DEVELOPING A FRAMEWORK FOR ASSESSING WORKPLACE & PRODUCT SAFETY CULTURE IN BAE SYSTEMS

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1 BAE SYSTEMS DEVELOPING A FRAMEWORK FOR ASSESSING WORKPLACE & PRODUCT SAFETY CULTURE IN BAE SYSTEMS AUTHORS Freyja Lockwood Rebecca Canham Michael Wright

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3 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems Freyja Lockwood BAE Systems Bristol, UK Rebecca Canham & Michael Wright Greenstreet Berman Ltd Reading, UK Abstract: BAE Systems has a broad portfolio of products and undertakes a wide spectrum of activities to remove potential hazards and mitigate the risk of harm to people, property and the environment. The company s approach to managing safety performance is informed by the recognition that, in continually evolving complex environments, it is essential to remain alert to potential issues and continuously review current practice. The academic literature provided key lessons from industry and research relevant to the continuous improvement of safety management. Namely, the influence of organisational factors upon safety performance, the importance of combining control measures with an engaged safety culture to minimise risks, and the need to recognise that the safety culture of an organisation may differ across distinct aspects of safety (such as product safety and workplace safety).this paper discusses these lessons and their implications for managing safety performance and assessing safety culture. It then outlines the rationale behind the decision to develop a bespoke assessment in partnership with Greenstreet Berman (UK-based safety consultants), and the development of a framework to assess both product safety and workplace culture across the company. Underpinning the development of this prototype assessment is a greater understanding of the cultural factors that are common to both workplace and product safety and how these can support a holistic approach to assessing the impact of culture on different aspects of safety. 1 Refining safety management BAE Systems delivers a wide variety of products, many of which are operated in challenging and high-risk environments. Ensuring that products are as safe as they can be for those who use them or may be affected by their use is a crucial aspect of product development, with a wide spectrum of activities undertaken to remove potential hazards and mitigate the risk of harm to people, property and the environment (Roland and Moriarty 1990). The application of engineering and management techniques has greatly reduced hazards associated with products. But it is vital to remain alert to potential issues and continuously review current practice. It was this drive to refine the management of product safety that lead to the work presented in this paper. BAE Systems is continually evolving, gathering assurance data, looking at changes in legislation and generally maturing attitudes and behaviours around product safety. This desire to ensure that the organisation strives to continually improve its safety performance is based on a recognition that in a continually evolving complex environment it is essential to challenge the norm (Hudson 2010). In support of this a detailed review of literature relating to safety culture and safety culture assessment methods was undertaken in 2013 to inform further development of safety practices within the organisation (Lockwood and Page 2013). The aims of this review were twofold: firstly, to understand current thinking within the academic and safety practitioner communities, and secondly to identify cultural assessments that could be employed to understand how organisational culture affects product safety within BAE Systems. A key finding highlighted from this review was that the safety culture and safety culture assessments were predominantly focused on workplace safety (i.e. occupational health & safety (H&S)). As a result the scope of work was broadened to cover both aspects. The rationale is presented later in the paper. In addition, the review also identified a number of key lessons from industry and research that are relevant to the continuous improvement of safety management. These lessons highlight the impact of wider organisational factors, the role of organisational culture and that safety is multi-dimensional.

4 2 F. Lockwood, R. Canham & M. Wright 1.1 Impact of organisational factors upon safety Recent history provides multiple examples whereby failures to ensure adequate safety mechanisms and controls have resulted in catastrophic accidents and incidents, including the break-up of the Columbia space shuttle (Wong et al. 2009). The Rogers Commission found that NASA's organizational culture and decision-making processes had been key contributing factors, with examples including: prioritisation of mission progress over safety, being overly optimistic about or underestimating risk levels, and lack of organisational learning (Vaughan 2004). There is a growing recognition across the defence industry that organisational factors are highly significant and incidents, such as Columbia, highlight a number of areas of interest. For example, the need to maintain an effective balance between operational pressures (e.g. time, resources and budgets) and developing products with optimal safety performance is well recognised; as is the need to avoid safety and operational effectiveness (or profitability) being viewed as competing priorities. In addition, lessons from historic safety problems in consumer products indicate how cost efficiency targets can affect the quality of product development processes (White and Pomponi 2003). NASA s inability to successfully resolve this tension between safety concerns and maintaining an efficient, productive business was identified as a powerful factor that influenced decision makers and ultimately led to the Columbia accident (Woods 2003). However, these examples risk promoting an either/or viewpoint, when in fact research indicates that the picture is significantly more complex than a safety versus cost or production versus safety equation (Dekker 2013). While cost and production pressures will almost always exist (Dekker 2013), many aspects of an organisation can affect safety (Dekker 2011, Reiman et al. 2010) as they continually adapt, manage, change and learn from a variety of goals and local pressures that are all simultaneously relevant (Dekker 2013, Leveson 2011). It is in this more complex space that BAE Systems has focused its efforts to refine its approach to managing safety performance. Safety performance is more than effective risk control measures. Safety policies, Safety Management Systems, hazard identification and risk classification procedures, etc. provide an effective means to manage safety. However, good practice indicates that attempting to improve overall safety performance without considering the wider organisational context is unlikely to have a long-term impact on practice (Leveson 2011) and ultimately on levels of product and workplace safety. Part of the wider context involves understanding how the culture of an organisation affects safety and the occurrence of incidents (Hopkins 2002, Hudson 2010). 1.2 Role of organisational culture Effective safety performance arises from a combination of control measures and culture designed to enhance safety. It is useful to think of good, or high-levels, of safety performance as something that an organisation has due to the structures, practices, controls and policies designed to enhance safety; and something an organisation is because of the beliefs, attitudes and values of its members in relation to safety (Reason 1998). This combination of competence and commitment is illustrated in Figure 1. Fig. 1. Effective safety performance is the combination of well-designed, managed risk control measures and a strong, engaged safety culture (adapted from An organisational culture which places a high-value on safety and promotes doing the right thing (Hudson 2010) can help ensure that trade-offs, such as those highlighted by the NASA example, are not at the expense of product safety, and that robust safety cultures can offset inherent limitations of safety systems (Hopkins 2002 citing Reason 2000). To cite Hudson (2007): Sound systems, practices and procedures are not adequate if merely practised mechanically. They require an effective safety culture to flourish. In effect, organisational culture can act as an effective, even critical, risk control mechanism. Within the literature, there is no single definition of organisational safety culture. It tends to be an umbrella term covering both safety culture or safety climate, for which there are also multiple definitions (Reason 1998, Mearns and Flin 2001, Zohar 2010, Guldenmund 2000) that are often used interchangeably (Glendon and Stanton 2000, Hopkins 2002). Most models encapsulate beliefs, values, attitudes and assumptions that are shared by a group and influence behaviour. However, in general terms, organisational culture can be considered as Who and what we are, what we find important, and how we go about doing things around here (Schein 1992, Hudson 2001). These shared assumptions, perceptions, and

