Safety Culture

LeadershipLeadership

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Positive Safety Culture

How to create, lead and maintain By Rosa Antonia Carrillo

THE ABILITIES TO COMMUNICATE WELL and engender trust are often listed as among the most important for leaders. Becoming skilled in these areas is challenging for many reasons, but seldom examined is the obstacle presented by the nature of culture. When a leader does not recognize that cul- ture impactshis/herownandothers’perceptionsof what is true, the result is unintended messages and consequences that damage the leader’s credibility. This has a negative impact on organizational effec- tiveness. This article focuses on how culture affects safety performance, providing case studies and cit- ing research, in order to motivate both formal and informal leaders to increase their competency incul- turemanagement.

Organizational Culture&Leadership Leaders influence the way others see reality

through language and action. That is how they shape and change culture. Many notable manage- ment scholars share the notion of leadership’s re- sponsibilityasdefiningreality (DePree,1987;Collins & Porras, 2002; Koestenbaum, 2002; Schein, 2004). Leadersaccept thechallengeof identifyingdysfunc- tional assumptionsand influencing the creationand adoption of new ones that will guide decision mak- ing towardorganizational success. According to Schein (2004), who pioneered the

concept, organizational culture is the sum of all the shared assumptions that a group has learned throughout its history. It is the residue of success. Assumptionsare thewaypeoplemakesenseof real- ity; they are shared ways of thinking, feeling and perceiving. Schein also says that the ultimate chal- lenge of leadership is the ability to perceive the lim- itations of one’s own culture and initiate the processes tomake itmore successful. The visible aspects of culture, elements such as

policies, procedures, language, stories and symbols, provide clues about the nature of an organization’s culture. However, the most powerful aspects are

invisible. They are the beliefs and assumptions that influencehowpeople thinkandact.Thesafety lead- ership journeybeginswith the examinationof one’s own assumptions. Some support safety-conscious behaviorandsomedonot.Aleaderbeginsa culture changebycorrectinghis/herownfalseassumptions first andcreatingopportunities for others to follow. Continuing with Schein’s model, when embed-

ding new assumptions, the leader first proposes an action to address a problem based on his/her own assumptions of what is right and wrong. Once a group takes action and perceives it to be a success repeatedly, a shared belief develops that it is the right action to take in that situation. Gradually, as more success is experienced, the belief becomes a shared assumption that may become so taken for granted that actingagainst itmaybe inconceivable. Once in place, assumptions are extremely difficult

tochange.Theprocess is timeconsumingandanxiety provoking, as one must first admit that long-held beliefs may be wrong. Until the new belief is proven trueandaccepted,one is thrown intoa timeof confu- sion, which may be laced with regret for past mis- takes, incompetence with the new skill or behavior required, anduncertaintyabout the future.

Themost central issue for leaders, therefore, is howtogetat thedeeper levelsof culture,how to assess the functionality of theassumptionsmadeat this level, and how to deal with the anxiety that is unleashed when those lev- els are challenged (Schein, 2004, p. 36).

Once the culture is estab- lished, people’s beliefs deter- mine how they interpret their experience. Asch’s (1955) con- formity experiments showed that 37% or more of humans

RosaAntoniaCarrillo,M.S.O.D., is president of Carrillo and Associates in Long Beach, CA. Her work focuses on culture change, safety perception surveys, leadership development and helping companies participate in OSHA’s Voluntary Protection Programs. Carrillo is a frequent presenter and the author of four books and many articles. She holds an M.S. in Organization Development from Pepperdine University. She is currently a faculty member in the Presidential Key Executive M.B.A. program at Pepperdine University, specializing in organizational behavior.

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Abstract: Managing culture is a key leader- ship competency. This article examines several cultural dynamics and assumptions that affect safety performance and how awareness of them can help SH&E leaders improve their effective- ness in strengthening the safety culture.

