Connecting Process Safety Performance Outcomes

to Process Safety Cultural Root Causes

Process Safety Culture – The Key to Sustainable Performance

1st Latin American Process Safety Conference

Building Culture and Competency
26-28 May 2008  Buenos Aires Argentina

Steve Arendt, Vice President

Organizational Performance Assurance
ABS Consulting, Houston, Texas USA
sarendt@absconsulting.com
Presentation Outline
„ What is process safety culture?
„ Telltale signs of a poor process safety culture
„ Essential features of good process safety culture
„ How to evaluate process safety culture
„ Connect process safety performance to culture
„ Culture case study example results
„ Industry needs/issues in process safety culture
„ Conclusions

3
Safety Culture Failures
„ Challenger & Columbia
„ Piper Alpha
„ Longford
„ Chernobyl
„ Flixborough
„ Texas City

4
What Is Process Safety Culture?
Our Company and Individual DNA

„ Culture is the tendency in all of us – and our

organization - to want to do the right thing in
the right way at the right time, ALL the time –
even when if no one is looking
„ Culture is the result of all the actions - and
inactions - in institutional/workforce memory
„ Culture is hard to measure and more difficult to
change; it will be the “root cause of the decade”

5
Telltale Signs of Safety Culture Disease
„Ineffective PSM system performance
„Inadequate reaction to fixing identified
problems - lack of follow-up/huge backlogs
„Superficial audits - “check the box”
mentality
„Inadequate metrics-misplaced confidence
in injury rates
„Poor management review at all levels

6
Telltale Signs of Safety Culture Disease
„Weak conduct of operations/lack of operating
excellence
„Poor incident reporting, learning and risk
review
„No MOOC (people, policies, or organization)
„Chronic cost-cutting and production pressure/
emphasis over process safety
„Plenty of “talk”, but hard to find examples of
leading by doing through the organization
7
 Accident Pyramid
Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

8
 Truncated Accident Pyramid
Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

9
 Improve Throughout the Pyramid

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

10
Process Safety Culture – Essential Features
1. Establish safety as a core
value
2. Provide strong leadership
3. Establish and enforce high
standards of performance
4. Formalize the safety culture
emphasis/approach
5. Maintain a sense of
vulnerability
6. Empower individuals to
successfully fulfill their
safety responsibilities
7. Defer to expertise
8. Ensure open and effective
communications
9. Establish a
questioning/learning
environment
10. Foster mutual trust
11. Provide timely response to
safety issues and concerns
12. Provide continuous
monitoring of performance
11
 We Need Something More than “Just
Opinions” upon which to Make Process
Safety Improvement Investment Decisions
„ Employee surveys are important, but they have weaknesses
„ Sometimes they are viewed as being informational, but not
providing definitive arguments for action
„ Particularly, expensive action…
„ The PAR approach “connects opinions with process safety
outcomes” that “prove out” the opinions
„ Recommendations from a PAR give confidence that you are
fixing things throughout the accident pyramid

12
Connecting the Dots – Process Safety
Performance Assurance Review (PAR)© Strategy
Process Safety/ESH Culture
Mapping of ESH Technical Evaluation Sources
Performance and Culture PSM/EHS
Surveys and Work
Evidence to Process interviews observations leading
indicators
Safety Culture Factors

Incidents and
investigation
Process results Process Safety/ESH Culture
Safety/ESH
Performance Audits and Essential Features
Information assessments Causal Factors
Sources Action item Tenets of Operation
completion
history

© ABSG Consulting, Inc.

13
Culture Case Study Example Results
„ Over the past two years, process safety performance and
culture reviews have been conducted for 10+ companies
in the oil, chemical, pharmaceutical, consumer products
industries
¾ Tens of 1,000’s of employees
¾ 50+ facilities – onshore and offshore
¾ Domestic U.S. and international
¾ Old companies and new companies
„ All of these studies included an evaluation of safety culture
– most also involved mapping to process safety
performance outcomes
„ Some observations and lessons from looking at the
combined results – company names not included

14
Typical

15
 Overall Culture Survey Results
Denmark Overall Average of all questions

PS Training
Obvious result,
but look into it
Employee Involvement

Employees
PS Procedures
Managers

Supervisor Oversight

Committment to PS

Reporting

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% Positive Responses

16
PAR Approach
„ Takes culture survey results and maps them to process
safety culture essential features
„ Takes technical performance outcomes and maps them
to the same features
¾ Weights PSM outcomes according to risk significance
¾ Not all findings are “created equal”
„ Identifies process safety culture issues that need to be
worked on
¾ Negative survey responses indicating a problem with one or
more culture features
¾ Supported by technical performance evidence from the field that
“backs up” the survey “opinions” so you can be certain that
these problems actually exist and are not “just feelings”

17
PAR Process Safety Performance vs. Culture Map
Culture survey results and other sources
are sorted into the 12 essential features

Analysis of all process safety

performance data (e.g., audit actions)
is sorted into the 12 essential features
18
 Cultural Causal Factors Needing Attention
Cultural Causal Factor Survey PAR
Score Rank
1. Process safety is NOT a core value 57 1
9. Lack of a questioning/learning environment 56 1
11. Non-responsiveness to safety concerns 59 2
3. Not meeting performance standards – “normalization of deviance” 61 2
5. Lack of sense of vulnerability 52 3
10. Lack of mutual trust 47 3
6. Empower individuals to fulfill their safety responsibilities 74 4
8. Ensure open and effective communications 70 4
7. Defer to expertise 58 5
4. Formalize the Safety culture emphasis/approach 69 5
2. Provide strong leadership 57 6
12. Provide continuous monitoring of performance 67 6