5 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 3 values guide action within the workplace, outlining appropriate behaviour for various situations, and right or accepted ways to do things (Schein 1992, Ravasi and Schultz 2006), such as the management of product safety (Hopkins 2002). There is agreement that a strong safety culture is one where an organisation places a high priority on safety-related beliefs, values and attitudes (e.g. Reason 1998, Guldenmund 2000, Hopkins, 2002), and emerges from the collective safety-related practices of people across the organisation (Hopkins 2002, Leveson 2011). A key message is that a wide range of factors influence people within an organisation, from their perception of organisational priorities, perceptions of risks, effectiveness of communications, to other aspects, such as team working and the effectiveness of processes, such as learning and sharing expertise. No one factor will determine behaviours, instead an interaction of cultural, perceptual and process-related factors will be in play at any given time. 1.3 Multi-dimensional nature of safety It is also important to recognise that safety is multi-dimensional. The focus of safety management in BAE Systems is on two key dimensions occupational H&S (concerned with protecting the health and welfare of people engaged in a work activity) and product safety (covering goods, services and intellectual property, and concerned with reducing the risk of harm to people, property, and the environment). Both product safety and workplace safety interrelate especially from a longer-term, through-life perspective. For instance, product design can mitigate workplace safety risks downstream. This is not only true for products developed for external customers, but also those developed for internal use, or built and maintained by employees. In this light, Product safety can be seen as an attribute of the product that emerges from the behaviours and attitudes of the people who conceive, design, build and support the product (Elliott 2011). The prominence of workplace versus product safety will also vary according to the context of operations within different lines of the business, for example whether activities are office-based or the extent to which they are safety critical and focused on manufacturing, etc. Fig.2. Workplace versus Product Safety. As shown in Figure 2, the distinction between these two aspects of safety can be considered as a distinction between different types of hazards (Hopkins 2009) that can result in relatively high frequency, low consequence events (e.g. slips trips and falls) and major hazard risks, that give rise to low frequency high consequence events (e.g. explosions) (Hopkins 2011). 1.4 Implications for safety performance and safety culture assessment Organisational culture will affect both aspects of safety. However, because safety culture research focuses predominately on workplace safety within an organisation, primarily accident prevention and improving occupational H&S it is unclear whether the findings can be directly applied to product safety. Cultural indicators of workplace safety performance have been broadly defined and there are numerous methods to assess safety culture. The key issue for this study is that there is relatively little literature indicating how organisational culture influences other dimensions of safety, such as process safety and product safety. This means that the interplay between organisational culture and product safety is less clear. To compound the issue, these two different aspects of safety are often managed separately within an organisation, with different communities of safety professionals, and varying levels of awareness in the employee population that are often dependent on role.