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formed in concert with others, persuading and justifying per- ceptions to shape what people believe and act jointly in that context.Whenpeoplegetdesir- able results, it reinforces their beliefs (Stacey, et al., 2002). Othersmight saypeople act

and that their beliefs are formed based on the results of their actions (Weick, 2001). If an action produces desirable results, a belief develops that it is the way to solve this prob- lem—the way to get what one wants. Figure 1 depicts the cycle of positive results rein- forcing beliefs that influence thedecision toact. This cycle poses a dilemma

because the belief may or may notbecorrect.Whenit iscorrect, the effect is to make life easier because one can act automati- callywithoutmakingadecision and get good results (Bargh & Chartrand, 1999).However, one canexperiencegoodresults that lead to the wrong belief. Witness some common unsafebehaviors suchas speeding, smokingor refus- ing to wear Nomex clothing because it is too hot. In the moment, the result feels good, but the person is unawareof the larger truththatatanymomentevents canshift andcause thepersongreatharm. Afundamentalquestionfor leaders is,dowework

on changing the belief directly or do we force the behavior changeand let thebeliefdevelopasa result of repeated experience with the new behavior? As noted, forcingabehaviorchangetoensureimmediate compliancemaybe thecorrectpathundercertaincir- cumstances. Moving from enforced compliance to self-directedbehavior,however,requiresthat individ- uals believe the new behaviors are the best way to solveaproblemtoget theworkdone. Weick (2001), who has studied major disasters,

says,“Thebasic ideaofsensemakingis that reality is an ongoing accomplishment that emerges from efforts to create order and make retrospective sense ofwhatoccurs”(p.106).Aculturechangeeffort is lit- erallyaskingpeople torecreateapartof their reality. Thus, facilitating sensemaking can be a powerful

leadership tool when done in groups. The leader mayuseanincidentorequipment failureas thesub- ject to leadadialoguetoarriveat thebeliefs thatwill guide correct decision making and action in the future. It is key toengagepeople in theanalysis and problemsolving. As Weick (2001) further proposes, “People learn

abouteventswhentheycomparewhat theyseewith what someone else sees and then negotiate some mutually acceptable version of what really hap- pened” (p. 447). If the leaderdoesnot actively facili- tate the discussion and share relevant data, the

selected a wrong answer to conform to those around them regardlessofvisualproof to the contrary. Berns, Chappelow, Zink, et al. (2006), confirmed this research. “We like to think that seeing is believing, but the study’s findings show that see- ing isbelievingwhat thegroup tellsyou tobelieve.”This infor- mation reveals that the power of culture is amoral. It can sup- port both healthy and un- healthybehaviors.

CreatingPositive Safety Cultures In general, safety culture is thought to influence

employees’ attitudes and behavior in relation to an organization’s ongoing SH&E performance (Choud- hry, Fang & Mohamed, 2007). Thus, leaders must understand organizational culture and their role in shaping it. Since safety culture plays a role as both cause and prevention of mishaps, understanding the role cultureplaysmeans lookingbeyond the individ- ualbehaviors, theequipmentandtechnical failures to a mindset that says incidents happen because it is normal behavior. In other words, they happen in large measure because of cultural conditioning cou- pledwithpredictablebutunexpectedevents. Using the framework in which leaders facilitate

the adoption of successful beliefs, this article points to several areas to investigate. They are typically areas where problems persist despite concerted efforts to fix them. The search for more functional beliefs can be conducted individually or in groups. Culture change, however, which is the adoption of newbeliefs andassumptions, occurs ingroups.This is what Weick (2001) describes as sensemaking and Stacey, Griffin and Shaw (2002) describe as the mind social process (whichisdescribedinmoredetail later). It is important to note that the examination of assumptions is an ongoing process since new infor- mation is continually revealed. Given the difficulty of working with beliefs and

assumptions, many ask, “Isn’t it better to start with changingbehaviorsince it isvisible?” Inurgentsitu- ations,enforcedcompliancetochangebehaviormay be justified.Alsobehavior-basedsafetyobservations appear to change behavior. However, one must remember that long-lastingchangerequireschanges in the theories of action that people use and in an organization’s learning systems (Argyris, 1999). Ultimately, the belief system must shift for the desiredbehavior tobe self-motivated. Toworkatthis level,onecanthinkaboutbeliefsas

the explanations people develop of how the world works,whatpeopleneedtodotoget theresults they want.Behavioral scientistsdebatewhichcomes first, the behavior or the belief. Some think beliefs come first, thatpeopleformoraretaughttheoriesaboutthe world and refer to those theories in order to act. Because people operate in groups, these beliefs are

Beliefs Actions

Results

Figure 1Figure 1 How Beliefs Form

If an action produces desirable results, a belief develops

that it is the way to solve this problem— the way to get what one wants. Figure 1 depicts the cycle of positive results rein- forcing beliefs that influence the deci-

sion to act.

