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An essential guide that offers an understanding of and the practices needed to assess and strengthen process safety culture Essential Practices for Developing, Strengthening and Implementing Process Safety Culture presents a much-needed guide for understanding an organization's working culture and contains information on why a good culture is essential for safe, cost-effective, and high-quality operations. The text defines process safety culture and offers information on a safety culture's history, organizational impact and benefits, and the role that leadership plays at all levels of an organization. In addition, the book outlines the core principles needed to assess and strengthen process safety culture such as: maintain a sense of vulnerability; combat normalization of deviance; establish an imperative for safety; perform valid, timely, hazard and risk assessments; ensure open and frank communications; learn and advance the culture. This important guide also reviews leadership standards within the organizational structure, warning signs of cultural degradation and remedies, as well as the importance of using diverse methods over time to assess culture. This vital resource: * Provides an overview for understanding an organization's working culture * Offers guidance on why a good culture is essential for safe, cost-effective, and high quality operations * Includes down-to-earth advice for recognizing, assessing, strengthening and sustaining a good process safety culture * Contains illustrative examples and cases studies, and references to literature, codes, and standards Written for corporate, business and line managers, engineers, and process safety professionals interested in excellent performance for their organization, Essential Practices for Developing, Strengthening and Implementing Process Safety Culture is the go-to reference for implementing and keeping in place a culture of safety.
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ESSENTIAL PRACTICES FOR CREATING,STRENGTHENING, AND SUSTAININGPROCESS SAFETY CULTURE
CENTER FOR CHEMICAL PROCESS SAFETYof theAMERICAN INSTITUTE OF CHEMICALENGINEERS
New York, NY
This edition first published 2018
© 2018 the American Institute of Chemical Engineers
A Joint Publication of the American Institute of Chemical Engineers and John Wiley & Sons, Inc.
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The rights of CCPS to be identified as the author of the editorial material in this work have been asserted in accordance with law.
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Library of Congress Cataloging-in-Publication Data
Names: American Institute of Chemical Engineers. Center for Chemical Process Safety, author.
Title: Essential practices for creating, strengthening, and sustaining process safety culture / Center for Chemical Process Safety of the American Institute of Chemical Engineers.
Description: New York, NY : American Institute of Chemical Engineers, Inc. :
John Wiley & Sons, Inc., 2018. | Includes bibliographical references. |
Identifiers: LCCN 2018023924 (print) | LCCN 2018024176 (ebook) | ISBN 9781119515142 (Adobe PDF)
| ISBN 9781119515173 (ePub) | ISBN 9781119010159 (hardcover)
Subjects: LCSH: Chemical engineering--Safety measures.
Classification: LCC TP150.S24 (ebook) | LCC TP150.S24 E87 2018 (print) | DDC
660/.2804--dc23
LC record available at https://lccn.loc.gov/2018023924
Cover images: ©jimmyjamesbond/iStockphoto; ©crisserbug/iStockphoto
Cover design by Wiley
Disclaimer
It is sincerely hoped that the information presented in this document will lead to an even more impressive safety record for the entire industry; however, the American Institute of Chemical Engineers (AIChE), its consultants, the AIChE’s Center for Chemical Process Safety (CCPS) Technical Steering Committee and the Process Safety Culture Subcommittee members, their employers, their employer’s officers and directors, AcuTech Group, Inc. and its employees, and Scott Berger and Associates LLC and its Principal, do not warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented in this book. As between (1) the AIChE, its consultants, the CCPS Technical Steering Committee and Subcommittee members, their employers, their employer’s officers and directors, AcuTech Group, Inc. and its employees, Scott Berger and Associates LLC and its Principal, and (2) the user of this document, the user accepts any legal liability or responsibility whatsoever for the consequence of its use or misuse.