6 4 F. Lockwood, R. Canham & M. Wright This highlights how, despite the idea that an organisation has a single safety culture, attitudes and behaviours may be divergent across different aspects of safety, such as occupational health & wellbeing and occupational safety, as well potential hazards associated with products. Peoples knowledge of hazards and risk, experience of incidents, the level of regulation and stakeholder concerns all interact to influence their perception of a hazard and their approach to managing the risks. Generally there is greater awareness of workplace safety within an organisation. The risks associated with workplace safety tend to be more visible, often with visible consequences, whereas product safety risks are often latent and less visible. Greenstreet Berman s experience also shows that when an organisation formalises policies and performance measures that focus on a single area of safety, this can compound skewed risk perceptions and subsequent behaviours. The implication is that any assessment of safety culture needs to be specific to each aspect of safety and avoid assuming that attitudes will be common across all areas of safety performance. The literature contains clear warnings that a focus on one aspect of safety at the expense of another can be fatal. In 2005, the BP Texas City oil refinery explosion killed 15 workers and injured more than 170 others, exemplifying how an organisation can excel in one aspect of safety (workplace safety), yet fail so dramatically in others (process safety). Quotations from the Chemical Safety Board s (CSB) incident report (Baker, 2007) included: BP has emphasized personal safety but not process safety, and a very low personal injury rate at Texas City gave BP a misleading indicator of process safety performance. BP was lulled into a false sense of security by becoming overly fixated with workplace safety performance. History repeated itself in 2010 with the Deepwater Horizon disaster. This one-sided concentration on workplace safety has been identified as a contributing factor in many previous process safety accidents (Hopkins 2011). Similarly, following passenger train derailments including Potters Bar (Health and Safety Executive (HSE) 2007), Hatfield (Office of Rail Regulation (ORR) 2006) and Grayrigg (Rail Accident Investigation Branch (RAIB) 2008), the ORR commented on Network Rail s push for workplace safety, but acknowledged the comparatively poor focus on procedural compliance, timely completion and escalation of maintenance activity and organisational understanding of their assets to determine the parameters of their safe operation. What these examples highlight is that it is not appropriate to assume that tools and techniques used to successfully manage and monitor workplace safety will translate into effective safety performance for other aspects, such as product safety. These incidents imply that attitudes towards different aspects of safety can vary within organisations. People may act differently in respect of workplace and product safety, in accordance with the attitudes prevailing in each area. A high rating for workplace safety attitudes and behaviours may not necessarily mean that the organisation will also have a high rating for product safety attitudes and behaviours, and vice versa. It is therefore important to address both. 1.5 Requirement for a bespoke safety culture assessment A key objective for BAE Systems is to understand the extent to which the organisational culture within the company affects product safety. In light of the cautionary accounts experienced in other sectors, this objective has been revised to consider safety performance overall, pulling together workplace and product safety, at least from a cultural perspective. As previously mentioned, an internal review of the available literature (Lockwood and Page 2013) has shown that safety culture assessments varied, both in terms of the cultural indicators used and the methods employed. It was also unclear how the range of cultural indicators associated with workplace safety related to product safety. Crucially, these indicators form the basis for most safety culture assessments. Secondly, most assessment methods focused on either workplace health and safety or sector-specific hazards, such as process safety or nuclear safety. None explicitly considered product safety. The absence of a consistent set of cultural indicators, only emphasised the need for a more robust understanding of the differences between product and workplace safety. This meant that it would not be possible to employ a workplace safety culture assessment to investigate both aspects of safety with any degree of confidence. The review (Lockwood and Page 2013) highlighted other areas of assessment good practice, including the need to adopt a multi-method approach. In addition to the lack of resources relating to product safety, many off-the-shelf assessments are single method approaches (e.g. questionnaire only) collecting data related to a specific aspect of safety culture. For example, a safety climate survey will collect data that provides insights into people s attitudes and perceptions of safety within the organisation. While a survey can be a cost-effective way to collect data across a large organisation, a key disadvantage is that the data will not help explain why these attitudes and perceptions exist only what they are. Similarly, a review of safety documentation will shed light on what safety procedures exist, and may give an indication of how an organisation prioritises safety, but it will not help with understanding what people think about those procedures or whether those procedures are consistently followed. Combining different methods (known as triangulation) would provide a more complete picture and allow different levels of culture to be compared and investigated, e.g., perceptions about safety, working practices, decision-making, how things are prioritised, what systems are in place to manage safety, the wider organisational culture, corporate strategy, organisational structure, working conditions, job demands, and non-safety related work practices, etc. Multi-method assessments do exist, for example the Loughborough Safety Climate Assessment Toolkit (LSCAT, undated), but it is unclear whether these could be directly applied to look at product safety culture.

