安全文化研究

1、V1.2Safety culture安全文化安全文化Dr. Mark FlemingSaint Marys Universitymark.flemingsmu.caV1.2Outline 大纲大纲Introduction and overview 介绍和概述介绍和概述Safety culture 安全文化安全文化Characteristics of positive safety culture 积极的安全文化的特点积极的安全文化的特点Safety culture development 安全文化培育安全文化培育Conclusions 结论结论V1.2High Reliability Orga

2、nisations高可靠性组织高可靠性组织Why Do Injuries Happen ?职业伤害为什么会发生职业伤害为什么会发生？HUMAN UNRELIABILITYconcentration, memoryDESIGN BOOBY TRAPS: hardware, proceduresOPERATING ENVIRONMENTtraining, supervision, resources, cultureCOMMUNICATIONassumptions, misunderstandings人不可靠注意力，记忆力设计陷阱：硬件，程序经营环境培训，监督，资源，文化沟通假设，误解V1.2Pi

3、per AlphaPiper Alpha钻井平台公众对Piper Alpha钻井平台灾难的质询V1.2It wont happen to me.When anyone asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. I have never been in an accident of any sort worth speaking about.I never saw a wreck and have never been wrecked,

4、 nor was I ever in any predicament that threatened to end in disaster of any sort.“当有人问我怎样才能最好地描述我在海上近当有人问我怎样才能最好地描述我在海上近40年的经历，我只是说平安无事年的经历，我只是说平安无事。在我身上从未发生过任何事故。我从未见过一个沉船事件，自己。在我身上从未发生过任何事故。我从未见过一个沉船事件，自己的船也从未沉过，我也从未陷入任何让我生命受到任何形式灾难的威胁的船也从未沉过，我也从未陷入任何让我生命受到任何形式灾难的威胁的困境。的困境。Edward J. Smith (Captai

5、n of the Titanic 泰坦尼克号船长)V1.2Piper AlphaIt is essential to create a corporate atmosphere or culture in which safety is understood to be and accepted as, the number one priority”对企业来说，营造一种氛围或文化是至关重要的对企业来说，营造一种氛围或文化是至关重要的。在这种氛围或文化中，安全被理解为，并且。在这种氛围或文化中，安全被理解为，并且被接受为头等重要的大事。被接受为头等重要的大事。(Cullen, 1990)V1.

6、2Safety management system not effective unless accompanied by a “good” safety culture Wish to stay alert to potential risk factors that increase the risk of a major disasterPro-active approach involving self-assessment and feedback of less visible elements of safety management systemDesire to win “h

7、earts and minds” to improve safetyAlternative, leading safety performance indicator安全管理系统不会有效，除非安全管理系统不会有效，除非 有有“良好的良好的”安全文化相伴随安全文化相伴随对会提高重大灾害的风险的潜在危险因素能一直保持警惕对会提高重大灾害的风险的潜在危险因素能一直保持警惕前瞻式方法涉及到自我评估和对安全管理制度较少的不可见的元素的反馈前瞻式方法涉及到自我评估和对安全管理制度较少的不可见的元素的反馈赢得赢得“人心和智慧人心和智慧”的愿望推动安全改进的愿望推动安全改进可选择的，引向安全绩效的指标可选择的

8、，引向安全绩效的指标Why focus on culture?为什么要关注文化为什么要关注文化V1.2Culture has been defined as: 文化被定义为：文化被定义为：A pattern of basic assumptions 一个基本假设的模型一个基本假设的模型Invented, discovered or developed by a given group由指定的一个团队发明、发现或开发由指定的一个团队发明、发现或开发Learnt from coping with problems of external adaptation and internal integr

9、ation 从处理外部适应性问题和内部整合问题中学习从处理外部适应性问题和内部整合问题中学习That has worked well enough to be considered valid 运行良好，足以被认运行良好，足以被认为是有效的。为是有效的。Is taught to new members (as the) 传授给新成员传授给新成员Correct way to perceive, think and feel in relation to problems 用正确的方法去感知、思考和感觉相关问题用正确的方法去感知、思考和感觉相关问题Schein 1990 p110Culture 文

10、化文化V1.2Elements of the culture 文化的要素文化的要素Basic assumptions: 基本假设基本假设Represent a system of shared meaning that is difficult to verbalize. Shared values that guide decision making.代表一个难以用语言表达的共享意义的系统。共享价值观指导决策代表一个难以用语言表达的共享意义的系统。共享价值观指导决策Espoused values 信奉的价值观信奉的价值观What people say is important express

