Developing Safety Culture - Final Year Reflections

Task: Demonstrate, in your own words, how you employed systemic thinking to
conceptualise the notion of safety culture.
(EA competencies 1.6, 2.1, 2.3 and 3.1 / CDIO 2.3 and 2.4)
Dell
I would like to take this blog as an opportunity to reflect on what Risk
Management has aided me in.
To me, really, Risk Management helped to achieve two things 1. to change my safety culture
2. to shift my thought processes from a purely technical, ' seek out
the one right answer, presented in a numerical form' approach, to a more
broad-minded and systemic manner of thinking.
I say this because of my experiences in the classes, the workshops, and the case
studies. I went from trying to define every problem into a small manageable
black box, and considering nothing but that one black box, to considering all the
aspects that tied into it, such as the people, the property, the laws , the
management of the company's reputation.
To say it was a quick process would be a gross over-exaggeration. At every
workshop and every class, we would be presented with problems (doing a hazard
analysis on a cup of coffee, or even on the downfalls of the Ford Pinto case) that
initially seemed too simple. Generally everyone had the same ideas and agreed
on the same things, and came to these conclusions almost immediately, and
they were fairly straightforward - ' Oh, clearly they should have glued that on ' or
' Oh , why didn't they think about reinforcing that '.
Yet, as the semester progressed, I began to notice that there was more to the
problem than just identifying hazards, or pointing out when something might fail
and how. It began to occur to me that in some way, these classes were
influencing my overall safety culture. Progressively, I was beginning to
understand that a plant was not merely a collection of nuts and bolts, valves and
pumps, pipes and fluid. A plant was also a collection of people. A plant was a
collection of goals.
As an illustration, every day, the primary goal of most managers and operators is
achieving a certain degree of productivity within a certain time, to a certain
quality. However, the manner in which they achieve these goals is strongly
dependent on their safety consciousness, or culture.
While I know Im about to go off on a tangent here, I suppose, before I go any
further, that it would be a good idea to explain what my interpretation of the
term safety culture is. Culture to me is the set of values one gains throughout
one's life that tell you what is the norm and what isn't. For example, in my
culture, as an Indian, the norm is to allow your parents to seek a spouse for you,
as in my culture, parents are placed much higher in the respect heirarchy than
God and teachers, and hence, any decision they make would clearly be one of
great merit. However, as I have discerned from some of my Australian-born
friends, their culture dictates that parents who make such a choice for you, or
even consider it, are robbing you of a major right: the right to choose who you
spend the rest of your life with. My parents, personally, also believe that it is a
child's right to find their own partner. Why do my parents not hold the more
traditional view of encouraging arranged marriages? It is because their values