7 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 5 The review of good practice also indicates that a robust assessment of culture would also consider the different levels of safety culture (Glendon & Stanton 2000), such as those suggested by Lawrie et al. (2006): Personal individual perceptions about safety, how it is prioritised within the organisation, etc. Behavioural what actually gets done at work, what is prioritised, what gets factored in when people make decisions. Situational systems in place to manage safety, dimensions of safety (i.e. workplace and product safety). These three levels of culture are not exhaustive. An assessment could also consider the influence of the wider organisation, in effect the environment in which safety activities occur, taking into account factors such as corporate strategy, organisational structure, working conditions, job demands, and non-safety related work practices, etc. (DeJoy 2005). Another aspect to consider is that BAE Systems is a complex multi-national company made up of a large number of levels, disciplines, domains and product-lines. These will be open to a range of individual, organisational and societal factors (Dekker 2011) and the manifestation of these factors will vary across an organisation, leading to distinct subcultures and divergent perceptions all influenced in different ways by their local context. It is also fair to assume that local practices, regulations, and operational pressures (Leveson 2011) will influence behaviours, attitudes and practices. A safety culture assessment needs to be sensitive to the existence of safety subcultures across the company and care must be taken in assuming that a singular profile can be fitted to any one organisation, especially those that are large and complex. Acknowledging and understanding this complexity will inform how safety is managed and how new safety initiatives are implemented across the company. There is also a desire to focus on identifying good practice within BAE Systems and what is going right, a view akin to thinking associated within the Resilience Engineering community (e.g. Hollenagel 2011). Often, the focus is on identifying hazards at the expense of identifying and heralding good practice. The assessment therefore, needs to show how organisational culture has contributed to success and whether it generates a supportive environment which enables a high-level of safety (Woods et al. 2010). To summarise, the review by Lockwood and Page (2013) concluded that BAE Systems required a method that would enable safety practitioners within the organisation to: Demonstrate how organisational culture is affecting safety performance (positively and negatively) across the organisation. Understand the similarities and differences between workplace and product safety attitudes and behaviour. Draw out examples of good practice and highlight where the culture is contributing to success. Identify good practice to indicate where the organisation is getting it right and to promote learning and sharing. Enable action planning and targeted interventions in order to proactively manage hazards. Demonstrate continuous improvement of safety performance None of the existing safety culture assessment methods satisfied all of these requirements, especially the need to compare workplace and product safety. As a result, a bespoke assessment was required. A partnership with Greenstreet Berman was formed to develop a novel approach to assessing safety culture. The next section will introduce the assessment, an overview of the development process, and will discuss how the tool is being validated. 2 Applying good practice in culture assessment 2.1 Assessment methods Greenstreet Berman undertook an extensive review of current safety culture assessment methods and engagement with BAE Systems stakeholders to identify key aspects of good practice in culture assessment. Firstly, culture is a subjective and qualitative facet. Measurement tends to involve the use of subjective tools, such as opinion questionnaires. In order to attain the level of confidence required for the assessment outputs, good practice indicates that a battery of measures, the results of which could be compared and cross referenced in a form of triangulation, would be appropriate. Typical forms of measurement include: Opinion questionnaires exploring peoples safety attitudes and perceptions, Workshop based assessments of peoples safety attitudes and perceptions, Leading and lagging indicators of behaviour, such as the proportion of incidents due to non-compliance with internal processes, procedures, etc., Observations of behaviours, such as at meetings and during toolbox talks, and assessment of processes as exemplified within documentation, Reviews of the root causes of incidents providing evidence of actual attitudes and behaviours.

8 6 F. Lockwood, R. Canham & M. Wright Secondly, as indicated in the previous section, it cannot be assumed that people adopt the same attitudes and behaviours across all areas of health and safety. Therefore, it was considered essential to measure each area of safety separately, namely workplace safety versus product safety. It may subsequently be found that people do approach both areas of safety in a common manner, which would provide a measure of success in achieving BAE Systems goal of holistic safety management. Thirdly, some current methods go beyond measuring culture to exploring the reasons for attitudes and behaviours. This typically takes the form of diagnostic workshops, exploring the factors underpinning peoples attitudes and behaviour. Such workshops tend to be supported by either open ended questions and/or a semi-structured set of prompts. Given the desire to better understand the link between the organisation s wider culture and safety attitudes and behaviour this was considered to be an essential aspect of the culture assessment. This approach to the diagnostic process should avoid imposing any one view of the factors underlying attitudes and behaviours, and should enable key factors to emerge from the investigation and then trace these back through organisational, perceptual and experiential antecedents. At a more granular level, there are many aspects of good practice in respect of questionnaire design, such as using neutral questions, avoiding terms that have multiple meanings and value loaded questions, which ensure that the assessment will generate credible results. 2.2 Identifying elements of product and workplace safety culture Some safety culture assessment methods are underpinned by a consolidated view of the elements of safety culture, providing them with theoretical power and content validity. To draw upon this, a review of safety culture research was completed, BAE Systems product safety activities were then profiled, and a generic model of safety culture was produced to guide the scoping of the assessment framework. A total of 85 existing models of safety culture were compiled from across operations and maintenance, design, and related industries such as aviation, defence, nuclear power, and manufacturing. From these, 16 models were selected for detailed review. They were selected on the basis that they: Were recognised as well-established models in common use, Were publicly available, with summaries and explanations, Reflected some of the occupational and product safety matters cited by BAE Systems. The detailed review enabled the identification and definition of safety culture factors in the following three ways: Those assessed by generic tools covering all forms of safety, Those assessed by tools aimed at occupational safety (i.e. workplace safety), Those assessed by tools aimed at major hazard safety, including operations and maintenance. The factors were compared across generic, workplace and major hazard safety as a test of whether they are similar or not. The elements covered by these tools are summarised in Table 1. Table 1. Comparison of existing assessment tools. Factors Generic tools OHS tools Major hazard safety tools Leadership & commitment Ownership, accountability Balancing safety & other commitments Challenging, no blame open culture Perceptions of procedures - Valid risk perceptions Commitment to training & competence Teamwork Communications Learning, reporting, sharing Combating normalisation Human factors & environment Management of change

