Creating and sustaining a safety culture: Some practical strategies

Ashleigh Merritt & Robert L. Helmreich

NASA/UT/FAA Aerospace Crew Research Project

Austin TX USA[1]

The word “culture” is being used a great deal in aviation these days. In addition to discussing the influences of national, organizational and occupational cultures, some researchers, regulators, and industry officials are now advocating a safety culture (Lauber, 1994; Maurino, 1994; Meshkati, 1995). But what is culture, and why is it important in aviation? What is a safety culture, and how does it differ from a safety initiative or a safety system? I think it is necessary to define culture and understand its parameters if one is ever to create or sustain a safety culture.

A Definition of Culture

Culture can be defined as the values, beliefs, rituals, symbols and behaviors that we share with others that help define us a group, especially in relation to other groups. Culture gives us cues and clues on how to behave in normal and novel situations, thereby making the world less uncertain and more predictable for us. There are two important and distinct components of culture. The surface structure, or outer layer of culture consists of observable behaviors and recognizable physical manifestations such as members’ uniforms, signs and logos, and documents. The deep structure, or inner layer of culture, consists of the values, beliefs and assumptions which underlie the surface structure and provide the logic which guides the members’ behaviors. Cultural misunderstandings occur when people interpret the surface structure of another culture from the vantage point of their own cultural logic or perspective. Ethnocentrism occurs when behavior from one culture is judged to be inferior by the values of another culture.

We all experience multiple cultural influences upon our lives deriving from our membership in national, organizational and vocational cultures. When these cultures are congruent, there is no uncertainty or hesitation - we know how to proceed because the underlying values and beliefs are sending us convergent messages. But when these cultures are in conflict, we become unsure of how to proceed or behave. The hesitation and uncertainty arising from divergent cultural messages can cause confusion, frustration, and even conflict, especially in emergencies and other time-pressure situations.   For example, some pilots at a regional airline recently refused to fly because they were concerned about the safety of an aircraft in icing conditions. The pilots’ professional culture was at odds with the organization’s demands. In aviation, the result of cultural incongruity is compromised safety. Pilots and other employees on the aviation “front line” do not need conflicting messages on how to behave and proceed.

Organizational Culture

While national culture is undoubtedly an important influence in aviation (Johnston, 1993; Maurino, 1994; Merritt, 1994), it is the organizational culture which ultimately shapes the perception of safety, the relative importance placed on safety, and members’ activities regarding safety. Every person brings their history and multiple cultural memberships with them to the company, hence an organization consists of many sub-cultures based on profession, work history, position, location, gender, age, and nationality, to name a few. The existence of so many organizational sub-cultures is not detrimental to the company, as long as these cultures are united by common values and beliefs represented in the organizational culture. An integrated organizational culture can be characterized by sub-group co-operation, a strong corporate identity, a positive organizational climate and high employee morale, all of which create a positive impact on service and safety. A discordant organizational culture on the other hand is characterized by a weak corporate identity, sub-group divisiveness, a negative organizational climate and poor employee morale, all of which creates a negative impact on service and overall safety standards.

    

If organizational culture has the potential for the greatest impact on safety, and an integrated organizational culture is preferable to one that is discordant, then strategies are needed which address two issues. The first more general approach aims at unifying and strengthening the organizational culture; the second aims to introduce safety as a shared value which will provide the underlying logic directing all members’ behaviors. Recall that the definition of culture involves the observable behaviors and the underlying values and beliefs. A safety culture is more than a group of individuals enacting a set of safety guidelines - it is a group of individuals guided in their behavior by their joint belief in the importance of safety, and their shared understanding that every member willingly upholds the group’s safety norms and will support other members to that common end.  

The Role of Management

The senior management plays such a crucial role within the organizational culture, that before outlining some practical strategies, I believe it is necessary to briefly address its role. First and foremost, senior management is a part of, not apart from, the culture. Management does not look down upon the organization and direct it by edict, rather it influences the culture as a participating component of the culture. It is the actual and not the espoused management practices that are noted by others in the culture. Hence, there is no point in appointing a Safety Officer if that officer is “in name only” without the discretionary powers required to enact and enforce safety policies. If employees observe management condoning or indirectly promoting something unsafe, then they lose faith in the system. Worse still, there is no redemption for senior managers who convince employee groups to accept a 5% pay cut, and then award themselves bonuses. No amount of rhetoric can undo the damage done to the culture by this action. When employee groups feel that they can not trust management, they will reject with suspicion any new initiatives. The first task for management is to gain and keep the trust of their employees.

