The Sociology of Safety. Vice President Associate Professor of Industrial Hygiene

Transcription

1 The Sociology of Safety Jeffery A. Hartle Dianna H. Bryant CFPS, MIFireE CIH, CSP Vice President Associate Professor of Industrial Hygiene Skillful Means, Inc. Central Missouri State University

2 Which Social Science? Psychology? Focus and study is on the individual Basis for Behavioral Based Safety Often blames the worker Managers become comfortable knowing that they are not responsible for causing accidents or preventing them (Kletz, 1991) Sociology? Focus and study is on social groups and organizations Offers different perspectives on accidents Often blames system or organizational factors Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 2

3 Sociology Patterns of human systems Observe and develop theories Use theories to review past events and predict future outcomes Examine failures of systems, resulting in: Accidents (localized failures) Disasters (catastrophic failures) Accident and disaster causation research provides fertile ground for new theories about human systems Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 3

4 Can We Study Organizations? Groups/organizations are more than the sum of their members May have a individual legal identity (corporations) Organizations are entities separate from the individuals in them Organizations generate collective phenomena Organizations are real and can be studied as distinctly social processes and factors (Warriner, 1956) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 4

5 Who s In Control? Purchase facilities Maintain equipment Implement procedures Organizations Hire Train Supervise Safe Place Design Engineering Physical Controls Safe Person Human Factors Motivation/Attitude Behavior Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 5

6 Characteristics of Organizations Structure/Hierarchy Externalities Power Decision making Culture Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 6

7 Structure/Hierarchy Bureaucracies are the ideal organizations (Weber, 1978) Efficient Hierarchy of authority Division of labor Standardization Prescribed rules Limited authority and specialization may not be the best arrangement for safety Trained incapacity Specialties function as inadequacies or blind spots (Merton, 1957) Efficiency for whom? People at the bottom are sacrificed for the sake of organizational objectives (Sjoberg, et al., 1984) Unanticipated consequences of a purposeful action (Merton, 1936) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 7

8 Externalities Everything outside of the organization Shifting costs to others to maximize profit Social costs Environmental damage For whom does safety pay? (Hopkins, 1999) Employers only bear 30% of the total cost [of accidents], the rest being borne by the worker and the community Preventing infrequent catastrophes costs too much Union Carbide plant, Bhopal, India Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 8

9 Power Organizations have taken over society (Perrow, 1991) Wage dependency Externalization of social costs Factory bureaucracy Power concentrated in the hands of the elite Those with the most power have the greatest discretion in interpreting the rules (Sjoberg, et al., 1984) Managerial decision makers isolated from consequences Organizations attempt to maintain control Corporate reaction to labor activism in 1920s (Rosner & Markowitz, 1987) Blame the workers Hold workers responsible for their own safety Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 9

10 Decision Making Management decisions support organization s goals Bounded rationality (Simon, 1957) Incomplete knowledge constrains decisions But most accidents are predictable! Managers intentionally remain ignorant of facts Knowledge is a necessary ingredient for ethical decision making (Schneider, 2000) Challenger accident Conflict in goals between managers and engineers Take off your engineer s hat and put on your manager s hat (Boisjoly, Curtis, & Mellican, 1989) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 10

11 Culture Western culture Organizational culture exists within the larger society Organizational goals assumed to reflect societal goals Unit culture reflects organizational culture What is the dominant culture for EHS professionals? New technology is always better than old Official vs. unofficial culture Official culture is for the public view Unofficial culture may be at odds Gauley, WV Official messageproject good for community Unofficial messagedoctors misled workers about tunnelitis Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 11

12 Barry Turner s Disaster Incubation Theory Organizations suffer from a failure of foresight Most disaster research starts at the event Focus is on response and recovery Turner focused on precursors of the event Incubation period Unnoticed events occur which are at odds with organizational norms about safe operation Turner, B. A. (1976). The organizational and interorganizational development of disasters. Administrative Science Quarterly, 21 (3), Turner, B. A. & Pidgeon, N. (1997). Man-made disasters. Oxford: Butterworth- Heinemann. Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 12

13 Common Features of Incubating Disasters Rigid perceptions and beliefs about the organization Decoys Focus upon the wrong signal, allowing other problems to develop Organizational exclusivity Disregard of nonmembers Information difficulties Noise Ambiguities about warnings Wrong or misleading information Involvement of strangers Outside the organization The public Failure to comply with regulations Do they apply to us? Perceived as out-moded What can we get away with? Minimizing emergent danger Underestimated Even when seen, undervalued Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 13

14 Case Study: Aberfan, Wales 1966 accident Killed 144, including 109 children in school 1939-Report predicts tip slides under certain conditions National Coal Board limits circulation of report Numerous tip slides occur throughout UK Community concerned as tip grows in size Citizens complain Borough gov t complains National Coal Board dismisses complaints as nuisances Focus is on mine safety, not tip safety No one understands coal issues except us! Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 14

15 Charles Perrow s Normal Accident Theory High-risk technologies are too complex to be controlled by humans Accidents are normal because the conditions for failure are built into the system Complex systems characterized by: Complexity (non-linear interactions) Tight coupling (little slack in the system) Perrow, Charles. (1984/1999). Normal Accidents: Living With High Risk Technologies. Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 15

16 Interaction/ Coupling Figure 3.1 Interaction/ Coupling Chart (p. 97) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 16

17 Key Concepts Linear Interactions Expected in familiar production or maintenance sequences Visible, even if unplanned Complex Interactions Unfamiliar, unplanned, or unexpected sequences Not visible, or not readily comprehensible Loose Coupling Delays possible Change order of sequence Alternative methods Tight Coupling Little slack in resources Buffers and redundancies built in Limited substitutions Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 17