9 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 7 Interviews with product safety practitioners and engineers were used to explore the scope of product safety in the context of BAE Systems. This then fed into an activity to profile the attitudes and behaviours cited by BAE Systems subject matter experts in respect of workplace and product safety, to assess if a common set of cultural factors could be applied to both areas. The views of BAE Systems professionals of what the key attitudes and behaviours are with respect to product safety and occupational safety were elicited. This involved defining the scope, attitudes, perceptions and behaviours that influence these aspects of safety performance. The interviews indicated that product safety involves designing products or services in a way that minimises the risk to others (e.g. users, maintainers, manufacturers, testers, the public, etc.) and are safe to operate. This requires a whole life cycle view of the product, from concept, through design and operation, to disposal. Many activities that impact the safety of products, such as testing manufactured products, may not be formally defined as product safety activities but nonetheless impact the safety of products. Quality assurance and SHE could be considered as part of product safety, as it is involved in everything that is done to produce the product. It was also noted that many people carry out activities that can impact the safety of a product without necessarily defining these as product safety activities, such as procurement. Product safety adds, in particular, the philosophy of setting safety standards; identifying how products might fail and associated hazards; assessing whether a product meets safety/risk criteria and then, as appropriate, going beyond the minimum requirements of standards. Following the initial interviews to scope and define product safety, the focus was turned to identifying the key similarities and differences between product and workplace safety. Two separate workshops were run with product safety and workplace safety practitioners from within BAE Systems, to elicit their views of what the key attitudes and behaviours are with respect to product safety and occupational safety. Both workshops followed the same format, with the facilitator leading the groups to first identify the critical activities associated with the area of safety in question (workplace or product safety), then the behaviours that enable these activities to occur, and finally the attitudes believed to lead to the desired behaviours. The outputs from these exercises were analysed by Greenstreet Berman and grouped into key themes during the workshops so that participants could validate the outputs. These are shown in Table 2. Table 2. Categorisation of example behaviours, attitudes and behaviours cited in BAE Systems workshops. OHS Product safety 1. Setting & leading safety expectations 1. Setting safety standards beyond compliance 2. Safety driven performance 2. Risk tolerance 3. Ownership, accountability & awareness 3. Shared ownership & accountability, understand roles 4. Engaging & acting on safety (team engagement) 4. Leadership 5. Enabling safety (equipment, procedures, information, etc.) 5. Commitment to effective safety not tick box 6. Open/challenging culture 6. Committed to competence 7. Communicating & sharing lessons 7. Just culture, trust, integrity 8. Reporting near misses & incidents 8. Questioning, challenging 9. Rewarding, recognising & consequences 9. Learning & sharing 10. Teamwork/self-directed safety 10. Relationships with clients open, honest, shared values It is worth highlighting that, notwithstanding differences in terminology, a single generic set of elements of culture could be mapped onto the attitudes and behaviours in each area of safety. It was found that the majority of attitudes and behaviours cited by the practitioners were analogous across product safety and occupational safety, albeit with differing terminology and emphasis. The resulting question sets would need to use different terminology for each area of safety, but could be formed around a common set of elements, enabling a comparison of results between the two. These elements are presented in the next section. 2.3 The ten elements The majority of existing tools reviewed, as per section 2.2, cover a similar range of elements and cultural indicators related to safety. The researchers from Greenstreet Berman consolidated the elements covered in existing tools, noting that there are many ways to divide and group the elements of safety culture. The elements, drawn from the review of previous research and other tools were compared to the outputs from the practitioner workshops. The resulting sets of elements were grouped into the ten shown in Figure 3.

10 8 F. Lockwood, R. Canham & M. Wright Fig. 3. Ten elements of a safety culture. 2.4 Evaluation of results Finally, an impartial assessment uses an assessment scale that has been defined prior to the assessment, rather than allowing retrospective evaluation of the level of safety culture. Whilst some current methods focus on identifying areas of improvement by identifying areas of weakness, the review identified that many methods use an absolute scale. This allows an organisation to judge the acceptability of its safety culture at the same time as it allows the identification of weaker and stronger areas. This approach should enable a focus on identifying and sharing good practice to support continuous improvement as per the requirements. 3 The BAE Systems Culture Assessment Framework 3.1 Overview of the multi-method assessment The methods, cultural elements and evaluation approach have been combined to develop a prototype Culture Assessment Framework that can be used to evaluate and compare both product safety and workplace safety. These inputs were drawn together to provide a bespoke approach that consists of four phases: Phase 1 Measure this combines selected methods (e.g. workshops, root cause analysis, questionnaires) to assess organisational practices, employee perceptions, attitudes & behaviours, and safety performance data. Businesses are able to select methods that are appropriate to their requirements and the resources available. Phase 2 Diagnose this uses workshops to gain an in-depth understanding of the results obtained during phase 1. Phase 3 Evaluate assessment results are mapped onto an evaluative scale to baseline current safety culture, enable a comparison of workplace and product safety, and identify areas for improvement. Phase 4 Action Planning & Feedback this involves activities to transfer and learn from good practice, address any weaknesses, and communicate results 1. Each phase is described in more detail below, and Figure 4 shows the overall framework with the various methods associated with each stage. 1 N.b. this phase is not part of the initial work to develop and pilot the framework and will not be discussed further in this paper.