CONTENTS
Supplemental Material Available on The Web
Acronyms and Abbreviations
Glossary
Acknowledgements
Preface
Nomenclature
Executive Summary
1 Introduction
1.1 Importance of Process Safety Culture
1.2 Definition of Process Safety Culture
1.3 Warning Signs of Poor Process Safety Culture
1.4 Leadership and Management Roles and Responsibilities
1.5 Organizational Culture, Process Safety Culture, and Business Success
1.6 Corporate Climate and Chemistry
1.7 Summary
1.8 References
2 Process Safety Culture Core Principles
2.1 Establish an Imperative for Process Safety
2.2 Provide Strong Leadership
2.3 Foster Mutual Trust
2.4 Ensure Open and Frank Communications
2.5 Maintain a Sense of Vulnerability
2.6 Understand and Act Upon Hazards/Risks
2.7 Empower Individuals to Successfully Fulfill their Process Safety Responsibilities
2.8 Defer to Expertise
2.9 Combat the Normalization of Deviance
2.10 Learn to Assess and Advance the Culture
2.11 Summary
2.12 References
3 Leadership for Process Safety Culture Within the Organizational Structure
3.1 Definition of Process Safety Leadership
3.2 Characteristics of Leadership and Management in Process Safety Culture
3.3 Leadership Vs. Management
3.4 Consistency of Process Safety Messages
3.5 Turnover of Leadership, Succession Planning, and Organizational Management of Change
3.6 Summary
3.7 References
4 Applying the Core Principles of Process Safety Culture
4.1 Human Behavior and Process Safety Culture
4.2 Process Safety Culture and Compensation
4.3 Process Safety Culture and Ethics
4.4 External Influences on Culture
4.6 Summary
4.7 References
5 Aligning Culture with PSMS Elements
5.1 Senior Leader Element Grouping
5.2 Risk Management-Related Element Grouping
5.3 Process-Related Element Grouping
5.4 Worker-Related Element Grouping
5.5 References
6 Where Do You Start?
6.1 Introduction
6.2 Assess the Organization's Process Safety Culture
6.3 Improving the Process Safety Culture of the Organization
6.4 Summary
6.5 References
7 Sustaining Process Safety Culture
7.1 Definition of Sustainability
7.2 Sustainability of Process Safety Culture
7.3 Process Safety Culture and Operational Excellence
7.4 Summary
7.5 References
Appendices
Appendix A: Echo Strategies White Paper
Appendix B: Other Safety & Process Safety Culture Frameworks
B.1 the Seven Basic Rules of the USA. Naval Nuclear Propulsion Program
B.2 Advancing Safety in the Oil and Gas Industry - Statement on Safety Culture (Canadian National Energy Board)
B.3 References
Appendix C: As Low as Reasonably Practicable
C.1 ALARP Principle
C.2 References
Appendix D High Reliability Organizations
D.1 the HRO Concept
D.2 References
Appendix E: Process Safety Culture Case Histories
E.1 Minimalist PSMS
E.2 – Peer Pressure to Startup
E.3 Taking a Minimalist Approach to Regulatory Applicability
E.4 Not Taking a Minimalist Approach to Process Safety Applicability
E.5 What Gets Measured Can Get Corrupted
E.6 KPIs That Always Satisfy
E.7 Abusing ITPM Extensions/Deferrals
E.8 the VPP Defense
E.9 Double Jeopardy
E.10 Best Case Consequences
E.11 New Kid in Town
E.12 the Blame Game
E.13 Conflicts of Interest
E.14 No Incidents? Not Always Good News
E.15 Check-the-Box Process Safety Management Systems
E.16 There's No Energy for That Here
E.17 Not Invented Here
E.18 PHA Silos
E.19 Knowing What You Don't Know
E.20 Bad News is Bad
E.21 the Co-Employment Trap
E.22 Stop Work Authority/Initiating an Emergency Shutdown
E.23 SWPs by the Numbers
E.24 Incomplete MOC
E.25 Post-MOCs
E.26 Mergers & Acquisitions
E.27 Poor Understanding of Hazard/Risk Leads to an Even Worse Normalization of Deviance
E.28 How Many Explosions Does It Take to Create a Sense of Vulnerability?
E.29 Disempowered to Perform Safety Responsibilities by “Omniscient
1
“ Software
E.30 What We Have Here is a Failure to Communicate
E.31 Becoming the Best
E.32 High Sense of Vulnerability to One Dangerous Material Overwhelms the Sense of Vulnerability to Others
E.33 Not Empowered to Fulfill Safety Responsibilities? Maybe You Were All Along
E.34 Normalization of Ignorance
E.35 Spark and Air Will Find Fuel
E.36 Operating Blind
E.37 Playing Jenga® with Process Safety Culture
E.38 Failure of Imagination?
E.39 Playing the Odds
E.40 Shutdown and Unsafe
E.41 Who, me? Yeah, you. Couldn't be. Then who?
E.42 Blindness to Chemical Reactive Hazards Outside the Chemical Industry
E.43 Dominos, Downed-Man “Nos”
E.44 Mr. Potato Head Has Landed
E.45 Sabotage, Perhaps. But of the Plant or the Culture?
E.46 This is the Last Place I Thought We'd Have an Incident
E.47 References
Note
Appendix F: Process Safety Culture Assessment Protocol
F.1 Introduction
F.2 Culture Assessment Protocol
F.3 References
Appendix G: Process Safety Culture & Human Behavior
End User License Agreement
List of Tables
1
Table 1.1
2
Table 2.1
Table 2.2
5
Table 5.1
Table 5.2
Appendix B
Table B.1
List of Illustrations
1
Figure 1.1 Linkage of Culture and Leadership to a PSMS
Figure 1.2 Mapping of CCPS Culture Principles to Corporate Climate and Chemistry
2
Figure 2.1 Overview of the Core Principles of Process Safety Culture
Figure 2.2 Anatomy of a Communication
Figure 2.3 Example risk matrix
3
Figure 3.1 Differences between Leader and Manager
5
Figure 5.1 Risk Based Process Safety Management System
Figure 5.2 Relationship between training and competency
6
Figure 6.1 Components of a Culture Assessment
Figure 6.2 Six-Step Culture Improvement Process
7
Figure 7.1 Critical Success Factors for Sustaining Process Safety Culture
Appendix C
Figure C.1 The ALARP Triangle
Appendix D
Figure D.1 High Reliability Organization Map (After Ref D.2)
Guide
Cover
Table of Contents
Preface
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SUPPLEMENTAL MATERIAL AVAILABLE ON THE WEB
Additional content referenced in this book as well as an electronic form of the culture assessment tool are available at www.aiche.org/ccps/publications/guidelines-culture
ACRONYMS AND ABBREVIATIONS
AI
Asset Integrity
AIChE
American Institute of Chemical Engineers
ALARA
As low as reasonably achievable
ALARP
As low as reasonably practicable
ANSI
American National Standards Institute
API
American Petroleum Institute
BBS
Behavior based safety
CBT
Computer-based training
CCC
Contra Costa County
CCPS
Center for Chemical Process Safety
DCS
Distributed control system
DIERS
Design Institute for Emergency Relief Systems of the American Institute of Chemical Engineers
EHS
Environmental, health, and safety
FMEA
Failure modes and effects analysis
HAZCOM
Hazard Communication (Standard – a U.S. regulation)
HAZOP
Hazard and Operability (Study)
HAZWOPER
Hazardous Waste Operations and Emergency Response (Standard – a U.S. regulation)
HIRA
Hazard Identification and Risk Analysis
HSE
Health and Safety Executive (United Kingdom)
IPL
Independent protection layer
ITPM
Inspection, testing, and preventive maintenance
ISA
International Society of Automation (formerly Instrument Society of America)
ISO
International Standards Organization, Industrial Safety Ordinance
ISD
Inherently safer design
LOPA
Layer of protection analysis
MI
Mechanical Integrity
MKOPSC
Mary Kay O'Connor Process Safety Center (Texas A&M University)
MOC
Management of Change
NEP
National Emphasis Program
NFPA
National Fire Protection Association
OE
Operational excellence
OSHA
Occupational Safety and Health Administration
PDCA
Plan-Do-Check-Act
PHA
Process hazard analysis
P&ID
Piping and instrument diagram
PSI
Process safety information
PSM
The USA OSHA Process Safety Management Regulation
PSMS
Process safety management system
PSSR
Pre-start-up safety review
QRA
Quantitative risk analysis
RAGAGEP
Recognized and generally accepted good engineering practice
RBI
Risk-based inspection
RBPS
Risk-based process safety
RC
Responsible Care®
RCA
Root cause analysis
RMP
Risk management program/risk management plan
RP
Recommended practice
SDS
Safety Data Sheet
SIL
Safety integrity level
SIS
Safety instrumented system
SOP
Standard operating procedure
SWP
Safe work practice
UKHSE
Health and Safety Executive (United Kingdom)
VPP
Voluntary protection program
GLOSSARY
CCPS has developed a standard glossary that defines many common terms in process safety. By reference the current CCPS Process Safety Glossary at the time of publication is incorporated into this book and can be found at http://www.aiche.org/ccps/resources/glossary. Additionally, there are some specific terms used in this book that are not currently included in the standard glossary. These terms are defined in the book as necessary when they are introduced.