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states that appear to be contradictory but are both right. In fact, they are interdependent. The human mind feels compelled to choose between apparent opposites such as society and the individual, or lib- ertyandequality inordertoeliminateambiguity.An example in safety would be choosing between pro- duction (efficiency) andsafety (process). Collins and Porras (2002) refer to polarities as

paradox,describing themas the“tyrannyof the or.” Business polarities they feel hold back performance includethebeliefs thatonecanonlyhave“changeor stability, lowcost or highquality,planning or oppor- tunism.”CollinsandPorras suggest replacing the or with both/and, but it is much more difficult in prac- tice than it sounds. Polaritypresentsahugearea

of opportunity to improve the safety culture and one’s ability to communicate commitment to safety. People eliminate am- biguitybyonlyfocusingonone aspectofapolarityatatime.So, when a leader talks about production, and does not specifically mention safety, the listener will likely assume that safety is not important to the leader. When confronted by polarity, it is difficult to hold two points of view at once, so people freeze on one point of viewor jumpbackand forth. Figure 2 is a metaphor for

polarity because one figure could not exist without the

discussion might happen informally and consensus will form without input from management. This could result in faulty problem solving since people typically interpret external events within the exist- ing culture and language system that created the problem(Daft&Weick, 1984).

Senge (1994) describes the introduction and acceptanceofnewassumptionsabout thewaywork isdoneviadialogue. Inadialogue, there isnoblame fixing, only open conversation to explore why peo- ple chose to work in what is or appears to be an unsafeway.Onemaydiscover thatpeoplehad logi- cal reasons for their actions, while other times they hadfaultyreasoning(operatingunder falseassump- tions). Support for change increases when the dis- cussion is treatedas aneducational shift rather than as anattitudeadjustment. In summary, culture change efforts seek to

replace nonfunctional (false) assumptions with suc- cessfulones.New, long-lastingbehaviorscomefrom changing the way one thinks. By definition, the leaderidentifiesthefaultyassumptionsandpresents newones thatdemonstrate successful results.

The Impact of CultureonCommunication: ThatWasn’tWhat IMeant! Leaders get frustrated when they take actions to

communicatetheimportanceofsafetyandlater learn that people got the message that management puts productionoversafety.Howdoesthishappen?Inthe author’s experience, themost likelycause ispolarity. It is embedded in the culture and it presents a great obstacle to management’s ability to communicate commitment to safety. According to Koestenbaum (2002), polarities are

Figure 2Figure 2 Rubin’s Vase

The safety leadership journey

begins with the examination of one’s

own assumptions. Some support safety-

conscious behavior and some do not. A leader begins a culture change by correcting his/her own false assumptions first and creating opportunities for

others to follow.

When confronted by polarity, it is difficult to hold two points of view at once, so people freeze on one point of view or jump back and forth.

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thorough communication at shift exchanges, reading and initialing the logbook, and better rounds. Then, the two supervisors said, “I thought this was supposed to be about safety. We’reonlyfocusingonproduction!”Theplant manager was shocked to hear that the super- visors had not connected safety with better communication and better rounds. To him, safetywas integrated into theoperationalpro- cedures; itwasn’t to the supervisors. A dialogue ensued and a tailboard was

integrated into the shift exchange to bring attention to safety. The languageandstructur- alchangehelpedtheoperators integratesafety and production. An interesting aspect of this exchange was that while the plant manager was shocked and frustrated, it was the opera- tions manager who understood the dilemma andsuggestedthe tailboardtomeet thesuper- visors’ expectationsof attention to safety. CollinsandPorras(2002)quoteF.ScottFitzgerald

who said, “The test of a first-rate intelligence is the ability tohold twoopposed ideas in themindat the same time and still retain the ability to function.” Their point is that visionary leaders can hold these polarities and communicate them in a way that helpspeople see that efficiencyandcaringare inter- dependent rather thancontradictory.