11 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 9 Fig. 4. Prototype Culture Assessment Framework. 3.2 Phase 1: Measure This phase is focused on data collection in order to measure attitudes and behaviour associated with product and workplace safety. The tools provided for this phase are presented below: Observing Behaviours guidance is provided for assessing observations of leadership, communication, attitudes and behaviours, reviewing documents and conducting incident investigation processes. Measuring & Comparing Perceptions two forms of measuring perceptions are included, namely: A survey questionnaire which explores perceptions of product and workplace safety attitudes and behaviours. A workshop tool to either add to the survey results and/or provide an alternative means of assessing perceptions. The workshop tool also explores the reasons for responses and relates these to how the business is managed. Performance a battery of suggested safety culture leading/lagging indicators are provided. These take the form of: Measures of leadership, communications, behaviours and organisational learning. Occurrence of repeat incidents and involvement of culture in incidents. Incident behaviours root cause analysis of the involvement of culture in incidents. This includes application of the 5 Why s form of root cause analysis supported by semi-structured prompts to explore: Examples of good practice, tracing the reasons for appropriate behaviours, Examples of incidents where inappropriate behaviours occurred. The root cause analyses are guided by a checklist of factors that might have contributed to behaviours, starting with attitudes of the individual and then going back through their training, supervision, management and organisational environment. As an exploratory exercise this makes use of open-ended questions. At the end of this phase analysis is conducted to identify key themes, surprising or contradictory results and areas for further exploration. These inform the second diagnostic phase. 3.3 Phase 2 Diagnosis For this phase the framework uses diagnostic workshops to explore the reasons for perceptions and behaviours identified during phase 1, and collect examples of good practice. These exploratory sessions use open-ended questions such as: Why do you think people might say this? Why might they have this view? What contributed to their perceptions and behaviours and in what way? The results from the diagnostic workshops can be combined with feedback from the root cause analyses to help trace the factors underlying behaviours. As previously noted, the diagnostic process is led by the emerging findings rather than

12 10 F. Lockwood, R. Canham & M. Wright imposing any pre-ordained view of the causes of behaviours and attitudes. A set of additional prompts are provided to facilitate diagnosis covering: Organisational culture, structure and working practices, Safety leadership behaviours of senior leadership and immediate supervisors, Perceptions and awareness of hazards and risks. As indicated, the framework includes a range of methods to measure attitudes and behaviours, and for diagnosing the underlying reasons for those attitudes and behaviours. Some methods perform both roles of measurement and diagnosis, as per Table 3 and thereby can be used to support both phases 1 and 2 noted above. Table 3. Measuring and diagnostic methods. Assessment methods Assessment Diagnosis Observations of behaviours & documentation Questionnaire survey of perceptions Workshop exploration of perceptions & underlying factors Root cause analysis Leading & lagging indicators Diagnostic workshops From these measures the framework provides: Overall assessment of a business product and workplace attitudes and behaviours, Cross validation of surveys and workshops with leading and lagging indicators, Comparison of results across the different elements of culture, Good safety culture examples. 3.4 Phase 3: Evaluate The assessment results from all parts of the framework are mapped onto the scale shown in Figure 5. Fig 5. Levels of safety culture. (The exact wording associated with each level may be amended after piloting dependent on feedback and results.)

13 Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 11 The scale can be used to assess both workplace and product safety. The scale is based on the work of Hudson (1998, 2001). The terms and descriptors were modified through discussion with BAE Systems subject matter experts to map onto company terminology and the understanding of each term. For example, a bureaucratic organisation may rely on adherence to procedures and process, emphasising regulatory compliance and is thus being characterized as a Managing culture. An organization that aspires to continued improvement may find senior leadership expressing aspirational safety goals and engagement of staff in trying to pre-empt problems and sharing lessons learnt is characterised as a Proactive organisation. Each measure within the framework has been mapped onto the scale for each of the ten elements cited in Figure 3. A numerical version of this scale was produced to allow questionnaire results to also be mapped onto the scale. 3.5 Comparing measures The results from each part of the framework can be compared as a test of their validity. The triangulation of results obtained from different assessment methods provides a cross-check and helps provide a greater weight of evidence. Observations of behaviours and documentation can be compared with perceptions, examples of behaviours in incidents and leading/lagging indicators. If the observation of behaviours, perceptions and behaviour in incidents is consistent, this would give greater confidence in the assessment results. Conventionally, safety culture is thought of as a cycle of (observed) leadership designed to promote certain attitudes, which influence employee perceptions that results in behaviours observed in events and indicators. Therefore, in principle, there should be consistency between measures. However, the comparison of measures may also identify conflicting results. For example, observations of directors, senior managers and supervisors may indicate a strong commitment to safety but the perceptions survey might indicate that employees do not perceive this to be the case. This, in the experience of Greenstreet Berman, is a common finding and can reflect, for example, senior leadership messages being diluted as they cascade through an organisation. This would be a candidate for further review within the diagnostic workshops to try and understand why the commitment of the directors is not perceived by employees. The diagnostic workshop would hopefully resolve differences in results by providing an explanation of differences in perceptions and an opportunity to reconcile conflicting results. Similarly, there are multiple ways to assess the reasons and underlying factors for perceptions (see Table 3). Again this helps cross check findings and increases the weight of evidence. It is important to emphasise that the culture assessment is part of a change process. It is essential to maintain peoples confidence and support during the presentation of the results. Providing a fair and balanced view of the results, both positive and negative, and being able to demonstrate their reliability and consistency will help to promote understanding and acceptance of results. As well as communicating the findings from the assessment, it is also important to communicate the background and confidence levels in the results. Some examples include: How representative are the responses of the business being assessed, for example was a greater than 30% response rate achieved? Was a representative response secured from all parts of the business? The weight of evidence, including data quality and trustworthiness. For example, response rate, quality of reviewed materials and range of incidents reviewed to inform the conclusions drawn. Acknowledgement of any anomalies in the results that cannot be explained by the feedback generated by the framework. Organisational, management, and participant confidence in the results presented. The framework provides advice on how best to present and use results as part of a process of continual improvement. This will feed into the final stage of the framework, Phase 4 Action Planning & Feedback. As previously stated this final aspect is not part of the initial development work and will form the focus of subsequent activities. 3.6 Selective use of measures The framework has been designed to enable different lines of business within BAE Systems to tailor the assessment to meet their requirements and local context. Essentially the initial phase is a pick and mix of methods, and guidance will be provided so that local practitioners can decide how best to apply the measures. For example, if a business has not previously assessed its culture, then there can be a greater justification for applying a combination of methods to ensure the baseline is correct and there is a robust understanding of attitudes and behaviours. A high weight of evidence and confidence in the findings may be required to justify a culture change programme, for example. In the event that a business has already completed an in-depth assessment, then it may choose to only apply one or more of the tools. Indeed, Greenstreet Berman s review of current practice indicates that it is common practice to: Apply employee questionnaires either every year or every two to three years, Track indicators on a quarterly or annual basis,