ACKNOWLEDGEMENTS
The American Institute of Chemical Engineers (AIChE) and the Center for Chemical Process Safety (CCPS) thank the Process Safety Culture Subcommittee members and their CCPS member companies for their generous efforts and technical contri- butions to this book. CCPS also thanks the members of the CCPS Technical Steering Committee for their advice and support.
CCPS Process Safety Culture Subcommittee
The Chairs of the Process Safety Culture Subcommittee were Eric Freiburger of Praxair and Shakeel Kadri, then of Air Products and now CCPS Executive Director. The CCPS staff consultant was Bob Rosen. The Subcommittee members were:
Steve Arendt
ABS Consulting
Steve Beckel
Potash Corp.
Henry Brinker
Monsanto
Cho Nai Cheung
Contra Costa County
Gretel D'Amico
Pluspetrol
Michael Dossey
Contra Costa County
Walt Frank
CCPS Emeritus
Lou Higgins
Solvay Specialty Polymers
Tom Janicik
Covidien – Retired
Dave Jones
Chevron
Jack McCavit
CCPS Emeritus
Dan Miller
BASF (Retired)
Gilsa Pacheco Monteiro
Petrobras
Anne O'Neal
Chevron
Richard Piette
Suncor
Ravi Ramaswamy
Reliance Industries Ltd. (Retired)
Randy Sawyer
Contra Costa County
Karen Tancredi
Chevron
CCPS offers special thanks to subcommittee members Anne O'Neal, Karen Tancredi, Steve Arendt, Gretel D'Amico, Gilsa Pacheco Monteiro, and Dan Miller, who provided significant input during the production of this book.
CCPS acknowledge AcuTech Group, Inc. for preparing the original manuscript. The AcuTech Team, under the leadership of Project Manager Michael J. Hazzan, also included David M. Heller, Scott Berger, and Martin R. Rose. Lou Musante of Echo Strategies provided additional content under subcontract.
Scott Berger of Scott Berger and Associates LLC provided a structural edit of the manuscript, provided additional content, and typeset the final book.
Peer Reviewers
Before publication, all CCPS books undergo a thorough peer review. This book was no exception; many people offered thoughtful suggestions and comments.
Wendy Alexander
Nova Chemicals
Steve Barre
Huntsman Chemicals
Michael Broadribb
Baker Risk
Jonas Duarte
Chemtura
Warren Greenfield
Ashland Chemicals (retired)
Dennis Hendershot
CCPS Emeritus
John Herber
CCPS Emeritus
Jim Klein
ABS Consulting
Paul Leonard
Arkema
Bill McEnroe
Monroe Energy
Paul Nielson
Cheniere Energy
Lawrence Pearlman
Oliver Wyman
Dennis Rehkop
Tesoro
Susie Scott
Oliver Wyman
Mike Smith
Plains Midstream
Mark Trail
ExxonMobil- Retired
David Black
Baker Risk
Dan Wilczynski
Marathon Petroleum
Omer Wolff
Formosa Plastics USA
PREFACE
I have worked in different sectors of the chemicals and oil refining businesses since the 1960s. I began as a lab technician who worked shifts for a major chemical company in Northern Ireland, where I grew up. It was there that I experienced my first and only chemical process fatality during my working years in the chemical industry. I have very vivid memories of that tragedy to this day.
Later I went to work for a chemical company in the United States and I quickly realized it was vitally important to pay careful attention to preventing accidents as the chemicals we worked with included carbon monoxide, phosgene, chlorine, isocynanates and peroxides. In 1982, I served as the environmental manager in a chemical plant that had a catastrophic explosion. The details of that event and its aftermath are embedded deeply in my memory.
In 2002, I was appointed to the U.S. Chemical Safety Board (CSB) as a Board Member and later as Chairman. At the CSB we investigated failures in the chemical, oil refining and other industries – failures that resulted in loss of life, property damage and community outrage. Sadly, I saw many examples – fires, dust explosions, loss of containment, mechanical integrity failures.
In my early years in the chemical industry there was a strong focus on safety, but the emphasis was on the slips, trips and falls type of safety – avoiding injury to workers. Metrics were developed for first aid cases, reportable injuries and lost work day injuries. This was and still is a good practice and for the more progressive companies it made for a safer workplace environment. These companies were said to have a strong safety culture. Of course, process safety was still important, but not in an organized way. We knew the hazards of phosgene or dinitrotoluene and we took steps to mitigate those hazards. In the more enlightened companies, greater attention was paid to the chemical process hazards, but the culture in many companies was to equate overall safety with personnel safety, including some measures of process safety.
While the personnel safety record in the chemical and oil industry was better than general industry, unfortunately there continued to be major and well publicized fires and explosions in these industries. Tragedies such as the 1989 Phillips 66 explosion in Pasadena, Texas, the 1974 Nypro cyclohexane explosion in Flixborough, England, and the 1988 Shell refinery explosion in Norco, Louisiana. In response to these and other incidents, the U.S. Occupational Safety and Health Administration published its regulations on the process safety management of highly hazardous materials, commonly known as OSHA PSM. The 14 elements of PSM set an obligation for the safe operation of facilities with highly hazardous materials. The process industries have been required to comply with these regulations since 1992.