11、ed through stories and myths人们通过故事和神话表达的内容是很重要的人们通过故事和神话表达的内容是很重要的Artefacts include: 人工制品包括人工制品包括Physical symbols e.g. status symbols, buildings, expected clothing, equipment and safety policies物理符号，如地位的象征，建筑物，预期着装，设备和安全政策物理符号，如地位的象征，建筑物，预期着装，设备和安全政策Behavioural norms e.g. greetings, gestures, ceremo

12、nies行为规范，例如打招呼，手势，仪式行为规范，例如打招呼，手势，仪式Iceberg model 冰山模型冰山模型基本假设信奉的价值观人工制品V1.2“The way we do things around here” CBI 我们做事情的方式我们做事情的方式“Safety culture is that assembly of characteristics and attitudes in organizations and individuals which establishes that as an overriding priority, nuclear plant safety

13、 issues receive the attention warranted by their significance” p1 INSAG-4. 1991安全文化是组织中特征和态度的集合，并且人们把它视为绝对优先的事情。核电厂的安全安全文化是组织中特征和态度的集合，并且人们把它视为绝对优先的事情。核电厂的安全问题由于其重要性得到重视。问题由于其重要性得到重视。“Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared

14、perceptions of the importance of safety and by the efficacy of preventive measures.” ACSNI拥有积极的安全文化的组织拥有如下特征：建立在相互信任基础之上的沟通，对安全的重拥有积极的安全文化的组织拥有如下特征：建立在相互信任基础之上的沟通，对安全的重要性有共同的看法，以及预防措施的有效性。要性有共同的看法，以及预防措施的有效性。Safety Culture: What Is It ?安全文化，它是什么？安全文化，它是什么？V1.2Safety culture and outcomes安全文化和结果安全文化和结

15、果Safety culture questionnaire responses have been linked with accident rates in the following industries:在下列行业中，安全文化问卷的回答与事故率相联系在下列行业中，安全文化问卷的回答与事故率相联系Nuclear power (Lee, 1998) 核电站核电站Offshore oil (Mearns, Flin, Fleming & Gordon 1997) 海上石油海上石油Chemical industry, (Donald & Canter, 1994) 化学工业化学工

16、业Manufacturing, (Brown & Holmes 1986), (Zohar, 2000) 制造业制造业Safety culture has been identified as a causal factor in:在下列事件中，安全文化已被确定为一个原因因素：在下列事件中，安全文化已被确定为一个原因因素：Chernobyl 切尔诺贝利切尔诺贝利Bhopal 博帕尔博帕尔Space shuttle Challenger and Columbia 挑战者号和哥伦比亚号航天飞机挑战者号和哥伦比亚号航天飞机V1.2Comparison of Chinese with US N

17、ationals 中国人与美国人的比较中国人与美国人的比较NationalityChineseExpatriatRules less importantImportance of heirarLanguage DifficultyJob clarityWork PressureReluctance to speakProductivity vs safeSupervisionRules & RegulationsSafety on rigRisk behaviour.6.4.20.0-.2-.4-.6中国人外国人规则没有那么重要层级的重要性语言困难冒险行为装备安全规章制度监督效率与安全

18、工作明确工作压力不愿意说话V1.2Main findings 主要发现主要发现No difference in self reported risk taking behaviour 在自我报告冒险在自我报告冒险行为方面没有区别行为方面没有区别Chinese staff valued hierarchy to a greater extent than expatriate staff与外籍员工相比，中国员工更加重视层级与外籍员工相比，中国员工更加重视层级Chinese staff indicated that rules were of less importance than gettin

19、g the job done中国员工指出，相对于把工作完成，规则没有那么重要中国员工指出，相对于把工作完成，规则没有那么重要Findings indicated that safety could be improved by using hierarchical structures to reinforce the importance of following rules结果表明，通过层级结构来强调遵守规则的重要性可以让安全得到改进结果表明，通过层级结构来强调遵守规则的重要性可以让安全得到改进Characteristics of a strong safety culture强有力安全文

20、化的特征强有力安全文化的特征Safety is learning driven 安全受学习驱动Safety is a clearly recognized value 安全是被清楚认识到的价值观Accountability for safety is clear安全责任明确 Safety is integrated into all activities 安全被纳入所有活动Leadership for safety is clear安全领导力明确 IAEA five characteristics of a strong safety culture 强有力安全文化的五个特店强有力安全文化的五

