On deaf ears

Words: Dr Mike Webster, Dr Jennifer Lunt, Malcolm Staves

We hear organisations including regulators saying boards need to engage with safety and health. That sounds like a good idea, but life is not so straightforward. Boards have different priorities, face different issues and sectoral challenges. The regulatory and moral imperatives that drive health and safety practitioners to ensure workers go home safe may be filtered or diluted at the top of the organisation.

Here we review the obstacles to senior executives' engagement; our follow-up feature will address potential ways to increase their receptiveness to safety and health messages.

Landmark lessons

To shed light on why boards may fail to engage in safety and health we have drawn on our experience and on a series of recent high profile incidents that have been subjected to rigorous investigations.

Robert Francis QC led the public inquiry into the poor care and high patient mortality at the Mid Staffordshire NHS Foundation Trust (http://bit.ly/1LSaha9). He noted in 2013 that numerous warning signs had been identified which should have alerted regulators to the problems developing at the trust. He said the organisational causes included:

• a culture focused on serving the system, not the patients

• an institutional culture that put more weight on positive information about the service than on information giving cause for concern

• standards and methods of measuring compliance that did not focus on the effects of a service on patients

• too great a degree of tolerance of poor standards and of risk to patients

• assumptions that monitoring, performance management or intervention were someone else's responsibility

• a failure to appreciate the risk of disruptive loss of corporate memory and focus resulting from repeated, multilevel reorganisation.

The report into the 2005 explosion and fire at the Buncefield, Hertfordshire, oil storage depot (bit.ly/1CfMJVj) identified both the underlying technical failures and broader organisational failings, which included:

• management systems for tank filling, though independently audited, were deficient and not properly followed

• fuel throughput had increased, increasing pressure on site management and staff -- and further degrading their ability to monitor fuel receipt and storage; the pressure on staff was made worse by a lack of engineering support from head office

• cumulatively, these pressures created a culture in which the primary focus was keeping the process operating -- and process safety did not get the attention, resources or priority it required.

The report into the 2005 fire and explosion at the Texas City oil refinery (http://1.usa.gov/1OrmfVi) identified several organisational issues as contributing to the incident:

• cost-cutting, failure to invest and production pressures from BP Group executive managers impaired process safety performance at the refinery

• the BP board did not provide effective oversight of safety culture and major accident prevention programmes; no board member was responsible for verifying these programmes

• reliance on Texas City's low personal injury rate as a safety indicator failed to provide a true picture of process safety performance and the health of the safety culture

• a "check the box" mentality was prevalent, where workers signed off safety policy and procedural requirements even when those requirements had not been met

• the refinery lacked a reporting and learning culture; personnel were not encouraged to report safety problems, and some feared retaliation for doing so; lessons from incidents and near-misses were seldom captured or acted on and safety lessons from an investigation of incidents at BP's Grangemouth refinery were not incorporated at Texas City

• safety campaigns, goals and rewards focused on improving personal safety metrics and worker behaviour rather than on process safety and management safety systems; though compliance with many safety policies and procedures was deficient at all levels of the refinery, Texas City managers did not lead by example on safety

• numerous surveys, studies and audits identified deep-seated safety problems at Texas City, but the response of BP managers at all levels was typically "too little, too late".

Common causes

We have considered only three incidents but common organisational failings emerge despite the different industry sectors. In particular, all three investigations found that cultures had developed in which the requirements of day-to-day business were viewed as being more important than the fundamental risk issues. This is not too surprising given that organisations will prioritise immediate goals over long-term ones.

Boards may believe if few people know about health or safety failings, they are unlikely to cause reputational damage

These cases indicate a range of obstacles to board engagement with safety, including:

• pressure to deliver to financial stakeholders -- these pressures ranged from continuing to grow the business at one end, to survival in the market place at the other

• lack of incentive to engage -- given the other pressures on an organisation and its board, the benefits to be gained elsewhere are perceived to be higher

• perception of low reputational risk -- boards may believe that if few people know about safety or health failings, they are unlikely to cause reputational damage; or that if they are exposed, customers and financial stakeholders may not consider them sufficiently harmful (this varies by sector)

• executives may not relate to major incidents in other sectors -- they may not see the transferable lessons from risk management failures

• safety and health engagement doesn't sell products -- the board's need to focus its resources on growth or survival will lead it to focus on areas that increase sales or reduce cost.