However, when the fourteen elements of PSM are examined there is an omission. That omission is the development and assessment of the process safety culture. I am very pleased that this absence has now been remedied by the publication of Essential Practices for Creating, Strengthening and Sustaining Process Safety Culture by the Center for Chemical Process Safety (CCPS) of the American Institute of Chemical Engineers. This excellent book fills a gap in the literature on process safety and guides companies and manufacturing facilities on the road to a strong process safety culture. It is the latest in a series of more than 100 high quality texts on process safety published by CCPS, many of which can be found on shelves in chemical plants and oil refineries around the world. Writing CCPS books requires the volunteer efforts of many experts from the chemical and oil industries. It is a time consuming but very satisfactory labor of love. I know because I have participated in the writing of a CCPS book.
This book offers several definitions of process safety culture. Even though there may be some disagreement about a definition of process safety culture, when you visit a facility you very quickly get a sense how important a positive process safety culture is to the facility. You will know it when you see it. From the first moment when you encounter a security guard or a receptionist to a tour of a control room you can quickly gauge the culture. Are process safety metrics displayed around the plant? Are operators communicating with each other in a professional manner? Is the senior manager well versed in the hazards of the operation?
As you read this book you will learn many aspects of how to develop a sound process safety culture. From my experience, a strong process safety culture must start with leadership. By leadership I mean everyone in a leadership position from the chairman of the board to the supervisor on the shop floor. They must set the example. It starts with leadership being aware of the hazards in their processes and putting in place the organization and expertise to control those hazards. Just as important, the senior leadership must communicate his or her concerns about the need for an effective process safety program. These concerns should be an ongoing part of senior leadership's communications with the organization. This is the way to ensure the establishment of a culture of process safety across the organization.
I commend CCPS on the publication of its latest book and I encourage readers to turn its lessons into actions in their day-to- day work of ensuring safety for employees, contractors and the surrounding community. As well as saving lives and preventing injuries it is vital for the financial success and reputation of the chemical process industries.
John S. Bresland
Shepherdstown, West Virginia
NOMENCLATURE
Culture:
When used alone in this book, the term culture specifically means process safety culture, and the two terms are used interchangeably. When used to refer to other types of corporate culture, the specific type of culture will be specified, e.g. business culture.
Element Names:
Process safety element names have been taken from CCPS
Guidelines for Risk Based Process Safety.
When alternative names are in common use, both the RBPS name and the common name are used, e.g., HIRA/PHA.
Operations:
The full spectrum of tasks and activities involved in running a facility, including process operation, maintenance, engineering, construction, and purchasing.
Operator:
An individual who runs the process from the control room and/or the field.
Process safety:
A disciplined framework for managing the integrity of operating systems and processes handling hazardous substances by applying good design principles, engineering, and operating practices. It deals with the prevention and control of incidents that have the potential to release hazardous materials or energy. Such incidents can cause toxic effects, fire, or explosion and could ultimately result in serious injuries, property damage, lost production, and environmental impact.
Process safety management system (PSMS):
A management system for implementing process safety. PSMSs include Risk Based Process Safety (RBPS) as defined by CCPS, the many PSMSs developed by companies to suit their specific requirements, PSMSs specified by regulations, and others.
References to process safety culture core principles:
Throughout the book the names of the core principles of process safety culture are typeset in
italics
. Italics are also used when the context requires use of a different syntax, including the negative forms, such as “They allowed
deviance to be normalized
, leading to…”
Should vs. must and shall:
The term
should
, used throughout the book, refers to actions or guidance that are recommended or presented as options, but not mandatory. The pursuit of process safety culture is very personal, and therefore a single approach cannot be mandated. The terms
must
and
shall
, commonly used in voluntary consensus standards and regulations, appear in this book only when quoting other sources. Quotes are offered only to provide perspective, and their use in this book does not mean that the authors consider the quoted text to be mandatory.
EXECUTIVE SUMMARY
Leading process safety practitioners have long recognized that the way leaders shape attitudes and behaviors can make the difference between success and failure in preventing catastrophic incidents. Investigations of incidents in the chemical, oil and gas sectors, as well as experience in the nuclear, and aerospace sectors have shown cultural failures rival management system failures as leading causes. Similarly, when long-term successes have been achieved, strong cultures of process safety excellence have been an integral factor.
This book provides current guidance on developing and improving process safety culture. It discusses how leaders can develop the commitment and imperative for process safety at the top, and then cascade that commitment throughout the organization. It shows how leaders can take the ultimate responsibility for process safety, and foster the core principles of process safety culture.
Of course, process safety culture does not exist in a vacuum relative to overall company culture. Changes to process safety culture may thus require changes in other aspects of the company culture, including, for example, operational excellence, human resources, and quality. This should not be viewed as a zero-sum game. Process safety may borrow key positive cultural attributes from other parts of the culture. Likewise, strengthening process safety culture may help strengthen other parts of the overall culture.
Leaders at any level of the organization will benefit from the guidance provided in this book. Senior executives will likely be drawn most to the first 3 chapters and the beginning of chapter 5, while the remainder of the book contains more detailed guidance useful at the implementation level. However, all readers will find useful information throughout the book.
After defining process safety culture, this book outlines 10 core principles of process safety culture:
Establish an Imperative for Process Safety
Provide Strong Leadership
Foster Mutual Trust
Ensure Open and Frank Communications
Maintain a Sense of Vulnerability
Understand and Act Upon Hazards/Risks
Empower Individuals to Successfully Fulfill their Process Safety Responsibilities
Defer to Expertise
Combat the Normalization of Deviance
Learn to Assess and Advance the Culture
The book then shows how these core principles strengthen process safety management systems (PSMSs), which implemented together can lead to success. The role of process safety culture in metrics, compensation, and other related activities is addressed. Lastly, the book discusses how to make process safety culture sustainable.
Appendices include more detailed descriptions of several concepts presented in the book, such as organizational culture, human behavior, and high reliability organizations, along with case histories useful for prompting culture discussions and a process safety culture assessment checklist.