LeadershipResponse to Incidents Shapes Culture In a multicultural environment, culture takes on

addeddimensions.Nationalculturesdifferonmany polarities (called cultural dimensions) such as indi- vidualism versus collectivism, high power distance versus low power distance (hierarchical vs. flat power structures), and uncertainty avoidance (Hofstede&Hofstede, 2005;Trompenaars&Hamp- den-Turner, 1997). These contribute to misunder- standingandconflict. These dimensions are not absolute. For example,

an individualistic culture has collectivist elements. Thus, people’s beliefs in one’s organization may be on a continuum between the two poles. The com- munication challenge increases when one adds a multicultural environment with employees from manycountries. In the author’s 19 years’ experience with multiple

industries,onedimension,universalismversuspartic- ularism (Trompenaars&Hampden-Turner, 1997), is a cultural polarity that shows up in conflict about the most effective way to communicate and learn from incidents.Universalismplaces the emphasis onobey- ing rules. It represents thebelief that certain rulesand truthscanbe identified, thenshouldbeappliedequal- ly to everyone. Particularism places greater emphasis on relationshipsandruleapplication is situational. The U.S. has one of the strongest universalism

societies,whichcontributes to the tendencytorelyon logic, rulesandproceduresas therightwaytohandle difficult situations.However, focusgroupswithmore than 3,000 employees over a 10-year period consis-

other.According toscientists, themind isnotable to visualizeboth thevaseandthe facesatoncebecause themindinterpretseachfigureaccordingtowhichis declared the background. In the realm of language, practiceandawareness increase themind’sability to see the whole picture, resulting in improved com- munication of management’s commitment to both safety andproduction. Twoexamples follow.The first demonstrates one

manager’s inability todealwithpolarity inhis com- munications. The second case took place at a power generation plant; it demonstrates how leaders can helpemployees copewithpolarity.

According to the Los Angeles Times, in 1997 Disneyland moved to what is known as “reli- ability-centered maintenance” to reduce costs. Then, for the first time in the park’s history two fatalities and10 injuries occurredbecause of equipment failure between 1998 and 2003. Workers interviewed said that the move “gut- ted worker morale and employees’ sense of ownership of the rides.” One supervisor who worked at Disney from opening day to 1997 whenheretiredsaid, “Ihavea lotof loyalty to Disneyland, but I feel that somebody’s got to say something about how they’re operating out there. When Disneyland opened, safety was the No. 1 thing. Now they say that today, too. But I think over time, profit became more important.” Why did they think this? They quoted Paul Pressler, park president, as say- ing, “We have to ride these rides to failure to savemoney” (Anton&Yoshino, 2003).

It appears that Pressler did not consider polarity and culture when he crafted his announcement about thenewmaintenancesystem.Thus,hedidnot introduce thesysteminawaythatalignedwithsafe- tybeliefsandpeopleinterpretedthechangeas“man- agementno longer cares about safety.”Also, it could be inferred that even if the new assumptions about thesafetyof thenewmaintenancesystemwereclear- lystated,caremustbetakennottouselanguagesuch as “we have to ride these rides to failure to save money,”which is likely to triggernegativeemotions. Disney’s response to the article, as can be expected, was that safety is the number one priority. The chal- lengeisbeingable tosustaincredibility for thatvalue while introducingcost-savingmeasures. In contrast, the next case demonstrates how mis-

communication can be averted by immediately addressingmisperceptions.

