the sociology of safety - american industrial hygiene ... a. hartle & dianna h. bryant 2006...

The Sociology of Safety

Jeffery A. Hartle Dianna H. BryantCFPS, MIFireE CIH, CSPVice President Associate Professor of Industrial Hygiene Skillful Means, Inc. Central Missouri State University

Jeffery A. Hartle & Dianna H. Bryant 2006 AIHce, Chicago, IL 2

Which Social Science?Psychology?

Focus and study is on the individualBasis for Behavioral Based Safety

Often blames the workerManagers 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 organizationsOffers different perspectives on accidents

Often blames system or organizational factors


Sociology

Patterns of human systemsObserve and develop theoriesUse theories to review past events and predict future outcomesExamine 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


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 themOrganizations generate collective phenomena Organizations are “real” and can be studied as “distinctly social processes and factors”(Warriner, 1956)


Who’s In Control?

Safe Person

Human Factors

Motivation/Attitude

Behavior

Safe Place

Design

Engineering

Physical Controls

OrganizationsPurchase facilities

Maintain equipment

Implement procedures

Hire

Train

Supervise


Characteristics of Organizations

Structure/HierarchyExternalitiesPowerDecision makingCulture


Structure/HierarchyBureaucracies are the ideal organizations (Weber, 1978)

EfficientHierarchy of authorityDivision of laborStandardizationPrescribed 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)


Externalities

Everything outside of the organizationShifting costs to others to maximize profit

Social costsEnvironmental 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 muchUnion Carbide plant, Bhopal, India


PowerOrganizations have taken over society (Perrow, 1991)

Wage dependencyExternalization of social costsFactory 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 consequencesOrganizations attempt to maintain control

Corporate reaction to labor activism in 1920s (Rosner & Markowitz, 1987)

Blame the workersHold workers responsible for their own safety


Decision MakingManagement decisions support organization’s goals“Bounded rationality” (Simon, 1957)

Incomplete knowledge constrains decisionsBut most accidents are predictable!Managers intentionally remain ignorant of facts

“Knowledge is a necessary ingredient for ethical decision making” (Schneider, 2000)

Challenger accidentConflict in goals between managers and engineers“Take off your engineer’s hat and put on your manager’s hat” (Boisjoly, Curtis, & Mellican, 1989)


CultureOfficial vs. unofficial culture

Official culture is for the public viewUnofficial culture may be at odds

Gauley, WV 1930-1933Official message-project good for communityUnofficial message-doctors misled workers about “tunnelitis”

Western cultureOrganizational 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


Barry Turner’sDisaster Incubation Theory

Organizations suffer from “a failure of foresight”Most disaster research starts at the event

Focus is on response and recoveryTurner focused on precursors of the event

Incubation periodUnnoticed 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), 378-397.

Turner, B. A. & Pidgeon, N. (1997). Man-made disasters. Oxford: Butterworth-Heinemann.


Common Features of Incubating Disasters

Rigid perceptions and beliefs about the organizationDecoys

Focus upon the wrong signal, allowing other problems to develop

Organizational exclusivityDisregard of nonmembers

Information difficultiesNoiseAmbiguities about warningsWrong or misleading information

Involvement of strangersOutside the organizationThe public

Failure to comply with regulations

Do they apply to us?Perceived as out-modedWhat can we get away with?

Minimizing emergent dangerUnderestimated Even when seen, undervalued


Case Study: Aberfan, Wales1966 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 complainBorough gov’tcomplains

National Coal Board dismisses complaints as nuisances

Focus is on mine safety, not tip safetyNo one understands coal issues except us!


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.