The concepts discussed in this book began to be developed in the wake of the loss of the Space Shuttle Columbia. Members of CCPS toured the Columbia launchpad the day before launch as part of a learning-sharing session with NASA safety experts. This personal exposure to tragedy motivated Jones and Kadri (www.aiche.org/ccps, “Process Safety Culture Toolkit”) to lead an effort to capture key culture lessons-learned from the Columbia investigation and apply them to the process industries.
Since that time, lessons continue to be learned about what makes process safety culture effective. This book attempts to distill the significant amount of published work, as well as the personal experience of CCPS member companies into actionable guidance.
Like other CCPS books, the guidance provided includes numerous options companies can choose from to suit their needs. While the book has been prepared with the similar care of a voluntary consensus standard, it is not a standard or a code, and has no legal or regulatory standing. And that is entirely appropriate to the mission of process safety culture – to create an imperative for process safety with felt leadership that comes from the heart, not forced by requirement.
1INTRODUCTION
1.1 IMPORTANCE OF PROCESS SAFETY CULTURE
The 2014 FIFA World Cup semifinal between Germany and Brazil featured two of the most technically proficient teams to contest a match. Within a half-hour, however, the difference between the two emerged, as Germany scored five goals on a shell-shocked Brazil on the way to a 7-1 rout.
The difference? Neymar da Silva Santos, the captain, leader, and culture-setter of the Brazilian side, had suffered a fractured vertebra in the previous match, and could not even cheer his teammates on from the sidelines. With their culture-leader absent, Brazil failed to execute their usually formidable game plan and suffered a catastrophic loss.
PSMS = Process Safety Management System
Similarly, process safety cannot succeed without culture leadership. Investigation of numerous incidents in major hazard operations has clearly revealed culture deficiencies. The data show that without a healthy process safety culture, even the most well-intentioned, well-designed process safety management system (PSMS) will be ineffective. For example, Union Carbide was known as a process safety technology leader in the early 1980s. However, weak culture at its Bhopal facility allowed many “Normalization of Deviance” failures leading to the December 3, 1984 tragedy. Simply stated, a strong, positive process safety culture enables the facility's PSMS to perform at its best. This gives the facility its best chance to prevent catastrophic fires, explosions, toxic releases, and major environmental damage.
Like all cultures, process safety culture starts with strong, committed, and consistent leadership. Just as commanding officers set the cultures of their troops, senior leaders of facilities and companies set the process safety culture of their organizations. Senior leaders set the underlying tone for how an organization functions and motivates the individuals within the organization to maximize the impact of their collective talent (Ref. 1.1).
Without leadership's direct, continuing, and strong participation in setting process safety culture, the culture will suffer gaps in one or more of the ten cultural principals (see chapter 2). This leadership should cascade through the organization, with each leader helping their subordinates, peers, and managers maintain focus on achieving the desired culture.
Leadership of culture should survive economic downturns and keep pace with upturns and technology changes. Culture leadership should persist through acquisitions and divestitures. Perhaps hardest of all, it should survive changes of personnel. Altogether, leadership should be committed to establishing and maintaining a sound process safety culture and should establish the proper philosophical tone for the culture. This tone should emphasize the true importance of process safety and the faithful execution of the PSMS. The importance of strong leadership will be further discussed in section 1.4 and in Chapter 3.
1.2 DEFINITION OF PROCESS SAFETY CULTURE
Many experts have defined culture as what people do when their boss is not around. A group of people with a common purpose (e.g., co-workers, teammates, and families) develops a set of beliefs, customs, and behaviors that become embedded in how the group thinks and works. With continued practice, these beliefs and behaviors become reinforced and integrated into the group's value system (12,13). As time goes on, the group's actions reflect common and deeply held values. The group expects newcomers to adopt or “buy into” these values to become accepted into the group.
Unfortunately, negative cultures can also exist, where common values result in attitudes and actions with negative consequences. In such cultures, peer pressure can reinforce negative behaviors. This may happen for example, if a new co- worker berated for following the approved procedure instead of the common but unsafe shortcut.
The International Nuclear Safety Advisory Group (INSAG) of the International Atomic Energy Agency (IAEA) made one of the first definitions of safety culture in the investigation of the aftermath of the Chernobyl accident in 1986 (Ref 1.4).
“Safety Culture is that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.”
The preceding definition describes the result of the culture, but not the culture itself (Ref 1.5). In the wake of the Challenger and Columbia disasters, NASA (16,17) began to recognize that key personnel defined organizational culture, and that change in personnel can lead to negative culture change:
“Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work; it defines “the way we do things here.” An organization's culture is a powerful force that persists through reorganizations and the departure of key personnel.”
Describing groundbreaking CCPS work in 2005, Jones and Kadri (18) adapted these published definitions to process safety and recognized the link of culture to management:
“For process safety management purposes, we propose the following definition for process safety culture: The combination of group values and behaviors that determine the way process safety is managed.” (emphasis added)
In the wake of its investigation of a refinery explosion in Texas City, TX, USA, the US Chemical Safety Board (CSB) leveraged the CCPS work Jones and Kadri described (Ref 1.9). CSB recommended that the company conduct an independent assessment of process safety culture at their five U.S. Refineries and at the Corporate level. The resulting Baker Panel report (Ref 1.10 identified numerous culture gaps and improvement opportunities. They then went on to say, “We are under no illusion that deficiencies in process safety culture, management, or corporate oversight are limited to the company.” This statement proved to motivate many process safety culture improvements in refining and chemical companies globally.
Additional study led CCPS to define process safety culture based on the critical role of leadership and management. CCPS's Vision 20/20 (Ref 1.11) CCPS stated that a committed culture consists of:
Felt leadership from senior executives. Felt leadership means more than a periodic mention of process safety in speeches and town hall meetings. It means that executives feel a deep personal commitment and remain personally involved in process safety activities.
Maintaining a sense of vulnerability.
Operational discipline, the performance of all tasks correctly every time.