In ameetingwithoperators, theplantmanag- er introduced a new policy, “Safety is our first priority.” The policy was made in reaction to an incident where putting production over safetywasnamedasa root cause.While intro- ducing thepolicy theplantmanageralsowent over someoperationalprocedures. At the conclusion, the facilitator asked the

group what practices they thought would most raise their awareness. They listed more

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training session introduced the pro- gram and the increased safety benefits ofparticipating. The program gained momentum

untilonepersonwhoreportedafailure tolockoutasanearmissreceivedarep- rimand inhis file. Theplantmanager’s beliefwas that thebreachofprocedure wastooserioustobeletgowithoutdis- ciplinary action. Participation in near- miss reporting all but stopped, the accident rate was up, and at union negotiations that year relationships were strained and confrontational betweenunionandmanagement. An outsider came in to improve

communication between the two par- ties, and the near-miss reporting inci- dent quickly arose as a critical incident that triggered the breakdown of man- agement-union relations. Union mem- bers believed management had broken its commitmentandhadused thenear- missprogramtoentraponeof itsmem- bers. No amount of explanation on the plantmanager’spart regardinghis rea- soninghelped. Itwasnotuntil theplant manager shifted his assumptions that the logjamwasbroken.Theplantman- ager did so by first apologizing to the unionmembers. Asheexplainedit,herealizedhehad

not trusted (believed) that by removing the fear of near-miss reporting he was support- ing safety rather than jeopardizing it. His belief thatwithholdingpunishmentwouldcommuni- cate condoning an unsafe action dominated his thinking.Hehadbrokenhiscommitment tonot seek disciplinary action, and had failed to trust people to learn fromtheirmistakes. He removed the letter from the employee’s

file and asked everyone to renew participation. Theplantmanager’swillingnesstoadmitamis- take restored a tentative trust line. Compliance to lockout improved, the near misses began to flow in and, over time, as measured via safety culture surveys, positive perceptions grew regarding the belief that “here we take the opportunity to learn from our mistakes” and “management caresaboutusaspeople.”

In these two cases, the managers had a negative impact on safety and lost the trust of their employ- ees. Inthelabfire, themanagerwasunabletocorrect his error.Thesecondmanagercorrectedhisbyapol- ogizing and embedding new beliefs in the culture (we learn fromourmistakes andmanagement cares aboutus) thatgrewover time.Theseexamplesshow that incidents offer opportunities for cultural trans- formation when trust levels are maintained and a manager communicates in a way that reinforces people’s belief that s/he is committed toboth safety andproduction.

tently showthat employeeshold“mymanager cares about us as people” as a key indicator of manage- ment’s commitment to safety (Carrillo, 2008). It is the author’s observation that when managers focus on the preferred universalism assumptions and neglect the importance of relationships (particularism), com- municationfails.Asthefollowingcase illustrates, this is especially true in theaftermathof an incident.

A lab technician at a pharmaceutical company seriouslyburnedhimself ina labdueto follow- ing improper procedure handling a flammable agentspill.Thedirectorgatheredeveryoneand gaveareportontherootcausesof theaccident. Heremindedeveryoneof theproperprocedure for handling chemical spills and ended by say- ing that a lot of work time had been lost so everyoneshould refocuson their jobs. By the following week everyone on the

safety committee had resigned because they said the director did not care about people. The safety committee chair, a chemist, said, “Everyone in the facility was talking about how all he cared about was getting the work done.” In actuality the director, a very ethical person,hadspentagreatdealof timewith the injured technician and his family. It did not occurtohimtotalkabouthispersonalconcern inhis communication to the staff. In this case, the director was not coachable.

Hedidnotwanttoletgoofhisbeliefthat“every- one should know I care, they’re intelligent.” He was technically competent, butdidnothave the inclination to adopt another version of reality and improvehis communicationskills.

People have an automatic filter that interprets what a speaker is saying according to their own experience (Argyris, 1999). This presents an enor- mous barrier to communication, particularly when polarities arepresent.Aleader responsible for creat- ing or maintaining safety must understand the nature of these filters and use language carefully. One’s words and actions are like the scalpel in the heart surgeon’s hand. Successful communication depends on the exact use of words and being con- scious of one’s actions. When a mistake occurs, one must recognize it so themessagecanberestatedand one’s actions clarified. In this way, the trust level needed to influence the culturemaybemaintained. Consider this manager’s handling of near-miss

reporting:

There is research indicating that open report- ing of near misses results in an organization’s ability tocorrecthazardsandunsafebehaviors before injuryordamageoccurs, thus resulting in fewer accidents (Jones, Kirchsteiger & Bjerke 1999; Van der Schaaf, Lucase & Hale, 1991). After hearing the evidence, a manufac- turing plant manager agreed to implement a near-miss reportingprogramandassuredpar- ticipants thatnoactionwouldbetakentopun- ish individuals who reported them. A short

People have an automatic filter that interprets what a speaker is saying according to their own experience. A leader respon- sible for creating or maintaining safety must understand the nature of these filters and use language carefully.

