Issue C11
drum overfilled Issue
12 Mismatch between
practices and
procedures not

An intermediate cause-
resolved in timely
manner
Procedure Issue C15

operator started unit with 122

exit valve closed - Technical Questioning Questioning and

and Learning Environment Issue
123 Correct Procedure Not Learning Environment
Finding was an employee Used
InadequateIssue
Critical Thinking
failed to follow the startup
C21
126 Procedure Use
Discouraged
procedure because the 230 Company Standards, Empowerment Issue
procedure use was not Policies and
Administrative Controls
C45

encouraged (SPAC) Not Used Resources available to fulfill

health, safety, and
environment roles and
233 SPAC Enforcement Issue responsibilities issue
C47

Leadership Issues C61

Ineffective
Support for programs management
and objectives issue demonstration of
commitment
C63 C64

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Summary

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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