This sums up several definitions of culture from other sources as it applies to environmental, health, or safety programs and issues:
(Ref 1.12):
“Safety and health are (or have become) part of the company culture—and frequently part of the management system. ‘Culture’ is traditionally defined as ‘a shared set of beliefs, norms, and practices, documented and communicated through a common language.’ The key word here is ‘shared.’ Companies have found that if safety and health values are not consistently (and constantly) shared at all levels of management and among all employees, any gains that result from declaring safety and health excellence a ‘priority’ are likely to be short-lived.”
(
Ref 1.13
):
“The attitudes, beliefs and perceptions shared by natural groups as defining norms and values, which determine how they act and react in relation to risks and risk control systems.”
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i
an
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i
o
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al
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ne
r
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y
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o
a
rd
(
Ref 1.14
):
“Safety culture means ‘the attitudes, values, norms and beliefs, which a particular group of people shares with respect to risk and safety’.”
UK
Heal
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and
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a
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ty
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x
e
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(
Ref 1.15
)
:
“The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization's health and safety management.”
These definitions share common themes and terms. For something to become embedded in the culture of an organization of group, it is believed by its members. The belief becomes a common or shared belief, a value, or a norm. These norms result in certain repeated actions or behaviors.
The shared beliefs and values may create a culture that is either positive or negative, either strong or weak. A strong positive process safety culture would generally exhibit norms such as:
Always doing the right thing even when nobody is watching or listening,
Not tolerating deviance from approved policies, procedures, or practices,
Maintaining a healthy respect for the risks inherent to the processes, even when the likelihood of serious consequences is very low; and
Performing actions safely, or not performing them at all.
Conversely, a negative or weak culture would generally exhibit norms such as:
Tolerating deviance from approved policies, procedures, or practices,
Allowing such deviance to become regular occurrences,
Exhibiting complacency regarding the operation's process risks; or
Allowing short-cuts to occur to get something done more quickly or more cheaply.
The CCPS Culture Subcommittee distilled the published definitions listed above, along with their personal ongoing experience in building and strengthening process safety culture. For purposes of this book, a sound or strong positive process safety culture is:
The pattern of shared written and unwritten attitudes and behavioral norms that positively influence how a facility or company collectively supports the successful execution and improvement of its Process Safety Management System (PSMS), resulting in preventing process safety incidents.
From this starting point, Chapter 2 will describe core principles of process safety culture. Chapter 3 will discuss the leadership dimensions of culture. Chapter 4 will address culture from the standpoint of organizational dynamics, human behavior, compensation, ethics, external influences (e.g. contractors, vendors, public sector), and metrics. Chapter 5 will discuss the ways in which culture can directly impact each element of CCPS's Risk Based Process Safety (RBPS) PSMS. Chapter 6 will provide a guide for getting started establishing a strong culture or improving culture. Chapter 7 will address how to achieve a sustainable culture. The appendices provide additional background on culture, case histories that may be useful in discussing culture issues, and a culture assessment protocol. Taken together, the concepts discussed in these chapters provide the concepts and guidance to make these concepts a reality in an organization.
This book does not discuss regulations, but instead comes from the point of view that a strong positive culture adequately addresses process hazards, whether regulated or not. This represents the first concept of a strong, positive process safety culture: the organization's leadership and all personnel believe in the necessity of process safety and commit to it, even in the absence of regulatory requirements.
Some people have expressed the belief that safety culture cannot change. They consider core principles, company values and principles, and how the company behaves. They then conclude that good cultures will stay good, while poor cultures cannot improve. Mathis disagrees, suggesting that those who claim culture is static may be resisting the culture change (Ref 1.5).
From a sociology point of view, cultures of all kinds develop via social conditioning. With the right conditioning, applied patiently over time, leaders can build strong positive cultures. Typically, this requires patience and persistence. It can take some time to build workers’ trust and to convince them that the intended culture change is not a temporary fad.
Conversely, negative conditioning can occur. Since trust can be lost much faster than it can be gained, even momentary lapses in process safety leadership can lead to rapid degradation in the culture.
Clearly then, process safety has an inherent capability to improve – and to degrade, and no single culture resides in the DNA of the organization. This makes it essential to have the patience to improve of process safety culture over time, and then maintain focus on culture over time to maintain consistent good performance.
While this book addresses process safety culture, the concepts of process safety culture are not unique to process safety. Good concepts may be leveraged from the overall company culture or various subcultures (e.g. the company's innovation, sales, financial, EHS, and other cultures). At the same time, if any of these company cultures contain values contrary to a good process safety culture, leaders need to recognize this and find a way to keep those values out of the process safety culture effort.
The company and facility's country and regional cultures should also be considered. These can make a culture effort either easier or more difficult. Diversity of the organization's personnel can inject a wider range of external cultures that could impact a culture effort. Essentially, everyone within a diverse group of employees will have to make unique kinds of culture changes to arrive at the desired common process safety culture. Diversity may also inject different languages or different ways that things are expressed into a given facility, and should be accommodated in the communications between personnel. Leaders of culture change need to consider these factors.
Diversity plays an even more significant role when a company strives to establish a global process safety culture. Each facility has a distinct culture. Any facility may have positive cultural aspects that will help the process safety culture transformation effort, just as they may have negative cultural aspects. The combination of positives and negatives may help some facilities transform culture more quickly, while other facilities may require considerable time and effort to transform. For this reason, companies may choose to take approaches to culture that leverage regional cultural strengths.
Additionally, process safety culture may not be completely uniform across a given company or site. While certain core values should exist, subcultures can and often will exist within an organization. These subcultures can vary by facility (one site vs another), workgroup (Inspection vs. Instrument/Electrical within Maintenance), occupation or discipline (e.g., Engineering vs. Operations), age, work shift, prior accident involvement, contractor vs. full-time employee, groups within an organization subject to different working conditions, and grade (management vs. non-management) (Ref 1.15). The difference in culture between daytime and nighttime shifts and between management and non-management can sometimes be significant.