have been influenced by their exposure to several other cultures, through media,
and personal friendships. For them, it is now normal to think of the average
western style of developing relationships.
Similarly, my 'safety' cultural values mostly consisted of ' take the basic safety
measures, make sure the equipment is working fine, and you have your PPE on,
make sure you get your work done and on time, and if you need to cut one or
two corners, that's fine, as long as no one notices '.
However, through my experiences with Rio Tinto ( who place safety above all
else ! ) and through the Risk Management unit, my values have been influenced
significantly to the point that I place it highest on my list of priorities too. Thus,
my safety culture now consists of consideration of others, and of my work area,
of the impacts of my actions both in the long term and short term on not only
myself, my family, and my friends, but on my company and the environment.
Coming back to the original point, the goals that a company and its employees
want to achieve, and how they go about achieving them are strongly dependent
on their safety culture. From the risk workshops, it was seen that companies like
Ford wanted to achieve high sales, and wanted to maintain their profit margin, at
the cost of ensuring their customers' safety, as that was their company culture :
safety was not a priority. The only safety they hoped to guarantee was of the
company's balance sheet. However, as that case illustrated, they did not think of
the negative impacts their decisions would have on the well-being of their
customers, on their reputation, and ultimately on the thing they most tried to
protect, their cash inflow. They did not think systemically.
And that brings me back to what the goal of the risk management unit was - get
people thinking systemically; get engineers thinking in ways besides 1+1 =2 , to
stop thinking in numbers, frequencies, statistics, dollar signs, and seconds by
giving them the tools and the ability to hear other people's perspectives on the
same issue. I cannot put into words how much I appreciate the lessons I have
learned, and the insight I have gained, and the humility I developed when
realising that safety is not a one-man show, and that my opinion is not the only
opinion, but that safety is about everyone, about interconnected teams of
people, and how their feelings towards safety, and hence, their safety culture,
influences how risk is managed. In a strange way, I've managed to achieve the
impossible for most engineers of this generation. In terms of safety, I've finally
become cultured!
Chuck
My journey to the understanding of safety culture
Let me begin by saying that I believe it is a natural human tendency to look at a
subject, problem or situation through a particular set of lenses and based on
what they see, formulate an opinion, assumption or standpoint on the
aforementioned. Speaking from personal experience, this method of derivation
often culminates in the person arriving at a very simplistic or otherwise narrow
minded understanding or viewpoint of the subject, problem or situation.
The notion of systems thinking was first introduced to me by a lecturer who
taught the subject called Productions Systems (Operations Management). His
learnings centred on the fact that a production facility was a system that
consisted of inputs, a process and this produced outputs. However, there was
also an environment in which this system worked as well as a feedback loop

whereby the outputs generated feedback to the inputs. What he was

communicating, in the context of business administration and production
management, was that no system or process was isolated and was impacted
upon by other various other internal or external influences. In other words, a
relationship existed between each individual component, the system and the
process.
Wikipedias online definition of Systemic thinking is the viewing of problems
rather as parts of a whole as opposed to being individual problems hits the nail
on the head, simply because viewing a problem or a concept in isolation could
lead to one making decisions or assumptions which in turn could unintentionally
aggravate the problem by not considering the whole picture. My understanding
of systemic thinking was paramount to my ability of finally being able to bring
together the many facets which together define safety culture.
Through the course of my risk management studies, I have been presented with
various case studies, viewpoints and theories. Many of which looked at either a
particular theoretical facet of safety, of culture, of safety culture or a particular
viewpoint of a person, department, regulatory body, government body or public
body. Looking specifically at case studies, I can remember three different case
studies which each individually looked at safety through the eyes of a regulatory
body via an inquest, through the eyes of employees and through the eyes of a
managing director. All three sets of eyes (lenses) provided me with a unique
insight into safety and the culture which affected it. This coupled with my own
interpretation and understanding of the events, their causes and possible
preventions initiated the germination process of understanding.
An understanding, or perhaps a realisation, that safety culture, very much like
any other human culture, is complex and very dependent on a multitude of
various factor and influences. The same as cultures are created over millennia
and are in turn shaped by numerous significant external events or interferences,
so the same holds true for a particular safety culture. In other words, the
particular dominant safety culture of a nation, community or organisation is the
summation (positive or productive and negative or counter-productive) of the
cultures of each individual component (political, societal, legal, environmental,
technological etc.) or person (operator, manager, owner etc.) that makes up the
nation, community or organisation. Therefore, I believe that it is an imperative to
utilise the previously mentioned systemic thinking approach in order to better
provide a more holistic perspective on what safety culture is to a particular
nation, community or organisation.
So in closing, through the subsequent utilisation of systemic thinking, I
personally have been able to better conceptualise what safety culture could be
defined as, what it could mean to various stakeholders and what can mould or
influence it. The attitudes, perceptions, beliefs and values of each individual
component or person (as previously defined) together all assist in creating the
overall attitude to safety (safety culture). The attitudes, perceptions, beliefs and
values all vary from person to person and from component to component simply
because each component or person is born into and raised within a unique
environment which contains a varying degree and number of the internal and
external influences.
Thus, in order to create a particular safety culture which is robust in nature, one
would have to ensure that the ability exists whereby a complete buy in and
adherence to the best possible safety management principles, procedures and
processes by all the individual components or personal could be guaranteed. This
could be achieved through the positive manipulation of particular values, beliefs,