21、个特店V1.2Safety is a clearly recognised value 安全是一个被清楚地认识到的价值观安全是一个被清楚地认识到的价值观It is clear to everyone that safety is the top priority. 每个人都清楚，安全是首要任务每个人都清楚，安全是首要任务The importance of safety is demonstrated by 安安全的重要性从如下两个方面得以展现全的重要性从如下两个方面得以展现 the decisions managers make and 管理者所做的决策管理者所做的决策 how manager

22、s allocate resources. 管理者如何分配资源管理者如何分配资源V1.2Leadership for safety is clear安全领导力是清晰的安全领导力是清晰的Managers take every opportunity to demonstrate their commitment to safety.Leaders across the organization are actively involved in safety and act as role models for others. Leadership skills are actively deve

23、loped 管理人员利用一切机会展示他们对安全的承诺。管理人员利用一切机会展示他们对安全的承诺。整个组织的领导们都积极参与安全活动，并成为其他人的榜样。整个组织的领导们都积极参与安全活动，并成为其他人的榜样。领导技能得到积极开发领导技能得到积极开发V1.2Accountability for safety is clear对安全的责任是清晰地对安全的责任是清晰地 There are clear lines of authority for safetyEveryone is aware of their specific tasks and responsibilities. Everyone

24、 feels ownership for safety within their span of control. The independent and distinct role of the regulator is understood and respected. 安全的权限很清晰安全的权限很清晰大家都知道他们的具体任务和责任。大家都知道他们的具体任务和责任。每个人都感到自己能要对其所控制范围的安全负责每个人都感到自己能要对其所控制范围的安全负责监管者的独立和独特作用得到理解和尊重监管者的独立和独特作用得到理解和尊重V1.2Safety is integrated into ever

25、ything 安全要纳入到所有活动中安全要纳入到所有活动中Safety is an approach to doing things rather than an activity; therefore it is part of all activities. An operation or task is only a success if completed safely. Factors that influence performance such as motivation are acknowledged to influence safety outcomes 与其说安全是一项

26、活动，不如说安全是一种做事的方法，因此它是所有与其说安全是一项活动，不如说安全是一种做事的方法，因此它是所有活动的一部分。活动的一部分。一个操作或任务只有在安全完成的情况下才是成功的一个操作或任务只有在安全完成的情况下才是成功的影响绩效的要素，例如动机，被公认是影响安全结果的。影响绩效的要素，例如动机，被公认是影响安全结果的。V1.2Safety is learning driven安全是学习驱动安全是学习驱动Striving for continuous improvement. Learning drives improvement. Actively seeking out lesson

27、s from operational experience and conducting self assessments. Seeking to understand both failure and success in order to improve. Encouraging reporting all failures追求持续改进。追求持续改进。学习驱动改进。学习驱动改进。积极从运行的经历中找出教训，并进行自我评估。积极从运行的经历中找出教训，并进行自我评估。为了改进，争取对失败和成功都进行了解为了改进，争取对失败和成功都进行了解鼓励报告所有失败鼓励报告所有失败V1.2Safety

28、culture maturity安全文化发展阶段安全文化发展阶段Safety culture development is broken down into five stages or levels of maturity, from poor to goodA number of similar models currently in use (e.g. hearts and minds, shell)Once the level has been established sites identify the actions required to move to the next lev

29、el安全文化的发展分为五个阶段或成熟水平，从差到好安全文化的发展分为五个阶段或成熟水平，从差到好目前有几个类似的模型在使用目前有几个类似的模型在使用一旦水平被确定下来，组织就需要确定要达到下一个水平所需要采一旦水平被确定下来，组织就需要确定要达到下一个水平所需要采取的措施取的措施Pathological Pathological 病态的病态的Level 1Reactive Reactive 反应式的反应式的 Level 2GenerativeGenerative内在的内在的 Level 5Bureaucratic Bureaucratic 官僚式的官僚式的 Level 3ProactivePr

30、oactive前瞻式的 Level 4改善安全文化改善安全文化计划落实评估监督V1.2Pathological 病态病态Why waste our time on safety? 为什么要在安全上为什么要在安全上浪费我们的时间？浪费我们的时间？Effort is focused on avoiding getting caught努力的重点是避免被抓到努力的重点是避免被抓到Loyalty and conformity is maintained through intimidation 通过恐吓保持忠诚和一致性通过恐吓保持忠诚和一致性Reaction to problems 对问题的反应对问题

31、的反应 Suppression 抑制抑制 Encapsulation 封装封装V1.2Reactive 反应式的反应式的We do something when we have an incidentInformation is controlled Information is manipulated to ensure we conform to organisational standards (e.g. target incident rate)We focus on finding who is at fault and using appropriate disciplineInc