19
9. Lack of a Questioning/Learning Environment
Technical Evidence No. of Finding Issues
„ Containment integrity issue allowed to exist 5
„ Safety hazard situation is allowed to exist 2
„ Unsafe work practice 2
„ Action item not completed, late, or chronic 5
„ Inadequate maintenance, inspection, testing 7
„ Inadequate monitoring or auditing 4
„ Inadequate training 3
„ Inadequate hazard, risk or RCA review/analysis 10

Culture Evidence (% positive responses)

„ In my work area, we actively participate in incident and accident investigations - 62.4%
„ In the past 12 months, I have received adequate training on process safety - 31.2%
„ Newly hired workers at my site receive adequate training in process safety - 30.1%
„ Contractors at my site receive adequate training in process safety - 25.5%
„ Overall, I am satisfied with the process safety training we receive - 36.4%

20
Lack of a Questioning/Learning
Environment – Possible Solutions
„ Widely circulate the CCPS Process Safety Beacon
„ Distribute summaries of incident reports that include what happened,
lessons learned, and how the lessons learned might apply locally
„ Employ a “high potential incident” practice of communicating notable
incidents across the company and industry
„ Modify the incident investigation system to more fully address “what
could have happened” instead of only the actual incident
consequences
„ Conduct table top drills with operating teams to discuss response to
operating problems and incident scenarios
„ Review key hazard scenarios with highest potential consequences
from PHA’s with operating and technical teams
„ For outside incidents with lessons learned that have serious potential
local consequences, require documented follow-up to ensure similar
conditions do not exist or are well managed locally
„ Conduct hazard awareness training for operating/technical teams
21
Ranking of Cultural Causal Factors Present –
Summary of Study Results

Cultural Causal Factor – Decreasing Frequency

1. Normalization of deviance
2. Non-responsiveness to safety concerns
3. Lack of a questioning/learning environment
4. No performance monitoring/pursuit of
improvement
5. Lack of sense of vulnerability
6. Lack of trust – unsafe reporting environment

22
Ranking of Cultural Causal Factors Present –
Summary of Study Results

Cultural Causal Factor – Decreasing Frequency

7. Not listening to technical experts
8. Process safety is NOT a core value
9. Lack of strong PS leadership
10. Ineffective communications
11. Lack of personal responsibility for process safety
12. No formalization of a “culture process”

23
Observations on Culture Results
„ The top three cultural problems were way above all the
others
„ Surprising that “culture foundation issues” were so low –
core value and strong leadership
„ Two of the 10 companies had process safety culture
problems that were not high in the other 8 cases
„ Seven out of 10 of the companies had undergone
significant organizational change in this decade
„ No direct information on cultural root causes – research
continues as to how these companies got to the point
where they are
„ Even without having robust cultural root cause
information, it is possible to heal culture disease

24
 Sense, Learn, and Fix at Every Level
Accidents
„ Put sensors, not censors,
at every level
Incidents

Precursors
„ Develop learnings at
Management System Failures every level

Unsafe Behaviors and Attitudes

„ Take corrective action at

ulture – Individual and Organizational Tendenciesevery level

© ABSG Consulting, Inc.

25
Putting Sensors at Every Level
„ Some activities must be monitored using leading
indicators if they want to improve, not just by having
accidents happen
„ Use a human health care analogy
¾ Lagging indicator = an autopsy after a heart attack
¾ Leading indicator = blood pressure, cholesterol, EKG
¾ Culture indicator = examining DNA
„ We must use leading indicators in process safety if
we hope to drive continuous improvement; we must
address culture for sustainable performance

26
 Examples of Process Safety Metrics
Accidents „ PS accident rate

„ PS incident rate
Incidents
„ Releases that don’t have consequences
„ Upsets/safety system challenges
Precursors „ Significant mgmt system failures

„ % WOs misclassified as RIK

Management System Failures
„ Action item backlog/aging
„ Inspection overdues
Unsafe Behaviors and Attitudes
„ Unsafe acts

„ Culture survey results

ulture – Individual and Organizational Tendencies
„ Work observations
„ Some leading indicators

© ABSG Consulting, Inc.

27
 Improve Throughout the Pyramid
rt a in
u Ce ?
r e
Accidents
Yo e t te r
, A B
Th s e
e Incidentsnd S tay
Y o u Fix tt e r a
I f B e ng
Bu t i ll Get erl yi s
g s W u n
Precursors
d a u s e
Th i n
h a v e o o t c
L
AL Management io r r
e h a v
System Failures
u t t he
r e / b h r o ug ho
r ec ur
tu
t ill
cul
f i x s w
nd em
a Attitudesobl e
Unsafe Behaviorsnand
, le ar c e pr
s en se or m an
d on't , pe rf
u
If yoCulture y r amid and Organizational Tendencies
p
– Individual
de nt
acci

© ABSG Consulting, Inc.

28
Industry Needs in Process Safety Culture
„ No formally recognized, systematic way to
evaluate culture
„ No widely recognized set of metrics
„ Lack of understanding of the "pathology of
process safety culture disease"
„ No prescription or set of remedies for curing
culture ailments
„ No case studies of evolution of cultural root
causes

29
Conclusions
„ Sustainable process safety performance must:
¾ Use a blend of risk management approaches
¾ Focus on establishing the right culture
¾ Let your “walk” lead your “talk”
¾ Use a layered approach to management system
control
¾ Sense, learn, and correct throughout the pyramid
„ Companies need motivation for self-examination and
change – the ability to integrate, analyze, and act upon
“weak signals”

30
Conclusions
„Have health check-ups to identify early
culture disease symptoms
„Establish process safety leading indicators
„Get “vaccinations” by regular, effective
management reviews of process safety
performance – spotlight good and bad
„Develop and administer process safety
culture “vitamins”

31
Time for Questions