Recent major rail incidents have caused considerable harm to people, property and reputations
When the derailment of 32 train cars of a freight train took place in Belford county, USA in August this year, preliminary investigations indicated that crew members mistakenly operated the train with the air brakes applied to several cars.
Last month, the Singapore metro system faced more than 20 hours of service delays. Initial investigations found that service disruption was caused by malfunctioning water pumps which led to flooding in a tunnel.
On the surface, it would seem that these incidents were caused predominantly by human error. Delving deeper, would evidence support these initial findings?
Holding it all together
Oftentimes slips, mistakes, lapses and violations are attributed solely to human error, but this is rarely a complete picture of the facts. There are latent causes: complexity of tasks, external distractions, poor procedures, poor training, poor capabilities and other complex organisational factors that lie beneath the surface.
A reoccurring reason for incidents is weak integration of the very things that smooth operations rely on: the human element, systems and procedures. These three factors need to come together, using organisational culture as the ‘bonding’ agent. Good organisational cultures enable seamless interaction, poor cultures create barriers.
After the incident: avoiding pitfalls
A typical reactive response to incidents is to identify and penalize the people involved. This is a flawed approach as it inadvertently creates a culture of blame and triggers undesirable events.
Employees will be tempted to cover up minor mistakes to avoid punishment. This in turn will create a poor safety culture, making the organisation vulnerable to larger and more dangerous safety incidents.
When things do not go according to plan, it is far more valuable for any organisation to review its organisational culture to understand underlying issues, rather than penalizing individuals.
Another typical action after incidents is the launch of investigations and audits to identify the weaknesses in procedures or systems. These often recommend process and system revamps, adding more checklists and steps to an already complex situation.
Facing a procedural quagmire, employees respond by using short cuts to achieve their tasks. There is no argument that it is beneficial to identify the weaknesses in procedures and system, but it is equally important to identify aspects of organisational culture that are preventing employees from following existing procedures and systems effectively and efficiently.
The constructs of organisational culture
The collective values, procedures, norms, traditions, beliefs and perceptions within an organisation are all latent factors that make up the organisational culture.
To create a productive, effective culture, it is necessary for any organisation to assess its current situation, and uncover and understand why things are done in the way they are done. Without any mechanism to monitor organisational culture, problems will only become visible when something goes wrong.
Another key factor affecting organisational culture is the country in which the organisation is established, causing an additional layer of complexity to global businesses. The renowned social psychologist Professor Geert Hofstede introduced several indices such as Uncertainty Avoidance (UAI), Power Distance (PDI) and Masculinity (MAS) to describe the culture of a country.
Individuals in countries with low UAI, such as Singapore (8) and Hong Kong (29), would often take risky/ challenging decisions compared to the individuals from countries with high UAI such as Japan (92) and France (86).
Organisations in high PDI countries would exhibit stronger hierarchy compared to the organisations in low PDI countries. Stronger hierarchy would suppress open discussions which could hinder safety communication in an organisation.
However, if the organisational culture is carefully tailored, it can create a sub culture which could overcome these effects or the culture of a country.
What we learned:
- human error is only the tip of the organisational iceberg
- latent, or hidden, factors are the patchwork of work culture. Culture is the glue that holds together the systems, processes and people that make up an organisation
- organisations need better responses to incidents to avoid further fuelling a poor safety culture, which could involve blaming, taking short cuts and eventually lead to larger and most harmful incidents
- organisational Culture Assessment brings latent issues to surface, showing the strong and weak cultural elements
- a robust approach to culture assessment and management brings widespread benefits, impacting profit, cost savings, employee engagement and organisational reputation.
Assessment and management
Having a mechanism to assess the organisational culture allows the organisation to effectively focus its improvement efforts on the elements yielding the greatest improvements to the organisational culture.
As any other periodical assessment method, organisational culture is cyclical. The frequency of assessment will depend on the magnitude of the issues related to organisational culture and the safety and risk commitment of the organisation itself.
The assessment cycle includes:
- setting up a health check and decision-making system
- developing a diagnosing method
- identifying improvement actions
- implementing those identified actions.
This cycle will repeat at a frequency defined by the organisation to assess the organisational culture and keep track of the effectiveness of the improvement efforts.
What good organisational culture looks like
The most immediate benefit of organisational culture assessment is that it provides a snapshot of the organisational culture, showing strong and weak cultural elements.
With this snapshot, the organisation is able to focus its efforts to improve weaker elements and promote a proactive approach to safety and risk management.
With time and persistence, safety and high-performance operations becomes everyone’s responsibility.
An engaged workforce
Collaboration among staff across seniorities and effective and efficient communication has become the essence for safe and reliable operation in a highly automated working environment such as modern railway systems.
A good organisational culture stimulates open communication about risk and safety in all levels of organisation. These discussions set effective strategic and tactical improvement objectives in terms of risk management, safety and operations.
Positive organisational culture motivates employees to carry out their work with higher level of risk awareness, putting a stop to risky working methods and corner-cutting, ultimately reducing the lost time to injuries and absenteeism.
It also promotes increased employee acceptance of new or changed procedures, greater ownership of decisions, and improved retention rates
It is widely known that a robust approach to assessing and maintaining an open, safety-first organisational culture will result in decreased incident rates. The digital era has transformed smartphones into megaphones, adding decibels upon decibels to one voice.
Any small incident will be posted to multiple social media platforms in a matter of seconds, damaging the hard-earned image of an organisation.
Having fewer incidents and ensuring reliable operations alone will help organisations to meet customer expectations and gain higher level of recognition from the general public.
Savings and profits
Good organisational cultures can produce financial gains. It would decrease the costs of incidents, compensations, service delays and lost working days.
Dr Thilina Weerasinghe, senior consultant at BMT, is a Human Factors expert with experience in Safety Climate assessment related activities for the rail, product design and power sectors. His areas of expertise include Human Factors & Ergonomics, Human Centred Design, Design Thinking, Product Design and Human Factors training to clients of different technical backgrounds.