32、idents appear to be random当有事故发生时，我们才做一些事情当有事故发生时，我们才做一些事情信息被控制信息被控制 信息被操纵，以确保我们符合组织标准（例如事故发生率目标）信息被操纵，以确保我们符合组织标准（例如事故发生率目标）我们关心的是发现是谁的错，并且使用相应的惩罚措施我们关心的是发现是谁的错，并且使用相应的惩罚措施事故的出现是随机的事故的出现是随机的V1.2Bureaucratic 官僚式的官僚式的We have systems in place to manage all likely risksInformation supports departmental

33、 interests, to make the department look good, to support departmental objectivesInformation flow is managedReaction to incidents Local fix: treats symptoms not root cause我们已建立各种制度来管理所有可能的风险我们已建立各种制度来管理所有可能的风险信息支持部门利益，信息支持部门利益， 使该部看上去不错，支持部门目标使该部看上去不错，支持部门目标信息流被管理信息流被管理对事故进行反应对事故进行反应局部整改：治标不治本局部整改：治标

34、不治本V1.2Proactive 前瞻式的前瞻式的We are always on the alert for risks that might emerge Information is important and we work hard to capture it and understand what is going on.Our outcomes are better that our industry averageStill surprised by some events我们对可能出现的风险总是很警惕我们对可能出现的风险总是很警惕信息是重要的，我们总是很努力掌握信息，并了解正

35、在发生的事情。信息是重要的，我们总是很努力掌握信息，并了解正在发生的事情。我们的结果比行业平均水平要好我们的结果比行业平均水平要好对一些事件仍感到吃惊对一些事件仍感到吃惊V1.2Generative 内在的内在的We know why we do not have incidentsInformation supports the missionInformation flows freely, honesty is valuedResponse to incidents: Global fix: try to fix every example of a problem, share inf

36、ormation with other stakeholders Inquiry: Get to the root cause of problem我们知道我们为什么没有事故我们知道我们为什么没有事故信息支持使命信息支持使命信息自由流通，诚实得到欣赏信息自由流通，诚实得到欣赏对事故的反应：对事故的反应：全方位整改：尝试整改一个问题的每一个例子，与其他利益相关者共享信息全方位整改：尝试整改一个问题的每一个例子，与其他利益相关者共享信息调查：寻找问题的根源调查：寻找问题的根源V1.2Norms andBehaviour规范和行为规范和行为Safety安全安全Safety Interventions

37、安全举措安全举措Safety Culture安全文化安全文化Enabler/Barrier促成要素促成要素/障碍要素障碍要素Culture and Safety 文化和安全文化和安全V1.2SafetymountainWhere are you? 你在哪里你在哪里Pathological病态的Reactive 反应的Bureaucratic 官僚的Proactive 先行一步的Generative内在的Improvement Orientated以改进为导向的Status Quo 现状V1.2Review systems that drive culture审视驱动文化的制度审视驱动文化的制度

38、SCM Improvement Process (SCMIP) developed to assess culture without the need to survey workersSCM改进过程改进过程Rational for SCMIPEmployee perceptions are based in reality i.e. perceptions of management commitment reflect their interactions with managersOrganisations with different cultures have different

39、practicesSafety culture improvement involves system changee.g. perceptions of management commitment is improved through training and evaluating leadership practices 所开发的所开发的SCM改进程序可以评估文化，不需要对工人进行调查改进程序可以评估文化，不需要对工人进行调查 SCMIP 的合理性的合理性 -员工的认知是基于现实员工的认知是基于现实 例如对管理层承诺的认知例如对管理层承诺的认知 反映了反映了他们与管理者之间的互动关系他们

40、与管理者之间的互动关系-组织文化不同，做法就不同组织文化不同，做法就不同-安全文化的改善涉及制度安全文化的改善涉及制度变革变革 例如管理例如管理层承诺的理念层承诺的理念通过培训通过培训和和评价领导力评价领导力的的实践实践得到提升得到提升V1.2Sample: Commitment to safety范例：对安全的承诺范例：对安全的承诺Managers Visiting the WorksiteSelect level打分打分Managers do not visit worksite to specifically discuss safety0Managers visit worksite

41、regularly to discuss safety as specified by a formal policy/ program (e.g. STOP）1There is a formal manager worksite visit program that specifies the number of visits to be conducted by each manager and tracks completion.2There is a comprehensive program that specifies how to perform a worksite visit, trains managers how to conduct a visit, evaluates managers to ensure they are competent and tracks frequency of visits and close out of actions.3There is a comprehensive program described above plus the quality of the managers visits is evaluated by