Such groups will tend to view safety through the lens of their own subcultures, rather than sharing an overall view of safety. The presence of subcultures within an organization can lead to misunderstandings and ultimately conflict between groups. The investigation into the Piper Alpha disaster (Ref 1.16) highlighted the lack of communication between the day and night shifts, despite there being shift hand-over and permit to work systems. However, subcultures can also be a positive influence on safety, by bringing different perspectives and a diversity of views to safety problems.
The culture of outside groups that interact with a facility can also influence its process safety culture. These outsiders include contractors, regulators, law enforcement, emergency responders, media, unions, corporate staff, boards of directors, interest groups, community groups, individual members of the public, among others. For example, the UK HSE (Ref 1.15) found that contract workers on offshore platforms had “markedly inferior” benefits and working conditions than employees. Contract workers did not receive holiday or sick pay, and they did the most dangerous and physical work. Their working conditions distanced them from the company's culture. Unlike employees, contractors viewed safety as subordinate to production. Unsurprisingly, contractors experienced more accidents than company employees.
Multi-cultural influences work in both directions. The cultures of the outsiders will affect the culture of the facility, and the culture of the facility will affect the culture of the outsiders. Therefore, a facility should communicate and partner with the outsiders to advance their process safety related cultures as they advance their own. Each of these outside groups has its own agenda and interests, and sometimes these interests will not be in accord with those of the company.
The way in which different parties communicate with each other, build trust, and resolve conflict will determine how much friction results. Chapter 5 addresses the external influences on culture and how it relates to the facility's and company's PSMS.
The CCPS RBPS book (Ref 1.3) includes process safety culture as a distinct PSMS element and defines some tangible actions. However, many of the recommended actions to establish a strong process safety culture are intangible. A healthy process safety culture cannot be successfully established by edict or by cookbook. It requires convincing employees and the abovementioned outsiders that a healthy process safety culture benefits them. The rationale should be carefully and fully explained, supported with empathy, and led by example in implementation. The tangible actions described in the RBPS book, such as formally defining process safety goals and objectives, formally defining responsibilities, accountabilities, and training requirements will be described in more detail in Chapters 4, 5, and 6.
1.3 WARNING SIGNS OF POOR PROCESS SAFETY CULTURE
In its book Recognizing Catastrophic Incident Warning Signs in the Process Industries (Ref 1.17), CCPS described typical warning signs that have been observed in facilities well in advance of incidents. CCPS argues that recognizing the presence of these warning signs allows companies to correct deficiencies early before they escalate into incidents.
Table 1.1 lists warning signs related to Process Safety Culture, organized by core culture principles that will be presented in chapter 2. Table 1.1 is organized in the form of a checklist that readers can use to find quick culture improvement opportunities before launching a formal culture improvement effort. This checklist may also be used to identify the core culture principles on which to focus initial work. It can also be useful to stimulate discussions about culture in leadership team meetings.
Table 1.1Checklist – Warning Signs of Gaps in Process Safety Culture
Warning Sign
Found?
Action
Establish an Imperative for Safety
• Widespread confusion between occupational safety and process safety
• Process safety budget reduced
• Leadership behavior implies that public reputation is more important than process safety
Provide Strong Leadership
• Frequent organizational changes
• Conflict between production goals
and safety goals
• Employee opinion surveys give negative feedback
• A high absenteeism rate
• Frequent changes in ownership
Foster Mutual Trust
• Strained communications between
management and workers
• A lack of trust in field supervision
• Favoritism exists in the organi- zation
• An employee turnover issue exists
Ensure Open and Frank Communi- cations
• Negative external complaints
• Inappropriate supervisory behavior
Maintain a Sense of Vulnerability
• Leaders obviously value activity- based behavior over outcome- based behavior (sometimes referred to as “check-the-box” activities or a “checklist approach”)
Understand and Act Upon Hazards
and Risks
• Signs of worker fatigue
• Overdue process safety action items
• Workers not aware of or not com-
mitted to standards
Empower Individuals to Success- fully Fulfill their Safety Responsibi- lities
• Job roles and responsibilities not well defined, confusing, or unclear
• Conflicting job priorities
• Frequent changes in priorities
• Supervisors and leaders not form- ally prepared for management roles
• A poorly defined chain of command
Defer to Expertise
• Conflict between workers and management concerning working conditions
• A perception that management does not listen
Combat the Normalization of Deviance
• Operating outside the safe
operating envelope is accepted
• Varying shift team operating
practices and protocols
Learn to Assess and Advance the Culture
• Slow management response to process safety concerns
• Everyone is too busy (helps foster “check-the-box” thinking
1.4 LEADERSHIP AND MANAGEMENT ROLES AND RESPONSIBILITIES
The responsibility for executing the PSMS and maintaining the process safety culture belongs to those persons who manage the company and its facilities. Process safety culture specifically is created through leadership.
Senior leaders have high-level and strategic oversight for both the management system and the culture. They delegate program and element responsibilities through the organization, and they create the culture. Leadership for process safety needs to start at the top of the organization, and then carry through all levels, to the plant floor. Strong leadership stewarding each function is needed to direct resources to the most critical risks and opportunities, clarify expectations, listen and learn, create passion, and provide clear, consistent messages. As discussed in Chapter 2, Leadership is a core principle of process safety. The role of management and leadership will be discussed in more detail in Chapter 3.
In a complex business with a high-risk profile that suffers from lack of leadership, cultural gaps will appear and can lead to process safety performance gaps. These in turn can lead to catastrophic incidents. Therefore, leaders in the chemical, oil and gas, and related industries have no role more important than stewarding the PSMS and process safety culture in their organizations.
What causes process safety cultures to fail? Roughton and Mercurio (Ref 1.18) state that in many cases these failures occur due to management style. Their research identified two primary types of management styles: authoritarian management and participative management.
Authoritarian managers stress productivity and often believe that people inherently avoid work. They operate by command and control, which may get tasks done. But they fail to motivate people because they do not fulfill basic human social and ego needs. Furthermore, this management style limits ingenuity, creativity, and problem-solving to only a few individuals, only partially utilizing the intellectual potential of the workplace.