14 12 F. Lockwood, R. Canham & M. Wright Complete root cause analysis on an as events occur basis, Incorporate the observations of behaviours and documentation into audits of safety management, annually or every few years, Re-run workshops where there is a justification to assess particular issues or if it is difficult to secure a representative response to employee surveys. Two complementary ways of assessing and comparing safety culture perceptions have been included, i.e. a questionnaire survey and workshops. These can be used in combination, especially when developing a baseline and as part of the initial assessment of culture. In combination they provide a measure of attitudes and behaviours and a richer understanding of these attitudes and behaviours. A questionnaire can be administered to a larger number of people to secure a measure of perceptions of culture, whilst workshops tend to provide more in-depth qualitative insights into culture and the factors influencing it. Workshops tend to be used to secure in-depth information from a smaller number of respondents, rather than to attempt to secure a statistically robust response from a larger proportion of people. 3.7 Piloting The overall aim of the pilot was to examine the feasibility of an approach that combines product safety and workplace safety in a single assessment using shared cultural indicators. Key objectives included: Validating the assessment framework and methods, Testing the deployment process, e.g. gaining access to participants, survey response rates, comms requirements, etc., Evaluating the impact the assessment had on the business from an operation perspective, Understanding the experience of participants and their view of the outputs. At the time of writing in December 2014, the draft framework was being piloted at two BAE Systems sites within the UK. Participants were drawn from representative samples that included different hierarchical levels and functional groups, e.g. manufacturing, operations, and engineering. All parts of the framework (with the exception of Phase 4) were deployed, including: Application of questionnaires to ~600 staff per site covering workplace and product safety. A small number (four per site) of workshops to explore perceptions of managers, supervisors and operators of workplace and product safety. Participants were grouped by role to facilitate open discussions. A review of two incidents per site covering workplace and product safety. Observation of a sample of safety-related meetings, documentation and incident reviews. Follow up diagnostic workshops. Participants were de-briefed at the end of the pilots to gather their feedback on its practicality and value, including: Their perceptions of the assessment process, such as: fairness; did it feel valid and useful; did they understand it; was it too long/short and so forth. Their thoughts on the accuracy of the benchmarking scale and the relevance, practicality and validity of the outputs generated by the framework. Their thoughts on how the assessment could be further developed and refined. At the time of writing the feedback had not yet been analysed and so the findings cannot be commented upon in this paper. In addition, the scale of the pilot was designed to enable a statistical assessment of the questionnaire. A series of statistical tests of the pilot results are intended, including: Factor analysis, to test the factor structure of the question set and indicate how the questions align to the factors. Correlation matrix to test whether some questions, with very high correlations (over ±0.8), are assessing the same issue and whether all questions measure the same general area, namely safety culture. Internal consistency to assess whether respondents are answering questions in a rational and consistent manner. For example, do they consistently agree that leadership is good at listening and asking questions? An internal consistency score of 0.6 to 0.8 (on a scale of 0.1 to 1) is indicative of good practice. The framework will be amended post piloting to reflect participant feedback on the various methods, the deployment process and credibility of the outputs, as well as the results of the statistical tests.

