The ghost in the machine.
Text: Markus Schöbel
How high-risk industries are sustained by a culture of safety.
Highly specialized organizations in the nuclear and chemical industries, civil aviation or the railway sector are inherently at risk of causing massive damage to themselves, people or the environment. Conversely, these organizations guarantee an extremely high level of safety on a daily basis by recourse to highly standardized technological and operational procedures. As a result, they are sometimes referred to as machine organizations. These intricate webs consisting of technological systems, the people that work with them and the organizations that coordinate and regulate the interplay between them are subject to the influence of another important but often overlooked factor: safety culture.
Safety culture first came into the spotlight in 1986 in the months following the Chernobyl reactor meltdown. Experts from the International Atomic Energy Agency (IAEA) identified a defective safety culture as one of the primary causes of the catastrophe. The concept of a safety culture served to encapsulate the broad spectrum of lapses and breaches observed, thereby expressing the collective failure at all levels of the organization (and the respective supervisory authorities).
Five years later, the IAEA published its INSAG-4 report, which provided the first official definition of “safety culture” in terms of its essential requirements, describing it as: “that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, […] safety issues receive the attention warranted by their significance.” Among the features highlighted in the report was the need for a questioning attitude on the part of the organization’s members and the provision of appropriate safety resources by its management, for example.
To this day, reports on inquiries into industrial catastrophes regularly cite failures at the level of safety culture. Aside from the often gradual decline of safety conditions over time observed at accident sites, such as defective alarm systems, inconsistent regulations or breach of established procedures, these failures increasingly include contributing factors that are further removed in terms of both time and space, such as the ignorance of top-level management in regard to warning signals (refinery explosion in Texas City, 2005), time and budgetary constraints affecting the launch of new technologies (Lion-Air Boeing 737-8 (MAX) crash, 2018) or failed state oversight (reactor meltdown in Fukushima Daiichi, 2011).
Today, high-risk industries acknowledge the importance of optimizing their safety culture almost without exception, and have implemented control mechanisms to this end. The prevailing view is that the cultural contribution above and beyond technological aspects is elementary and indispensable to the safety of systems, as these systems are ultimately invented, developed, built, serviced and maintained by people. Unlike technological components, people reflect on their actions, adjust them according to the situation at hand and communicate with one another while collaborating.
The spirit of a safety culture can be observed in an organization’s policies, process descriptions and brochures. It usually includes the allocation of certain responsibilities to particular functions or individuals, systems for reporting and assessment of incidents, targets in the sense of a learning culture, and processes such as the development of management staff. It is promoted in training programs, measured using indicators and assessed through document analyses, interviews and site inspections (conducted in the course of reviews). Safety culture is one of the few concepts rooted in the social sciences to have become established in the everyday operations of these predominantly technology-based organizations. Its positive and indispensable contribution to system safety is a matter of general consensus.
Scientific research into safety culture, by contrast, has struggled to gain momentum, held back by concerns over the appropriate theoretical framework, the methods to be employed and the resulting practical implications. A general starting point that has become established in expert circles is the model developed by US organizational researcher Ed Schein, which pinpoints an organization’s culture primarily in the “taken-for-granted and shared assumptions” of its members. These assumptions are learned and internalized, specifically in the course of successful adaptation to external circumstances (e.g., “How should we interact with each other in the supervisory process?”) and necessary integration into existing social structures (e.g., “Who is in charge here, and is it acceptable to criticize them?”).
According to this understanding, positively changing a safety culture involves exposing, scrutinizing and questioning assumptions and procedures that are thought of as taken-for-granted (because they work). Unfortunately, critical questioning of this sort tends to be most vigorous precisely when a safety culture has failed. This timing is unfortunate, however, particularly if the organization is to learn from the failure.
Depending on the severity of the consequences, there is often a focus on individual blame, even though this is generally not conducive to improving a safety culture, and can even have destabilizing effects such as an erosion of trust in management or a feeling of alienation from one’s work as a result of excessive new safety regulations. Moreover, this kind of retrospective analysis of accidents focuses chiefly on deviations from target outcomes, in order to determine precisely what those involved did wrong or failed to do, whereas a proactive understanding of culture also involves knowing what steps were taken by those involved and why they thought it was a good idea to behave in this particular way.
And this is where the key to a better understanding of safety culture is to be found: in the supposedly taken-for-granted assumptions that account for the success – or indeed the “safe operation” – of an organization. This also includes the not uncommon but largely disregarded episodes in which individuals averted a system’s collapse with their expertise, courage and independence. The kind of safety culture that encourages these skills has already been described on a theoretical level in numerous models and guidelines. Further practice-oriented research is needed to identify the most effective ways for organizations to implement this knowledge. It is also clear that safety culture in today’s organizations is more subject than ever to changing global, digital and economic framework conditions, making this spirit all the more worthy of protection in the future.