• little need or desire for external reporting -- health and safety issues may represent bad news; as such, there is likely to be little desire to put such information in the public domain unless there is a good story to tell or demand from customers or stakeholders

• they can get away with it -- if organisations perceive that not engaging will have no effect on their key business objectives, they can try to get away with ignoring it

• safety costs money -- it is difficult to motivate organisations to spend on uncertain health and safety benefits (if they have had no serious accidents) when they can see the definite advantages of spending on, say, marketing.

What lies beneath

Insights from research into what drives executive decision making, in particular the subconscious biases and shortcuts that drive more rapid, automatic responding, can help the understanding of why such obstacles exist.

Underlying sources of the obstacles to board engagement include:

• Incentives -- behaviour that is reinforced by reward is generally repeated. At the Mid Staffordshire trust, obtaining foundation trust status appeared to incentivise board behaviour aimed at astute financial and target management rather than care quality. In the absence of negative publicity, safety shortcomings may have no real sustained impact on external incentives such as market share, share prices or reputation. A board is only as good as the way the external world perceives it, and this requires the external world to have some knowledge from which to draw its perceptions. As such, if safety issues are not reported to the external world by the board, safety can remain "under cover".

• Concern about loss of productivity -- based on a perception that more time and effort spent managing risk diverts resources away from production. Linked to this is "loss aversion", where predictable losses have more sway over our decisions than uncertain gains. Halting operations to rectify a safety problem may prevent an accident. However, the more certain loss that the board might perceive is that it will slow productivity. This could help explain the results of a recent survey of board members by professional services firm EY (bit.ly/1MMRPli). The study found the top five risks as seen by boards are: financial; operational; regulatory; cybersecurity; reputational. Safety does not feature.

• A firefighting mentality - this focuses on addressing the immediate problems rather than taking account long-term and broader issues. "Hyperbolic-discounting"; in which perceived short-term pay-offs dominate long-term eventualities in our decision making could help account for the throughput pressures at Buncefield, for example.

• Too great a degree of tolerance of poor standards and of risk -- this can be a result of what Karl Weick and Kathleen Sutcliffe describe in their book Managing the Unexpected: Resilient Performance in an Age of Uncertainty as reflecting "organisational norms" that tolerate poor standards and fail to notice creeping change and deterioration. Norms may be shaped by board members' backgrounds; some will be grounded in risk, coming from engineering or operations, but others will not. Norms may also be influenced by lack of awareness of standards -- especially in sectors where safety is not viewed by the corporate board as business critical.

• Concern about the difficulties in managing risk -- based on a perception that managing safety and health risk is complex, reinforced by "cognitive ease" biases that favour the path of least resistance. This can explain why personal safety can receive more attention than process safety as at BP Texas City, and why tick-box mentalities arise. Measuring the appropriate use of personal protective equipment is considerably more straightforward than anticipating the knock-on effects of uncontrolled liquid hydrocarbon overflow.

• Putting more weight on positive than negative data -- some leaders do not like to hear that there are potential (or real) problems, and people who raise these problems are viewed as troublemakers or as lacking commitment to the organisation. Several biases can compound this effect, including "optimism bias" whereby we infer risk immunity and "confirmation bias" when we select information that confirms our preconceptions. This can give rise to a board ignoring early warning signals and becoming divorced from operational issues. Such biases could also engender what human factors expert Sidney Dekker calls "organisational narcissism"; an assumption that a reputation for success in mitigating risk guarantees continued success, as ascribed to NASA in the lead-up to the 1986 Challenger space shuttle explosion. Continually "getting away with it" can reinforce complacency at board level. In the face of unavoidable hazards, denial can also occur. Rather than be overwhelmed by anxiety, we psychologically numb ourselves to risk so that we can continue working in hazardous environments. Denial could allow a board to continue on an established course of action rather than respond to emerging risks.

• Assumptions that safety and health is someone else's responsibility -- as there is a safety and health function; this can result in no one taking responsibility and lead to something going wrong.

These are the common obstacles to board engagement. In our follow-up feature, we will explore some of the potential ways to overcome them.

The authors would like to acknowledge the contributions to this article by Michael Cooke, global head of health, safety and environment at Rolls-Royce and François Germain, vice president of health and safety, Total Refining & Chemicals.