15 4 Conclusions Developing a framework for assessing Workplace and Product Safety culture in BAE Systems 13 This paper has discussed the importance of ensuring a high-level of safety performance and the challenges this can entail, as well as the importance of considering the impact of organisational factors. It highlights that safety performance arises from an effective combination of control measures and an engaged safety culture one that arises from assumptions, perceptions, and values, shared by people within an organisation that guide action and shape accepted practice with regard to safety. The need to monitor and manage different aspects of safety was considered, in this case workplace and product safety, along with the consequences of failing to do so effectively. Next the paper has focused on outlining the rationale behind the decision to commission a bespoke safety culture assessment, given the number of tools already available. This is followed by an overview of the assessment tool being developed in partnership with Greenstreet Berman. Notably this includes an overview ten generic cultural factors that are common to both product and workplace safety, and a more indepth understanding of how these two aspects of safety differ. During a conference in 2014, the BAE Systems keynote presentation discussed an approach to Product Safety underpinned by a company-wide culture of safety and accountability, a culture which is based upon undertaking activities because they are the right thing to do (Fielder et al. 2014). If the culture assessment framework described here is deemed to be an acceptable solution, it could support the refinement of that approach. It has the potential to enable safety practitioners within BAE Systems to monitor and manage occupational H&S and product safety culture in a more cohesive manner and target continuous improvements based on an in-depth understanding of how organisational culture affects safety performance within BAE Systems. References Baker, J. (2007). The Report of the BP US Refineries Independent Safety Review Panel. pdfs/16_01_07_bp_baker_report.pdf. Accessed 26 th November CSB (2007). US Chemical Safety and Hazard Investigation Board: Refinery Explosion and Fire, BP Texas City, 23 March Investigation Report, No I-TX, March Accessed 4 th December De Joy, D.M. (2005). Behavior change versus culture change: Divergent approaches to managing workplace safety. Safety Science, 43 (2), Dekker, S. (2011). Drift into Failure. Aldershot, UK: Ashgate Publishing Ltd. Dekker, S. (2013). Product and safety. Hindsight, Eurocontrol Newsletter, Summer Accessed 1 st December Schein, E. (1992). Organisational Culture and Leadership, 2nd ed., pp 8-9. San Francisco: Jossey-Bass. Elliott, C. (2011). Principles of Product Safety: comparisons with other sectors. BAE Systems Unpublished Technical Report, PSPIP Project Document Reference # PS107 / Issue 1. Fielder, P., Roper, A., Walby, B., Fuse, J., Neely, A. & Pearson, C. (2014). Product Safety in a World of Services: Through-Life Accountability. In Addressing Systems Safety Challenges: Proceedings of the Twenty-second Safety-critical Systems Symposium, Brighton, UK, 4-6 th February Accessed 20 th November Paper_master.doc. Glendon, A.I. & Stanton, N.A. (2000). Perspectives on safety culture. Safety Science, 34, Guldenmund, F.W. (2000). The nature of safety culture: a review of theory and research. Safety Science, 34, Hollnagel, E. (2011). How to be safe by looking at what goes right instead of what goes wrong /(1)%20Erik%20Hollnagel%20ESRA%206%20april.pdf Hopkins, A. (2002). Safety Culture, Mindfulness, and Safe Behaviour: Converging Ideas? Working Paper 7, National Centre for OHS Regulation, Australian National University. National Research Centre for Occupational Health and Safety Regulation Hopkins, A. (2009). Thinking about process safety indicators. Safety Science, 47, Hopkins, A. (2011). Management walk-arounds: Lessons from the Gulf of Mexico oil well blowout, Working Paper 79, National Research Centre for OHS Regulation, Canberra. Hudson, P.T.W (1998) Safety Culture The Way Ahead? Theory and Practical Principles. In Profiting Through Safety. Proceedings of the 1stInternational Aviation Safety Management Conference. IASMC, Perth, (ed. L. Hartley, E. Derricks, S. Nathan and D. MacLeod), pp Hudson, P.T.W. (2001). Safety Management and Safety Culture: The Long, Hard and Winding Road. In Occupational Health and Safety Management Systems (ed. W. Pearse, C. Gallagher and L. Bluff), pp Crowncontent: Melbourne, Australia. Hudson, P.T.W. (2007). Achieving a Safety Culture in Aviation. Accessed: 4 th December Hudson, P.TW. (2010). Safety Science: It s not rocket science, it s much harder. Inaugural address T.U. Delft. 24 September Accessed 27th November HSE (2007). HSE Potters Bar Investigation Board, Train Derailment at Potters Bar 10 May 2002: A Progress Report by the HSE Investigation Board May Accessed 4 th December Lawrie, M., Parker, D. & Hudson, P. (2006). Investigating employee perceptions of a framework of safety culture maturity. Safety Science, 44, Leveson, N (2011) Engineering a safer world. Cambridge, Massachusetts: MIT Press. Lockwood, N.F. & Page, H. (2013). Understanding our inherent safety culture: review of organisational safety culture assessment methods & internal safety initiatives. Unpublished BAE Systems Technical Report, TES Issue 1, October LSCAT (undated). Loughborough Safety Climate Assessment Toolkit (LSCAT) sbe/downloads/offshore%20safety%20climate%20assessment.pdf. Accessed 27 th November 2014 Mearns, K.J. & Flin, R. (2001). Assessing the state of organizational safety culture or climate? In Validation in psychology (ed. H.D. Ellis and N. MacRae). Piscataway, NJ, USA: Transaction Publishers. ORR (2006). Train Derailment at Hatfield: a Final Report by the Independent Investigation Board, July Accessed 4 th December Ravasi, D & Schultz, M (2006). Responding to organisational identity threats: exploring the role of organisational culture. Academy of Management Journal, 49 (3),

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