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Energy Facility Contractors Group. Washington, D.C. June 8, 2005. The Challenge of Changing Organizational Culture ---- Building A Safety Conscious Work Environment. Billie Pirner Garde Clifford & Garde Washington, D.C. “How Are We Going to Build a Safety Conscious Work Environment?”.

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Washington d c june 8 2005

Energy Facility Contractors Group

Washington, D.C.

June 8, 2005


The challenge of changing organizational culture building a safety conscious work environment

The Challenge of Changing Organizational Culture----Building A Safety Conscious Work Environment

Billie Pirner Garde

Clifford & Garde

Washington, D.C.



Safety culture or scwe
Safety Culture or Environment?”SCWE ?

  • Safety Culture and Safety Conscious Work Environment are two distinct but related concepts:

    • Safety Culture refers to the necessary attention, personal dedication and accountability of all individuals engaged in any activity that has a bearing on safety;

    • SCWE refers to the willingness of employees to identify safety concerns without fear of reprisal or apathy.

  • SCWE is an attribute of Safety Culture

EFCOG June 2005


Doe definition of safety culture
DOE Definition of Safety Culture Environment?”

“The safety culture of an organization is the product of individual and group values, attitudes, competencies, and patterns of behaviors that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs.”

DOE Implementation Plan for DNFSB Recommendation 2004-1, Dec. 2004, p. 48

EFCOG June 2005


Safety relies upon the free flow of information throughout the organization
Safety Relies Upon the Environment?”Free Flow of Information Throughout The Organization

Overt Retaliation….

Discouragement….

Lack of responsiveness….

Lack of Competence….

Hierarchal Suffocation.

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Chernobyl 1986
Chernobyl - 1986 Environment?”

Chernobyl disaster resulted in international acknowledgment of importance of safety culture in avoiding unacceptable consequences, and use of term.

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EFCOG June 2005 Environment?”


“Obviously A Major Malfunction” Environment?”

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Unacceptable consequences
Unacceptable Consequences Environment?”

“No fundamental decision was made at NASA to do evil; rather, a series of seemingly harmless decisions were made that incrementally moved the space agency toward a catastrophic outcome.… No rules were violated; there was no intent to do harm. Yet harm was done. Astronauts died.”

Diane Vaughan, The Challenger Launch Decision 409-410 (1996)

EFCOG June 2005


Fatal blind spot
Fatal Blind Spot Environment?”

“The [Shuttle] program’s structure was a source of problems, not just because of the way it impeded the flow of information, but because it has had effects on the culture that contradict safety goals. NASA’s blind spot is it believes it has a strong safety culture…”

Columbia Accident Investigation Board (CAIB), Chapter 8, page 203.

EFCOG June 2005


EFCOG June 2005 Environment?”


EFCOG June 2005 Environment?”


Lessons not learned
Lessons Not Learned Environment?”

In neither [the Challenger or Columbia] impending crisis did management recognize how [organization] structure and hierarchy can silence employees, and take appropriate mitigating actions, such as polling participants, soliciting dissenting opinions, or bringing in outsiders who might have a different perspective or useful information, to overcome the organizational constraints.

CAIB, page 202.

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EFCOG June 2005 change it.”


What the nrc did about safety culture after chernobyl
What the NRC Did About Safety Culture After Chernobyl change it.”

  • Benchmarked Good Safety Cultures;

  • Established Expectations for Licensees;

    • Strengthened internal regulations against retaliation for raising concerns (10 CFR 50.7);

    • Issued SCWE policy statement identifying SCWE attributes (May, 1996 and October, 2004);

    • Aggressively investigates retaliation allegations;

    • Monitors licensee SCWE performance indicators.

  • Takes Enforcement Action.

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Nrc expectations
NRC Expectations change it.”

The NRC expects that licensees will establish and maintain a safety conscious work environment in which employees feel free to raise concerns both to their own management and the NRC without fear ofretaliation.

May 1996 SCWE Policy Statement

October 2004 SCWE Policy Update

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Millstone 1996 order
Millstone 1996 Order change it.”

Millstone issues were a wake-up call on SCWE concerns:

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The ultimate question
The Ultimate Question change it.”

Would I lose my job for that???

Sorry! I can’t afford to lose my job.

Would you raise a nuclear safety concern?

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Davis besse 2002 incident
Davis-Besse 2002 Incident change it.”

Davis-Besse incident was the result of a lack of safety culture.

DB - A Hole in the HeadStainless steel liner bulged, but did not fail

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Alyeska pipeline 1991 1999
Alyeska Pipeline 1991 - 1999 change it.”

  • Exxon Valdez clean up failure;

  • Spy “sting” on critics and employees;

  • Congressional investigations, increased regulatory oversight, multiple lawsuits by employees and critics;

  • Complete loss of public confidence;

  • Collapse of internal safety culture.

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Doe and safety culture
DOE AND SAFETY CULTURE change it.”

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Doe s lessons learned
DOE’s “Lessons Learned” change it.”