18 Case Study: Three Mile Island Nuclear reactor is complex system Actual process is unseen by operators Gauges indicate working condition Accident on March 28, 1979 Leak in cooling system flooded pneumatic instrument lines Instruments indicated false signals Open valve released radioactive water Core almost melted down True signals were hidden in multiple false signals Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 18

19 High Reliability Organizations (HRO) Theory An organization is an HRO if it could have failed > 10,000 times or more, but did not Based on 3 organization studies: FAA air traffic control Diablo Canyon nuclear plant Two U.S. Navy carriers in peacetime Univ. of California- Berkeley Geoffrey Gosling, Todd R. LaPorte, Karlene H. Roberts, Gene I. Rochlin, Paul Shulman, and Karl Weick Other proponents Joseph Marone & Edward J. Woodhouse Aaron Wildavsky Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 19

20 Characteristics of HROs Leadership places a high priority on safety and reliability Short-term efficiency is second to high reliability Leaders communicate very clear operational goals Significant redundancy exists Duplication (2 different units with same job) Overlap (2 different units with some functions in common) Error rates reduced through: Decentralization of authority Strong organizational culture Continuous operations and training Richer is safer (Wildavsky, p. 58) Organizational learning First, trial and error Supplemented by anticipation and simulation Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 20

21 Case Study: U.S. Navy Carriers Leadership CO briefs new crew Never break ship s rules unless safety is at stake Common commitment to goal of reliability Redundancy Technical resources Personnel resources Constant flow of info on multiple radio channels Errors Reduced Decentralizedlowest ranks can stop flight ops Closed system with common culture of reliability Flight ops & training Learning Organization Innovations a result of earlier accidents Extensive use of simulation Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 21

22 James Reason s Organizational Accidents Theory Individual accidents Specific person/group is the cause and victim System failures or organizational accidents Multiple persons Multiple causes Multiple levels of responsibility Reason, James. (1997). Managing the Risks of Organizational Accidents. Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 22

23 Swiss Cheese Model Hazards Defenses Losses Defenses can be breached Figure 1.5 Accident Trajectory (Page 12) Active failures Errors at sharp end of system Has immediate effect Now seen as consequence, not cause Latent conditions Errors beyond individual psychology Errors at top levels of organizations Present in all systems Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 23

24 Latent Conditions Exist for years May combine with active failures or local circumstances Created by strategic decisions Often top-level choices Government, regulators, designers, corporate managers Impact pervades the organization Changes culture Lies dormant until interactions occur, then overwhelm defenses Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 24

25 Case Study: Nakina, Ontario Derailment Railroad bed laid in 1916 Rail bed built on portion of beaver dam Train observes missing railroad bed in 1992 Rails suspended in air, train can t stop, overturns, kills 2 crewmen Latent Failures Railroad kills beavers to reduce road bed damage Dam is not maintained and weakens Heavy rain raises water level, soaks roadbed, washes out sludge No active failures! Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 25

26 Thoughts on Redundancy Reason Defenses in depth create a variety of problems in complex sociotechnical systems (p. 54) Conceal errors and their long-term consequences May not respond to individual failures Perrow Redundancy increases complexity Redundancy make the system opaque to operators Fixes, including safety devices, often merely allow those in charge to run the system faster, or in worse weather, or with bigger explosives (p. 11) HROs Redundancy is essential to achieve reliability Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 26

27 Fantasy Documents Lee Clarke Everything will work right the first time Every contingency is known and prepared for Intended to support organization s view of reality Goal is NOT to deceive the public, but to deceive themselves Political organizations are able to ensure the public that government is in control of systems over which the government has no control Managers may substitute own judgment of risk for the professional judgment of experts Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 27

28 Failure of Hindsight Brian Toft Organizations must learn from their own experience and experiences of others Negative feedback must be provided internally or it will be provided externally (regulations) Organizational learning Passive (perception) Active (implementation) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 28

29 Conclusions Sociology provides insights about organizational behavior that impacts on safety and health Organizations resist change Environmental, health, and safety are perceived as reducing profit What values will EHS professionals adopt? What is the dominant culture of your organization? EHS professionals have often adopted the values and assumptions of their employers regarding responsibility for risk (Rosner & Markowitz, 1987) Ethical codes must guide EHS decisions, not profits! Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 29

30 Additional Sources Clarke, L. (1999). Mission improbable: Using fantasy documents to tame disaster. Chicago: University of Chicago. Hopkins, A. (1999). For whom does safety pay? The case of major accidents. Safety Science, 32, LaPorte, T. R. and Consolini, P. M. (1991). Working in practice but not in theory: Theoretical challenges of High-Reliability Organizations. Journal of Public Administration Research and Theory, 1 (1), Roberts, K. H. (1990). Managing high reliability organizations. California Management Review, 32 (4), Rosner, D., & Markowitz, G. E. (Eds.). (1987). Dying for work: Workers safety and health in Twentieth-Century America. Bloomington: Indiana University Press. Toft, B. and Reynolds, S. (1997). Learning from disasters: A management approach (2nd ed.). Leicester, UK: Perpetuity Press. Turner, B. A. (1992). The sociology of safety. In David I. Blockley (Ed.), Engineering safety (pp ). London: McGraw-Hill International. Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 30

31 For More Information Jeffery A. Hartle CFPS, MIFireE Vice President Skillful Means, Inc. 850 NE 771 Knob Noster, MO (toll free) (mobile) Dianna H. Bryant CIH, CSP Associate Professor of Industrial Hygiene Central Missouri State University Warrensburg, MO (work) (mobile) Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 31