Risk tolerance and killer kultures

Every organisation has a general risk tolerance, and some have a killer culture. Watch out for confidential or fake health and safety data.

Some aggressive or relaxed habits are designed to circumvent personal and organisational risk assessment. Safety psychologist David Broadbent explains the cultural causes in a fatal lockout incident and in an infamous disaster.

In killer kultures, there are usually telling deficiencies in planning, equipment, communication, procedure, habitual transgressions, and a relaxed attitude towards risk and implementing standards. Indifference to the health and safety of workers or the public takes many forms.

Watch out for sycophantic mid-level managers more focused on the political prize of ‘getting the job done’ and vague notions of ‘discipline’ or ‘stepping in line’. They may not have any real understanding of the process, or they may have enough knowledge to be dangerous.

The degree of acceptance of risk is usually set by top management. In safety-speak we call the crucial issue risk tolerance. Anyone on site or at head office who err on the side of political and organisational issues, directly contribute to growing a killer kulture.

Killer kulture struck during lockout at Cheshire

A cardboard recycling business in Cheshire in the UK has about 120 workers. It was time to clean out one of the hydro-pulping machines, a big drum with blades inside.

Fred came to work early to clean the hydro-pulper before the shift. He had arranged this with the shift supervisor the night before. Fred isolated the machine with his lock and got to work.

An hour later it was time to start the shift and Fred was nowhere to be seen. The supervisor noted Fred’s lock on the panel. The remains of Fred were found in the hydro-pulper.

I happened to meet Jack, safety manager of the paper company. A fatality while a machine is isolated is scary. Jack had told the engineering boffins to spare no expense to find out how this happened.

They reported that it could not have happened! But Fred had a bit of a reputation for leaving the key in the lock when he isolated a piece of equipment. Half the plant knew he did this. It certainly was not the written procedure. Someone had spoken to Fred about that some months before.

The only way that hydro-pulper could start is with the lock removed. Someone else must have removed that lock to start the machine at beginning of shift.

I think there was no ill will, but somebody removed Fred’s lock, started the machine, realized what had happened, turned off the machine, replaced the lock, and placed the key on the peg in the supervisors office.

Safety manager Jack said; “We have a killer on the plant, and we don’t know who it is. Nobody has resigned or left so they must still be there”.

Unsafe became normal

If you see someone doing something unsafe, would you always step up and say something to them? The answer on this site was clearly No. On this site, management allowed unsafe acts. A combination of unsafe acts killed Fred.

A killer culture is any workplace that tolerates deviations from safe practice and allow those deviations to become the norm, without establishing and removing the causes of that culture.

Incident investigations often find “normalisation of deviance”. Whether your site has 3000 employees or 120 employees makes little difference.

We have to develop a zero tolerance to shortcuts at every level, particularly among senior leadership. Killer Kultures always percolate just beneath the surface. It takes only a circumstance or two to turn it loose like Frankenstein, a monster of our own creation.

Deepwater Horizon risk tolerance case

The Deepwater Horizon (Macondo) disaster is a classic example on a grand scale, although fatalities occur on a much smaller scale of operations too. A confidential survey commissioned by Transocean only weeks before the explosion stated that workers were concerned about safety practices and feared reprisals if they reported mistakes or other problems.

After all, “real men don’t whinge”. Heard that before? If your operational guys say this, there is a real reason to be concerned.

Now I am sure that it will be said that senior management launched the confidential survey to know what was going on. That may or may not be so. The real question here is, why were people conflicted over whether or not they should report or not?

And what was management reaction to this conflict? There is always a reason and you need to know. Unless you want to know only certain attitudes.

For example, if you dismiss someone for raising a safety concern, would you expect that people don’t report? This is exactly what was reported to have occurred on the Deepwater Horizon rig.

Risk culture artefacts

If we take a look at some of the artefacts of culture, we get some further insight into the Killer Kulture on the Deepwater Horizon. There had been previous spills and fires on the Deepwater Horizon.

The US Coast Guard had issued pollution citations 18 times between 2000 and 2010, and had investigated 16 fires and other incidents.

The previous fires, spills, and incidents were not considered unusual for a Gulf platform and have not been connected to the April 2010 explosion and spill. This, in itself, should have been very scary and an enormous warning sign.

It was not seen that way and demonstrates a high degree of ignorance, or adaptive or willfull blindness to safety culture. It seems that “fires” were an accepted practice on a Gulf rig?

Deepwater Horizon had other serious incidents as well, including one in 2008 in which 77 people were evacuated from the platform when it listed and began to sink after a section of pipe was accidentally removed from the platform’s ballast system. Ouch.

By April 20 in 2010 the Deepwater Horizon well operation was already running five weeks late. Leaked internal BP documents clearly indicated that BP engineers had  concerns as early as 2009, that the metal casing BP wanted to use might collapse under high pressure.

Then in March 2010 the rig experienced problems that included drilling mud falling into the undersea oil formation, sudden gas releases, a pipe falling into the well, and at least three occasions of the blowout preventer leaking fluid.

The rig’s mechanic stated that the well had problems for months and that the drill repeatedly kicked due to high gas pressure providing resistance. These things were ignored.

Yet even after the disaster, and other like it, we see repeats of these sorts of responses throughout the majority of organisations. Killer Kultures do not want to learn from disasters.

Workers ordered to take safety shortcuts

Survivors of the Deepwater explosion are on record as saying that BP ordered them to take shortcuts on the day of the explosion. It was independently corroborated that chief driller Dewey Revette had a loud argument with senior BP staff (Dewey was a contract driller) over an instruction to replace the drilling mud with seawater.

Many on the rig could not recall ever having drilled without using “mud”. Doug Brown (chief mechanic) overheard Dewey being told “well, that’s how it’s going to be” and then the BP guy just walked away.

Despite his better judgement, Dewey did as instructed. Dewey died and the BP guys are alive. It is well known that the drillers were unhappy with the instruction they had been given. Most of them died.

Fake safety data

The Macondo rig ran on high risk tolerance to the point of being a conscious Killer Kulture. Many workers admitted to entering fake data into the safety management system. Worse, this data was used to justify management decisions.

The report commissioned by Transocean concluded that the company had a distorted view of safety on the rig due to the false data!

There were so many cultural artefacts visible above the waterline that this could not fly. I can only assume Transocean finally reached the same conclusion. After all, they entered a guilty plea.

Protect us from management

If you saw someone doing something unsafe would you step up and say something to them? Do you believe that the majority of the people who work in your organization would also step up and say something if a task or process looked potentially unsafe?

Most people do not say anything, let alone stop a process. On the Deepwater Horizon some spoke up, but did as they were told anyway.

• David G Broadbent is a safety psychologist and the founder of TransformationalSafety.Com. He is based in Australia, with clients in Asia and Africa. This post contains extracts from his global circular.

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