The DOE committed to an assessment of the lessons learned by NASA and the NRC as a result of the loss of the Columbia and the near miss at Davis-Besse, in response to DNFSB Recommendation 2004-1; which was adopted in its entirety by the Secretary of Energy in December, 2004.

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Does ism by itself provide the tools to improve safety culture throughout the doe complex
Does ISM, By Itself, Provide the Tools change it.”to Improve Safety Culture Throughout the DOE Complex?

“It is our belief that robust implementation of ISM could lead [DOE] and its contractors to a stronger safety culture….However, without robust and active support by [DOE] Senior Management, ISM will not lead to an enduring [DOE] safety culture, nor is ISM specifically designed to improve an organization’s safety culture.”

NNSA, CAIBLessons Learned Report, February 19, 2004, p. 4

.

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Integrated Safety Management change it.”

ISM plus behavioral attributes and a plan to develop, measure and monitor progress toward building a safety culture.

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Building a robust safety culture is an art and a science
Building A Robust Safety Culture Is An Art and a Science change it.”

  • “Safety Culture” is not the soft side of management issues – it is the hardest!

  • “Safety Culture” can be built, or re-built, using proven organizational development; methodologies, but a bad culture will not simply evolve into a good one by declaration;

  • “Safety Culture” behaviors are often counter-intuitive and must be learned and reinforced;

  • Driving fear and apathy out of workplace, i.e. SCWE, takes consistent performance management and mitigation strategies.

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Key elements of culture change
Key Elements Of Culture Change change it.”

  • Leaders must “make the case” for change;

    • The organization must collectively identify the desired “end state” for the new work environment, i.e., behavioral attributes;

    • The management team must understand the baseline issues and challenges facing organization under each attribute;

    • There must be a single, clear set of behavioral expectations for everyone, and additional expectations for leadership;

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Key elements of culture change cont d
Key Elements Of Culture Change change it.”(cont’d)

  • There must be measurable performance indicators;

  • There must be a dedicated infrastructure to guide culture change and establish new norms;

  • The organization needs to receive training on new skill sets and new expectations;

  • Work plans to address problem areas and behaviors should be developed and worked; and

  • Progress should be measured regularly through self assessments and external reviews.

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Taking on the challenge
Taking on the Challenge! change it.”

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“We have a vision of a people-based future. We know our work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

Ed Aromi, President of CH2M Hill - Hanford

August 23, 2004, General Delivery Message

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Work environment attributes examples

Commitment work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

Conservatism in Safety Decisions

Problem Identification & Resolution

Training Adequacy

Self-Assessment

Trust

Communications

Free Flow of Information

Alternative Avenues for Concerns

People Management

Prevention of Retaliation

Work Environment Attributes(Examples)

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Assessment of the current state
Assessment of the Current State work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

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Behavioral expectations for everyone
Behavioral Expectations work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” For Everyone


Key scwe performance measures

Nuclear Organization work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

Key SCWE Performance Measures

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Commitment to Free Flow work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

of Information

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Training training training
Training, Training, Training work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

Preventing Retaliation

Communications Training

Management Training

101

Listening Skills


Scwe infrastructure
SCWE Infrastructure work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”

  • Additional support is needed to assist organization in making change:

    • Executive involvement in personnel decisions that may impact safety culture;

    • SCWE mentors and advice to assure consistency and fairness;

    • Alternative avenues for minority opinions or employee concerns.

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Preventing the unacceptable consequences
Preventing the work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Unacceptable Consequences

“If I look back on it now… I should have done everything in my power to get it stopped. I should have taken over the meeting and all that. But, no, really I’m not that grade structure or anything.”

Bob Ebeling, Interview, March 19, 1986 Diane Vaughan, The Challenger Launch Decision (1996)


Preventing the unacceptable consequences1
Preventing the work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Unacceptable Consequences

“I felt like going in there and interrupting or waiting until they got through ... but I didn’t … I said, ‘Mike, did you hear that she got that we are still not finished [with the foam Strike Issue] … Mike said to me, ‘Well, what are the rules for engaging a manager here? What is the protocol for doing that?’ ... And I remember saying ‘Mike, for an issue like this, where we have a flight safety concern, I don’t think the protocol should matter. It shouldn’t matter at all. … Rocha left without speaking to Ham.”

CommCheck, Mike Cabbage and William Harwood, 2004

EFCOG June 2005


Preventing the unacceptable consequences2
Preventing the work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Unacceptable Consequences

EFCOG June 2005


Preventing the unacceptable consequences3
Preventing the work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Unacceptable Consequences

EFCOG June 2005


Preventing the unacceptable consequences4
Preventing the work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.” Unacceptable Consequences

“The prudent response of the production technicians as they saw unexpected behavior of the explosive provided the only effective barrier preventing a drop of explosives with potentially unacceptable consequences. …”

EFCOG June 2005


EFCOG June 2005 work sites should always be places where workers are not afraid to identify safety issues, to help each other be safe…. We maintain an open, respectful work environment, and never lose sight of our people.”


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