See all the amazing photos here: http://cryptome.org/2012-info/costa-concordia/0041.htm
Culture not Rocks Sink Ships
Another guest post by Dr Robert Long – If you liked this article then you should read the whole series: CLICK HERE
These amazing photos of the Costa Concordia are a stark reminder that poor safety culture sinks ships.
The picture of the large rock jammed in the hull has captured the moment when the psychological and cultural factors of this event came together. Incidents and accidents are rarely about failed technology, but rather a complex web of cultural and psychological factors. The 10 organisational dimensions of safety culture are:
1. Leadership (Sensemaking)
2. Preparedness (Mindfulness)
3. Thinking and Practice (Cognitive Dissonance)
4. Influences (Psychosocial Triggers)
5. Systems
6. Core Vision
7. Priorities
8. Learning Capacity (Resilience)
9. Competence
10. Actions
These organisational factors operate at three levels: primary-physical; secondary-psychological and tertiary-cultural. Secondary and tertiary levels operate ‘below the line’, see Figure 1. Secondary and tertiary levels are mostly unseen. They are embedded in implicit (gut) knowledge ‘under the surface’ and become apparent in times of turbulence. It’s only when implicit knowledge is extracted by physical events that we see the results of poor safety culture. Unfortunately by then, it’s all too late.
Much more work should be done by organisations to assess safety culture and attending to safety cultural challenges as a normal course of operations. This is what Prof Weick (2001) means by Managing the Unexpected. Weick’s definition of mindfulness means much more than just ‘having your wits’ about you. Mindfulness is about:
- Preoccupation with failure;
- Reluctance to simplify interpretations;
- Sensitivity to operations;
- Commitment to resilience; and
- Deference to expertise.
Weick calls mindful organisations, High Reliability Organisations (HROs).
The Human Dymensions MiProfile safety culture survey assesses the HRO health of an organisation on a 30 point scale. MiProfile assesses implicit knowledge at three levels across 10 organisational factors. The MiProfile methodology is downloadable off the Human Dymensions website. The following matrix at Table 1 indicates the structure of the MiProfile survey:
Table 1. MiProfile Safety Culture Survey 30 point structure
| Organisational Factors | Physical (Primary) | Psychological (Secondary) | Cultural (Tertiary) |
| Leadership (Sensemaking) | |||
| Preparedness (Mindfulness) | |||
| Thinking and Practice (Cognitive Dissonance) | |||
| Influences (Psychosocial Triggers) | |||
| Systems | |||
| Core Vision | |||
| Priorities | |||
| Learning Capacity (Resilience) | |||
| Competence | |||
| Actions |
The 30 point scale rating provides organisations with a HRO health score. Based on the score and recognised areas of challenge, organisations can develop an evidence-based safety culture program. If your organisation already has a safety culture program, the matrix can serve as a format for gap analysis. The matrix is also a useful structure for incident investigation.
You can see a video demonstration of MiProfile at: http://vimeo.com/24764673
As is often the case with accident investigations much energy is devoted to individual blame, physical circumstances, systems error, human error (whatever that means), denial, defensiveness, smoke screens and spin. None of these will bring back the lives lost or ruined by this tragedy and will hardly provide effective analysis of safety culture.
The evidence of poor safety culture is apparent even in the latest news reports including a recording between Livorno port officials and Captain Francesco Schettino. In this recording 30 minutes after the grounding of the vessel the Captain is heard in default (implicit) mode already in denial. What kind of safety culture automatically defaults to denial in times of turbulence and crisis?
Figure 1. Primary, Secondary and Tertiary Hazards and Risks
Author’s Resource Box
Dr Robert Long
PhD., (UWS) BEd., (USA) BTh., (SCD) MEd., (Syd) MOH (La Trobe), Dip T., Dip Min., MACE, CFSIA.
Executive Director – Human Dymensions Pty Ltd
Rob has a creative career in teaching, education, community services, government and management.
Rob is engaged by organisations because of his expertise in culture, learning, risk and social psychology. He is a skilled presenter and designer of learning events, training and curriculum.
Web Link: www.humandymensions.com
Blog: http://web.me.com/robertlong2/HDblog/Blog/Blog.html
{ 2 comments… read them below or add one }
Well said Gene, I am sure there will be many more cultural questions like this which will emerge in the coronial inquiry.
Indeed.
What kind of organizational culture promotes to captain a man whom his supervisor described as a ‘daredevil, who drove the ship like a Ferrari?’
What kind of a culture permits the captain to depart Marseilles a month earlier, in 60 knot winds, over the prohibition of the harbor master?
What kind of culture permits a captain to remain the captain of a 114,000 ton ship, with 4200 souls in his care, if he is described as an ‘authoritarian manager, such that no subordinate could get their voice heard?’
What kind of culture manages ‘not to know’ when his own crew members describe him as ‘reckless’?
What kind of culture selects for a captain a man who, in a time of grave emergency, descends into denial, and then leaves the ship before all the passengers are safe? Did they really not know? Or did their process select *for* such a man? In either case, why?