It is also management’s responsibility to provide leadership and a common vision which unifies the cultural sub-groups. Management that uses a “divide and conquer” strategy with its employee groups gets exactly that, a divided and ultimately defeated organization. In at least two airlines that I am aware of, management announced the pilots’ salaries to other employee groups as a strategy to intimidate the pilots at salary renegotiation time. The net result has been complete sub-group divisiveness - the ground personnel are not prompt at push-back, gate agents are civil but uncooperative, and the pilots feel isolated and attacked. And everyone mistrusts management!

Given the unique role of management in culture, as the group centrally positioned to influence and unite all other groups, many cultural strategies originate with and/or require the full enthusiasm of management. But before any action can be taken, to strengthen or alter the culture, there must be a clear perception of the existing culture. What is the present culture? Is it united or divided against itself? What are the behavioral manifestations, and the underlying values and beliefs that are guiding work behaviors, particularly those relating to safety? There are several ways that these cultural understandings can be reached, ranging from a one day focus group with participants from all areas of the organization (Schein, 1992) to ethnographic investigations requiring several months (Trice & Beyer, 1993).

The NASA/UT/FAA research group has adopted a mixed methodology of empirical questionnaires, observations, and interviews to understand organizational and national cultures. The expanded Flight Management Attitude Questionnaire includes Human Factors items and organizationally specific items about safety practices, interactions with other employee groups (including management and the training department), and some open-ended questions which prompt respondents for their opinions about perceived weaknesses in the airline and suggestions for improvements. The Line/LOS Checklist is used to systematically observe and evaluate on-line behaviors across different phases of flight or work-cycle. Members of our research group train and calibrate members of the organization in the use of the Line LOS checklist, followed by a month of jump-seat observations across all fleets and routes. The interviews allow participants to voice opinions which the researchers might otherwise miss.

While the checklists provide information about the observed behaviors, the interviews and the open-ended questions probe the underlying beliefs and values. Once the information has been collected and analyzed, a meeting of all interested parties (management, trainers, researchers) is then scheduled to discuss the findings. Once the culture is known unto itself via this three-pronged analysis, it can be compared with an ideal safety culture, and interventions can be designed to meet the perceived shortfalls.

Strategies for Cultural Unification and Change

Management can direct cultural shift by articulating the desired values, and reinforcing the appropriate norms, but again, the efforts of management in this direction must be sincere. While it may be possible for management to direct people to change their work behavior, management can not direct people to change their values. Without the underlying values in place to guide the behavior, behavior shifts will be short-lived. This is one of the truest and at the same time most frustrating aspects of culture - change is slow. Having said that however, it is possible to signpost the path to cultural change in several ways.

Role models

Managers, chief pilots, check and training captains, gate managers and pursers are all role models. If these people understand and support the desired values, they are in a better position to transmit these values and practices to others. As such, the organization’s role models should be active promoters of the culture and its desired outcomes. By that I mean firstly they should internalize those values, and secondly they should be consistently available and responsive to all employees who query or challenge the company’s values and norms.

New Member Socialization

New-hires (who by definition are seeking cultural membership) can be quickly and successfully socialized into the organization in very direct fashion. Rather than leaving the new member to discover the organizational norms through observation, trial, and error, a mentoring system allows a senior person to explain the culture to the newcomer. By explaining the airline’s history, its present focus, its quirks and idiosyncrasies, its successes and challenges, the senior person socializes the newcomer to the airline’s culture. The senior person is also available to explain why something is done the way it is, thereby revealing the underlying or implicit structure of the company. Published histories and guidelines also provide the newcomer with the “company line” - what it means to be a member of the culture. Because first impressions influence later beliefs, successful socialization acts as a cultural shortcut, the most direct route to strong cultural membership.

Organizational Language

Language encodes and reveals values, hence it provides another opportunity for management to strengthen the culture by articulating the values and publishing the norms. For example, does the management send a divisive “us and them” message or an integrated “we” message in its intracompany communications? Do the operations manuals clearly articulate the desired norms and behaviors or are they too vague and/or disjointed in their specifications? Guidelines should be published and posted publicly and repeatedly as visual reminders of the cultural norms. As well as the formal language of the organization, there are also stories and myths about “heroic founders”, employees who “went the extra mile”, or “how we overcame early adversity” which all reflect and perpetuate the culture. These anecdotes are powerful transmitters of values, extolling the culture with every recounting.