attitudes and perceptions held by each individual component or personal,

towards achieving an improved organisational atmosphere towards safety (safety
culture). An atmosphere wherein everyone values the safety of themselves, their
colleagues, their managers, the public and the environment with equal and
significant importance.
Noam
Safety Culture - The role of systemic thinking in conceptual brainstorming
So how does one conceptualise safety culture? What are the driving forces which
let us exercise judgement in our daily life? This notion or perceived notion is
examined through the use of systemic thinking. Systemic thinking lets us
organise our thoughts into a system, where imagination and logical arguments
are stored. Using this method, the individual is not limited by specified
constraints or rules, and are given freedom to think, much like freedom of
speech. However, without a boundary, the system would not be contained and
too many variables would exist, this is where one's own knowledge and expertise
comes into effect placing a control boundary around the system, in which
information is exchanged between surroundings and the system. Concept maps
done on safety culture in the past few weeks have done exactly this. The topic of
interest is placed in the centre, and we can create a better understanding of the
ambiguities that surround this topic.
For example, in my first concept map, safety culture was an alien notion to me. I
had little to no experience in this area and this affected how I perceived the
notion of safety culture. So I thought back to my basics, who, what, when, where
and how safety culture is concerned in modern society. Even though my lack of
train of thought was constantly hindered by my inability to conceptualise and
visualise safety culture, I was able to brainstorm a web of ideas that could be
affected by safety culture through this form of systemic thinking. This learning
effect was more evident in my second concept map where my train of thought
changed to a more focused, logical and specific form and I was able to formulate
ideas and apply them to multiple perspectives instead of my own.
This brings up my second point, the ability to interpret multi-dimensional
scenarios through multiple perspectives. This idea was an even harder notion to
capture in terms of thinking systemically. Safety Culture can sometimes be a
contradictory term, where an individual from one country may have opposite
notions of safety culture then someone from another. It does not even have to be
that from another country but in the same person, for example, a celebrity actor
who inhibits the role of a character in a movie, takes on the characteristics of
that person and their perception of safety culture. However, this is contradictory
in the sense that the same person who would act in such a way which challenges
their own beliefs and ideas of safety culture would outside of acting, could be
totally opposite.
Another example comes in the form of social pressure, where an individual would
challenge their own notion of what is safety and what incorporates the culture
behind it, due to submitting to power groups or maybe just to satisfy the
stakeholders that would be affected by their decision. This social pressure is one
of the driving forces which can sometimes corrupt positive systemic thinking,
alongside many others such as economical and cultural factors. By human
nature, humans have always adapted to situations to survive. It is this selfpreserving nature that makes the decisions we make and hence the amount of
systemic thinking we put into these decisions, at times bias. If for example, we
consider the most vulnerable part of a human's evolutionary cycle, adolescence,

a teenager is subject to many societal pressures which render the ability to think
systemically difficult at times and the lines between safety culture and what is
actually safe becomes blurred.
Many cases of system failures and faulty safety culture are a result of poor
decision making and an inability to think about the consequences of actions and
the associated parameters with such a decision. Such actions can have
disastrous consequences, as hazards are not identified and probability due to risk
is not thought of in detail, such as BP Gulf of Mexico oil spill. It is important to
think systemically, especially for topics which would affect not only ourselves but
everything around us; people, stakeholders, environment, ecosystem and the
earth which links it all together as a system. Most personal decisions made in
everyday life are instantaneous and do not affect many groups besides the
individual. It is important to distinguish these apart from corporate safety
culture, where sense of responsibility and trust given by the public is much
higher. It is clear to me that listening and contributing, develops positive safety
culture and due to our diversity as individuals from all around the world, different
attitudes and group effort systemic thinking is key to ethical considerations and
accommodating foreign matters into guidelines and conceptualising safety
culture. This can effectively in my opinion minimise unnecessary risk and
probability, give safety assurance (evidence) and provide inherent safety for all.