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Leveson, Cutcher-Gershenfeld, Barrett, et al. (2004), report that JimKennedy,one-timedirectorof the Kennedy Space Center, said in an interview that “the most important cultural issue the shuttle pro- gram faces is establishing a feeling of openness and honesty with all employees where everybody’s voice isvalued.”TheKraft (1995)reportonthespace shuttle program notes that concerns about shuttle safety were dismissed by managers who labeled thosewhobroughtupconcernsasbeingpartners in an unneeded “safety shield” conspiracy. The assumptions held by some engineers were com- pletely different than those held by the managers making thedecisions toproceed. This tragedy illustrates the necessity for leaders

to understand cultural dynamics and how to break- downthenaturalbarriers theypresent to communi- cation. It may not be enough to express support for openness and trust. Even if members of one subcul- ture listen to and examine disconfirming informa- tion, they may not to see the fallacy of their own assumptions.As noted byAsch (1955) and Berns, et al. (2005), it is the very nature of group dynamics to block out disconfirming evidence. This is an uncon- scious process, so it takes skilled inquiry to uncover the assumptions and beliefs that keep members of different subcultures from seeing the truth in each other’spoint of view. SH&E professionals can play a key role in bridg-

ing the gap between subcultures. First, however, they must recognize their own assumptions. Some evidence points to a significant divergence in assumptionsbetweenSH&Eprofessionalsandman- agers. For example, in a 2005 worldwide survey, 24 SH&Eprofessionals and21executives responded to a request to prioritize a manager’s role in achieving the primary goals of an SH&E program (that had been previously selected on the survey). Seventy- four percent of the managers listed “hold regular SH&E communication events with staff and associ- ates” as their top priority, while 70% of the SH&E professionals had it as the sixth priority for man- agers. SH&E professionals felt management’s first priority should be taking SH&E into account when makingbusinessdecisions (Carrillo, 2005). Such differences in expectations are significant

because they reflect a fundamental disagreement on how to solve a common problem: how to improve SH&E performance. When a group fails to meet the expectations of another, credibility and respect, both key ingredients for collaboration, may break down. Special effort is required to bring these two groups together to understand each other’s expectations and views.Otherwise,membersofonegroupcouldmake negative assumptions about the other group’s com- mitment or competency based on a difference of pri- orities,whicharebasedonbeliefs.

AssumptionsAboutCorrective Actions In 1941, Heinrich set the focus of accident pre-

vention on human error: “Among the direct and proximate accident causes for industrial accidents,

ABrief Review of Trust Trust is mentioned often throughout

these case studies because, in the author’s experience, lackof trust constantlyemerges as an issue in safety improvement efforts. Briefly,what is trust?Experts linktrustwith the willingness of the individual to take risksbasedonhis/her relationshipwithan individual or organization. Three factors haveemergedintheresearchontrustasthe corecharacteristicsofanindividualthatcan be trusted: ability, benevolence and integri- ty (Schoorman,Mayer&Davis, 2007). Ability means technical competence,

benevolence is the belief that the trusted person will act on others’ behalf, and integrity is actingonasetofprinciples that the trustee finds acceptable. If a leader is viewed as having ability and integrity, but notbenevolence, there isnotrust.Thisdoes notmeancompetenceand integrity arenot important; it means they are not enough (Schoorman, et al., 2007). The perceiver must believe that the leader will act in his/her best interest, that the leader cares about thepersonasan individual. To create a positive safety culture, a

leader must address the trust level within the organization and the degree to which s/he is trusted personally. Trust is like money in the bank, without it one cannot get a loan. Loans are what one needs when trying to change a culture. Think

about the kinds of changes needed. Is the shift toward assumingmore personal responsibility? Is it to confront another’s unsafe action? Stop an unsafe job?Allof these takerisk.Researchoffers the insight that risk ismore likely tobe taken ifpeople trust the personasking themto take it.