Interaction/Coupling

Figure 3.1 Interaction/ Coupling Chart (p. 97)


Key Concepts

Linear InteractionsExpected in familiar production or maintenance sequencesVisible, even if unplanned

Complex InteractionsUnfamiliar, unplanned, or unexpected sequencesNot visible, or not readily comprehensible

Loose CouplingDelays possibleChange order of sequenceAlternative methods

Tight CouplingLittle slack in resourcesBuffers and redundancies built inLimited substitutions


Case Study: Three Mile IslandNuclear reactor is complex system

Actual process is unseen by operatorsGauges indicate working condition

Accident on March 28, 1979Leak in cooling system flooded pneumatic instrument linesInstruments indicated false signals

Open valve released radioactive waterCore almost melted down

True signals were hidden in multiple “false signals”


High Reliability Organizations (HRO) TheoryAn organization is an HRO if it could have failed > 10,000 times or more, but did notBased on 3 organization studies:

FAA air traffic controlDiablo Canyon nuclear plantTwo 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 proponentsJoseph Marone & Edward J. WoodhouseAaron Wildavsky


Characteristics of HROs

Leadership places a high priority on safety and reliability

Short-term efficiency is second to high reliabilityLeaders communicate very clear operational goals

Significant redundancy existsDuplication (2 different units with same job)Overlap (2 different units with some functions in common)

Error rates reduced through:Decentralization of authorityStrong organizational cultureContinuous operations and training

“Richer is safer”(Wildavsky, p. 58)

Organizational learningFirst, trial and errorSupplemented by anticipation and simulation


Case Study: U.S. Navy Carriers

LeadershipCO briefs new crewNever break ship’s rules unless safety is at stakeCommon commitment to goal of reliability

RedundancyTechnical resourcesPersonnel resourcesConstant flow of info on multiple radio channels

Errors ReducedDecentralized-lowest ranks can stop flight opsClosed system with common ‘culture of reliability’Flight ops & training

Learning Organization

Innovations a result of earlier accidentsExtensive use of simulation


James Reason’s Organizational Accidents Theory

Individual accidentsSpecific person/group is the cause and victim

System failures or organizational accidentsMultiple personsMultiple causes Multiple levels of responsibility

Reason, James. (1997). Managing the Risks of Organizational Accidents.


“Swiss Cheese” ModelHazards → Defenses →LossesDefenses can be breached

Active failuresErrors at ‘sharp end’ of systemHas immediate effectNow seen as consequence, not cause

Latent conditionsErrors beyond individual psychologyErrors at top levels of organizationsPresent in all systemsFigure 1.5 Accident Trajectory (Page 12)


Latent Conditions

Exist for yearsMay combine with active failures or local circumstances

Created by strategic decisions

Often top-level choicesGovernment, regulators, designers, corporate managers

Impact pervades the organization

Changes cultureLies dormant until interactions occur, then overwhelm defenses


Case Study: Nakina, Ontario DerailmentRailroad 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 FailuresRailroad kills beavers to reduce road bed damageDam is not maintained and weakensHeavy rain raises water level, soaks roadbed, washes out sludgeNo active failures!


Thoughts on RedundancyReason

Defenses in depth “create a variety of problems in complex sociotechnical systems” (p. 54)

Conceal errors and their long-term consequencesMay not respond to individual failures

PerrowRedundancy increases complexityRedundancy 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)

HROsRedundancy is essential to achieve reliability


Fantasy Documents

Lee ClarkeEverything will work right the first timeEvery contingency is known and prepared forIntended 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 controlManagers may substitute own judgment of risk for the professional judgment of experts


Failure of Hindsight

Brian ToftOrganizations must learn from their own experience and experiences of othersNegative feedback must be provided internally or it will be provided externally (regulations)Organizational learning

Passive (perception)Active (implementation)


Conclusions

Sociology provides insights about organizational behavior that impacts on safety and healthOrganizations 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!


Additional SourcesClarke, 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, 143-153.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), 19-48.

Roberts, K. H. (1990). Managing high reliability organizations. California Management Review, 32 (4), 101-113.

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. 186-201). London: McGraw-Hill International.


For More Information

Jeffery A. Hartle CFPS, MIFireE

Vice PresidentSkillful Means, Inc.850 NE 771Knob Noster, MO [email protected] (toll free) 660-441-1976 (mobile)

Dianna H. Bryant CIH, CSP

Associate Professor of Industrial Hygiene

Central Missouri State University

Warrensburg, MO [email protected] (work)816-914-6571 (mobile)