Participative managers recognize that people can be positively motivated by the satisfaction of doing their job well. Accordingly, direct control and punishment can be successfully replaced by self-direction. Workers committed to their work seek responsibility rather than avoid it. They then exercise their capacity for imagination, ingenuity, and creativity, often to the benefit of both safety and productivity.
Roughton quotes an old military adage that summarizes the importance of leadership to successful management: “There are no bad troops, only bad officers.” Clearly, leadership is integral to establishing a sound culture.
1.5 ORGANIZATIONAL CULTURE, PROCESS SAFETY CULTURE, AND BUSINESS SUCCESS
CCPS (Ref 1.3) describes four foundational blocks of a PSMS:
Commit to Process Safety,
Understand Hazards and Risks,
Manage Risks; and
Learn from Experience.
This links to the familiar Plan-Do-Check-Act (PDCA) cycle as shown in Figure 1.1, with leadership providing the culture that drives success.
Figure 1.1 Linkage of Culture and Leadership to a PSMS
Strong, positive leadership in process safety will establish the groundwork for a sound process safety culture. That sound culture will then lead to a robust PSMS that in turn drives improved and sustained process safety performance.
Since process safety follows the PDCA approach used in other operational and business systems, improving process safety culture will also likely lead to improvements in other cultures, such as EHS, Quality, and technology, and therefore lead to stronger business performance (see section 1.5 and Appendix A).
Likewise, process safety culture of an organization does not exist in a vacuum. Instead, it inextricably links to the organization's overall culture, including other subcultures such as business practices, overall EHS, quality, and even the culture of stakeholders that interface with the organization (e.g., neighbors, customers, etc.), and others.
In the ideal case, a strong positive process safety culture mates with other strong positive cultures to build an overall strong positive corporate culture, as discussed by Musante (Ref 1.19). This kind of strong and integrated culture is sometimes referred to as Operational Excellence. The Musante reference, titled Doing Well by Doing Good: Sustainable Financial Performance Through Global Culture Leadership and Operational Excellence, is reproduced with permission as Appendix A.
A weak or negative process safety culture may be coupled with, for example, a strong business culture. This may provide financial success and avoid process incidents for some time, but ultimately a major process safety incident can cause it to fail catastrophically. However, strong business culture can be leveraged to build a strong process safety culture. Likewise, when both process safety and business cultures are relatively weak, first strengthening the process safety culture can be a stepping stone to building an overall positive business culture.
1.6 CORPORATE CLIMATE AND CHEMISTRY
If process safety culture underpins everything in a PSMS, then what underpins the culture? What conditions either support or inhibit the development, maintenance, and sustainability of the process safety culture? Mathis and Galloway (Ref 1.5). identify seven milestones on the safety culture improvement journey. Two of those milestones are climate and chemistry.
Corporate Climate refers to the conditions within an organization as viewed by its employees. In the case of process safety, management creates an organization's climate through four components: Commitment, Caring, Cooperation, and Coaching. Two organizations may have a common set of activities, from which an external viewer might infer the same culture. However, the cultures may be very different. For example, soldiers in combat and participants in a survival reality TV show may share some common tasks, i.e., surviving in harsh outdoor conditions, but the climate or environment for these two situations are totally different and therefore the cultures will be very different.
Corporate Chemistry refers to the structure of the culture. Like the elements that make up a molecule or the elements in the soil that nurtures the growth of plants, safety culture is built around the elements of Passion, Focus, Expectations, Proactive accountability, Reinforcement, Vulnerability, Communication, Measurement, and Trust. (Ref 1.5).
In developing the culture principles presented in this book, CCPS considered both climate and chemistry. Some culture principles addressed both climate and chemistry, as shown in figure 1.2, facing.
Figure 1.2Mapping of CCPS Culture Principles to Corporate Climate and Chemistry
1.7 SUMMARY
Process safety culture has been recognized as a contributing factor in many significant incidents that have occurred in the processing industries in recent years. Process safety culture in any facility forms the foundation of the PSMS, regardless of what is written. The quality of demonstrated leadership directly affects the strength and quality of the process safety culture, and the quality and health of the process safety program itself. While managers of PSMS's clearly serve as process safety leaders, all managers and executives in enterprises that manage major process hazards can and indeed should demonstrate process safety leadership and help set a strong, positive culture.
CCPS defines process safety culture as:
“The pattern of shared written and unwritten attitudes and behavioral norms that positively influence how a facility or company collectively supports the development of and successful execution of the management systems that comprise its process safety management system, resulting in the prevention of process safety incidents.”
Other definitions related to safety culture and particularly process safety culture can be found in the literature. There is no single definition of safety or process safety culture. Numerous definitions have been presented in the literature in recent year. The CCPS definition embodies all the lessons learned in the literature to produce a definition serving the major hazard industries ranging from upstream oil and gas, through refining, chemicals and pharmaceuticals to manufacturers who handle chemicals and practice chemistry in other industries.
Process safety culture and the organizational culture that it fits into are strongly linked. The process safety/safety culture of an organization cannot exist in a vacuum. Any problems or issues in the organizational culture will also show up in the process safety culture, and elsewhere in the organization as well. Likewise, efforts to improve process safety culture can spill over to positively impact the overall culture of the organization. Organizations that have a strong overall culture and strong process safety culture have been shown to consistently have better financial performance. There is a strong business case for strengthening and sustaining process safety culture.
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Organizational Culture and Leadership
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Safety Series No. 75 – INSAG-4, Safety Culture
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STEPS to Safety Culture Excellence
SM
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Columbia Accident Investigation Board Report
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Nurturing a Strong Process Safety Culture
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Culture's Confusions
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Measuring safety culture in the offshore oil industry
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Safety Culture: A review of the literature
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HM Stationery Office,
The Public Inquiry into the Piper Alpha Disaster
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CCPS,
Recognizing Catastrophic Incident Warning Signs in the Process Industries
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Roughton, J, Mercurio, J,
Developing an Effective Safety Culture: A Leadership Approach
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Musante, L. et al.,
Doing Well by Doing Good: Sustainable Financial Performance Through Global Culture Leadership and Operational Excellence
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