CommunicationAcross Subcultures Occupational groups (engineering, maintenance,

sales) aswell as the largergroups createdby thedivi- sion between management and labor form subcul- tureswithinthelargerorganizationalculture.Eachare neededforthecompanytofunction,yetmanyofthem conflict, causing the company tobe less effective than it could be (Schein, 1996). Several examples reflect subculturedivisions that affect safetyperformance. When Vaughan (1996) coined “normalized

deviance” in her analysis of the Challenger disaster, she concluded thatNASAmanagementhadcreated a closed culture in which decisions obviously ques- tionable to the outside world were seen by NASA’s management asprudent and reasonable. It can truly be said the Challenger launch deci- sion was a rule-based decision. However, the cultural understandings, rules, procedures and norms that always had worked in the past did notworkthis time. Itwasnotamorallycalculat- ing managers violating rules that were respon- sible for the tragedy. Itwas conformity (p. 386).

Managing, shaping and creating

culture is a leader- ship competency. Any attempt to

work at the cultural level

requires patience and willingness to make corrections

and apologies along the way. The latter helps

maintain the trust level a leader needs

to be effective.

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time each subunit develops its own procedures that seem more logical. This is due to what Snook (2000) calls “logics of action” [and Schein (1996) calls cul- tural dynamics]. When the system suddenly becomes tightly coupled, the informal procedures developedby thesubunitsno longerapplyand lead todisaster. Snook (2000) suggests that the typical command-

and-control response of increased policies and pro- cedures does not address the core issues that if addressed would prevent future incidents. Instead, he urges professionals and managers to realize that the important question is not how to fix pilot error, crew inaction or even practical drift. The more fun- damental question is, what can be done given this reality of human behavior? How can practical drift beaddressed ifnotwith increasedandtighter rules? A beginning would be to accept that drift will

occur and more rules are not the answer. Snook (2000) also emphasizes the dynamics of sensemak- ing tobothexplainhowpeople come tobelieve that not following the procedure makes more sense, and engage people in an inquiry that could lead to a moreprofoundsenseofawarenesswhichmightpre- vent future tragedies more effectively than increas- ing rules andprocedures.

88% are unsafe acts of persons, 10% are unsafe mechanical or physical conditions and 2% of accidents are unpreventable” (p. 20). Over time, profession- als pointed to error in blaming individuals and introduced systems thinking which fo- cused on improving culture and organizational systems to prevent accidents (Carrillo & Simon, 1995; Vaughan, 1996; Whittingham, 2004). More recently, organization-

al effectiveness research has turned to the natural sciences and questioned the assump- tionsmanagementholds about cause and effect and organiza- tional control. Since a great deal has been written about systems thinking, this discus- sion focuses on the implica- tionsofwhat iscalledthe“new science” (Wheatley, 2006). Snook (2000) analyzes the

downing of two Army Black Hawk helicopters over north- ern Iraq in 1994, which caused 26 deaths. He references Secre- taryofDefenseWilliamPerry’s findings, which focused on technical failure and human error, and resulted in increased procedures, policies and train- ing to prevent the same prob- lems from recurring. Snook takes an organizational psychology approach to offer a theory about why the participants failed to follow procedure without blaming individuals. Snook’s (2000) “practical drift” theory offers an

insightful answer and provides direction for actions that could address the unpredictable nature of orga- nizational behavior which produces such disasters. Hedefinespracticaldrift as “the slowuncouplingof practice from procedure” (p. 24), a mechanism that operates across time and levels to explain how the actionsof individuals,groupsandorganizationalele- mentscancombine intoadisaster.Heconcludes that the typical response of tightening procedures and increasing penalties for failure to comply would in- evitably lead to the samepathologybecause in time, thenewprocedureswouldalsobe ignored. According to this model, practical drift occurs

when procedures are designed for tightly coupled systems, but day-to-day experience shows them to be loosely coupled. Coupling is the level of interde- pendence between subunits. When elements are tightly coupled, whatever happens to one system directlyaffects theother.When the systemis loosely coupled, no consequences are experienced for neglecting to followstandardprocedure.Thus, over