Make the Membership Attractive

Making the cultural membership more attractive unites the cultural subgroups and creates a proud and motivated workforce. While this can be done with financial incentive programs like profit-sharing, it can also be achieved with an early success or the presence of a common enemy. Everyone wants to be on a winning team - it encourages greater striving. At the same time, group membership can be strengthened in the face of opposition. The common enemy might be a competitor, or “hard times” to be survived - something against which the group can strive.

Be Proactive

With regard to safety, it is important to be proactive, rather than waiting for incidents and then reacting in a band-aid fashion. To this end, periodic safety audits can identify weaknesses in the system. The philosophy of blame and punishment is divisive and creates sub-group defensiveness. An integrated approach uses system-wide investigation and remediation aimed at upholding a shared value, i.e., system wide safety. To that end, the organization needs to encourage and reward vigilance and inquiry from all its members (Meshkati, 1995), seeking to mend the system rather than killing the messenger.

Capitalize on Timing   

As stated earlier, cultural change is slow and can not be cynically manipulated. Nonetheless, it is possible to capitalize upon propitious moments to advance the desired values and norms. It may involve the open discussion of incidents and safety breaches as they occur. It may also involve the very public announcements of organizational successes. An organization can capitalize upon moments in its daily life which “tell the stories” of its culture.

CRM in the Safety Culture

 

As a final summary, let’s consider Crew Resource Management from the perspective of a safety culture. The allocation of resources (money and people) for CRM training sends a clear message from management about the value they place on the training. When the airline’s role models actively endorse CRM, the behaviors discussed in training are reinforced on the line, becoming a behavioral norm. New-hires are paired with mentors who are strong believers in CRM, and they learn quickly. Management continues to send positive messages about CRM with its commitment to recurrent training, and repeated references to CRM in its publications. Stories begin to circulate of CRM successes, how CRM “saved the day”. Consider what Captain Al Haynes has done for the cause of CRM as a shared value within the pilot community. Since the UAL811 accident, the successful handling of which Captain Haynes attributed to his CRM training, Haynes has been mythologized and his exploits told and retold throughout the aviation community. In this way, the value of CRM is shared and reinforced. CRM becomes accepted to the point that to not actively support it is to risk being ostracized by other members of the culture. As CRM is integrated into the safety culture, CRM begins to “makes sense” - it provides the logic that guides members’ behavior. Eventually, when asked why CRM-related behaviors are practiced as they are, members will smile and answer “because it’s always been done that way”.

References

Johnston, N. (1993). CRM-Cross-cultural perspectives. In E. L. Wiener, B. G. Kanki, & R. L. Helmreich (Eds.), Cockpit Resource Management. San Diego, CA: Academic Press.

Lauber, J. (1994). Safety Cultures and the importance of Human Factors. CRM Advocate, 94 (4), 1-3.

Maurino, D. (1994). Cross cultural perspectives in Human Factors training: Lessons from the ICAO Human Factors Programme. The International Journal of Aviation Psychology, 4, 2, 173-181.

Merritt, A. (1994). Cross-cultural issues in CRM training. In Proceedings of the Sixth ICAO Flight Safety and Human Factors Regional Seminar and Workshop (pp. 236-243). Amsterdam, the Netherlands, May 17-19, 1994.

Meshkati, N. (1995). Cultural context of the Safety Culture: A conceptual model and experimental study. Presented at International Topical meeting, Safety Culture in Nuclear Installations, Vienna, April 1995.

Schein, E. (1992) (2nd. Ed.). Organizational culture and leadership. San Francisco, CA: Jossey Bass.

Trice, H. M., & Beyer, J. M. (1993). The cultures of work organizations. Englewood Cliffs, NJ: Prentice Hall.

 


[1] Presented at the Third Australian Aviation Psychology Symposium, Sydney, Nov. 20-24, 1995. The research reported here was supported by NASA-Ames Research Center Cooperative Agreement NC22-286, and by FAA Grant 92-G-017; Principal Investigator, Robert L. Helmreich.

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