Tips for Leading High-Performance Cultures •Createopportunities fordialogueandconversation to createbuy-

in for safebehaviors, andavoid relianceon rules andpolicies. •Use relationshipbuilding to strengthencommitment andbuy-in

rather than rules and logic.Respect andkeeping commitments is key. •Accept thatmistakes arenecessary for learningbecausepeople

learn throughaction.Apologize andmoveonwhennecessary. •Invent aprocess that acknowledges thatpeoplewilldrift fromthe

procedureandmanage theeffects. Leaderswantpeople to contribute their creativity to solveproblems, and theywant toavoiddisasters. •Communicate that youcare. It opens thedoor to collaboration

andacceptanceofnew ideas. Blame, guilt andpunishments increase resistance. •Consider how culture will impact the interpretation of messages.

Prepare thoughts and words carefully before delivering them at meetings and presentations. •Recognize that changegenerates anxiety. Planhowtomanage

yourownandsupport others inmanaging theirs. •Noticehowothers feel aroundyouandhowyourwordsare

interpreted.Get feedbackand respond.Donot take it personally. •Notice thatdepartments, professions and roles create subcultures.

Donot assume they share commonmeaning.Helpbridge thegap and translate. •Learn toviewpolarity andparadoxas anecessity to the success

of theorganization, stop trying to resolveor eliminate ambiguity. •Delve into thebeliefs andassumptionspeople areusing to tackle

problems.Aleaderhelpspeoplediscoverwhat couldwork,does workordoesnotworkbyaskingquestionsorproviding insight. Merebehavior change isnot enough.Extraordinary improvements come fromshifts inbeliefs about theway thingswork.

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Conclusion Aleader must be able and willing to look within

torecognizeanddispel thefalsebeliefs thatkeepone from seeing the truth. While doing so, s/he must remember that the truth is revealed in layers so that what seems to be true today can change when new evidence is revealed. People learn from action. Mis- takes happen. Letting go of self-blame and blaming others frees leaders to learn from the mistakes and continue to take the actions necessary to direct an organizationwith courageandcompassion. Managing, shapingandcreatingculture isa lead-

ershipcompetency.Someprinciplesandskills to ful- fill that competency are described in the cases presented. They demonstrate that culture is com- plex. Any attempt to work at the cultural level requires patience and willingness to make correc- tions and apologies along the way. The latter helps maintainthetrust levela leaderneedstobeeffective. It is thenatureof culture tobe stable andnot eas-

ilychanged.Groupswant toholdonto their cultural assumptions because culture provides meaning and makes lifepredictable.Anysweepingchangecreates ambiguity,whichpeopledonot likeandtrytoavoid. Usingexistingassumptions tocreate change reduces resistance. Itwouldbedifficult toemployanempow- erment approach in a hierarchical, command-and- control culture. These implications take on greater dimension inmulticultural environments. Thefindingsofmajor incident investigationspoint

to the fallacy of believing that rewriting, fixing and increasing rulesandprocedures is enough toprevent similar incidents. Clarifying and posting policies is helpful to those who write and discuss them. But by themselves, they represent a limited formof commu- nicationandtheyarenot the tools thatwill transform culture. That is much more likely to happen in the process of sensemaking, havingdiscussionsofdiver- gent viewpoints with people one trusts. These con- versations create a common understanding and the opening for a new belief. A belief is only accepted, however, once it is testedandprovensuccessful. Finally, much has been written about identifying

and letting go of dysfunctional beliefs as part of the process needed to maintain and create a positive safety culture. Organizations have strong positive assumptions that support this work as well. These mayincludeassumptionssuchas“everyonedeserves a safe and healthy workplace,” “everyone should go home intact,” and “no matter our differences we can agree that safety is important.” The differences appear to be in how these assumptions are acted on. With the information that culture change produces anxiety, perhaps it would be wise to point to these assumptionsandsay thatpeoplearenotbeingasked to change so much as they are being asked to align with others on their expectations for the best way to act fromthesepositiveassumptions. �

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