Draft Safety Culture Definition and Framework Released

Transcription

1 31 Octber 2013 Draft Safety Culture Definitin and Framewrk Released The Natinal Energy Bard (NEB r the Bard) tday released a discussin paper titled Advancing Safety in the Oil and Gas Industry: Draft Safety Culture Framewrk. The NEB will be seeking cmments frm the public and industry n this bdy f wrk until January 30, The NEB, the Canada Nva Sctia Offshre Petrleum Bard, and the Canada-Newfundland and Labradr Offshre Petrleum Bard wrked tgether t prpse a cmmn draft Safety Culture definitin and a framewrk. This bdy f wrk was develped t prmte learning and a shared understanding f the emerging discipline f Safety Culture acrss the il and gas sectr in Canada. It is als intended t express the NEB s expectatins f its regulated cmpanies t build and sustain a psitive Safety Culture. The Bard began explring hw t advance Safety Culture in the il and gas industry back in Since that time, the NEB has cnsulted extensively with internatinal experts n the tpic f Safety Culture, including Dr. Mark Fleming frm Saint Mary s University in Halifax, in rder t gain a fuller understanding f what a healthy Safety Culture lks like in practice. The Bard als recently amended its Natinal Energy Bard Onshre Pipeline Regulatins t include requirements fr management system prcesses designed t supprt the develpment and maintenance f a healthy Safety Culture fr NEB-regulated cmpanies. Cmments and questins n the Draft Safety Culture Framewrk may be submitted t the NEB until 30 January 2014 using the fllwing methds: safetyculture@neb-ne.gc.ca Mail: Safety Culture Cnsultatin Attentin: Claudine Bradley Natinal Energy Bard 444 Seventh Avenue SW Calgary, Alberta T2P 0X8 Fax: r (tll free)

2 Backgrund ADVANCING SAFETY IN THE OIL AND GAS INDUSTRY DRAFT SAFETY CULTURE FRAMEWORK The perating envirnment f the Nrth American il and gas industry experienced a mnumental shift n 20 April 2010 with the blwut f an ffshre well in the Gulf f Mexic. Sadly, the accident killed 11wrkers. It als created the largest il pllutin disaster in United States histry. That event was fllwed by ther ntable incidents acrss Canada and the United States including several pipeline ruptures, spills, and explsins. As a result f these events and thers, Canadians have begun questining the inherent risks and benefits assciated with il and gas explratin, prductin, and transprtatin. Nw, mre than any ther time, there is grwing interest in what regulatrs are ding t prtect the public and the envirnment, and t ensure that bth regulatrs and energy cmpanies are demnstrating an unwavering cmmitment t safety. Safety includes safety f wrkers and the public, prcess safety, peratinal safety, facility integrity, security and envirnmental prtectin. Carefully designed and well-implemented management systems are essential t keep peple safe and prtect the envirnment. A management system is a set f interrelated r interacting prcesses and prcedures that rganizatins use t implement plicy and achieve bjectives. In high hazard industries such as the il and gas sectr, these bjectives are typically related t the management and reductin f peratinal risk. A management system includes the necessary rganizatinal structures, resurces, accuntabilities, plicies, and prcedures t achieve that bjective. A recent cmparative study 1 f several majr industrial accidents that ccurred between 1982 and 1995 indicated that mst f the affected rganizatins had management systems r prgrams develped; hwever they were nt effectively implemented r reviewed n a regular basis t ensure adequacy and effectiveness. The study fund that when majr accidents ccur, there is ften an bservable discnnect between the cmpany s visin and plicies (what they say) and their planning, implementatin, mnitring and review (what they actually d). The authrs f the final reprt shared several verarching lessns based n the findings f the study, including the cnclusin that management systems and persnal attitudes twards safety g hand-in-hand in creating rbust defenses t serius incidents. Similar findings have been eched in mre recent investigatin reprts. The Michigan il pipeline rupture and the Gulf f Mexic blwut investigatin reprts nted that safety management systems were nt effective, substantially increasing the negative effects f these incidents. Anther key finding f majr industrial accident reprts is a disturbing pattern f rganizatinal cultures that lack the cmmitment and necessary resurces t ensure that each emplyee and cntractr puts safety ahead f cmmercial pressures. There is clear evidence frm analysis f glbal incidents that safety culture is a key factr in mst high cnsequence accidents. This has highlighted the need fr cmpanies t develp a pervasive rganizatinal 1 Det Nrske Veritas. (2011). Majr Hazard Incidents: Arctic Offshre Drilling Review. 1

3 culture in which safety is a cre value and preeminent pririty demnstrated by all persnnel at all times. Fr this reasn, Nrth American il and gas regulatrs are cllectively seeking t advance safety culture in cncert with effectively implemented safety management systems. In May 2013, a special meeting f Nrth American il and gas regulatrs was cnvened in rder t discuss imprving safety and envirnmental utcmes by leveraging safety culture. This meeting included representatives frm the Natinal Energy Bard (NEB), Canada Newfundland and Labradr Offshre Petrleum Bard (C-NLOPB), Canada Nva Sctia Offshre Petrleum Bard (C-NSOPB), United States Bureau f Safety and Envirnmental Enfrcement (BSEE), and the United States Pipeline and Hazardus Materials Safety Administratin (PHMSA). Attendees discussed each ther s philsphical and practical apprach t safety culture advancement and assessment and explred pssibilities fr future cllabratin. The dialgue highlighted mre similarities than differences in the regulatrs perspectives n culture including their cllective desire t raise awareness f its imprtance in preventing adverse events. During that meeting, several pprtunities were identified by the regulatrs t mve a cncerted safety culture effrt frward, including: Building a shared understanding f the term safety culture amng regulatrs and regulated cmpanies; Articulating clear regulatry expectatins as they relate t safety culture; and Cllabrating n the develpment f reference and resurce material fr industry in rder t prvide clarity and cnsistency in terminlgy, and safety culture dimensins and attributes, where pssible. Fllwing that meeting, the NEB, C-NSOPB, and C-NLOPB established a technical wrking grup tasked with prpsing a cmmn draft safety culture definitin and a framewrk designed t capture critical cultural dimensins, attributes, and descriptrs. This discussin paper represents the first deliverable f that crdinated effrt. Its purpse is t prmte learning and shared understanding f this emerging safety discipline acrss the il and gas sectr in Canada. It is als intended t express these bards expectatins f cmpanies they regulate 2 t build and sustain a psitive safety culture while scrutinizing fr ptential cultural threats. What is Safety Culture and Why is it Imprtant? Culture influences what peple see, hear, feel, and say. Perhaps mst imprtantly, it influences the decisins and actins (behavirs) f peple in an rganizatin, and these 2 In Canada, frntier and ffshre il and gas activities are regulated, depending n lcatin, by three independent regulatrs under mirrred regulatry framewrks the C-NLOPB under the Canada-Newfundland Atlantic Accrd Implementatin Act, the C-NSOPB under the Canada-Nva Sctia Petrleum Resurces Accrd Implementatin Act r the Natinal Energy Bard, n frntier lands and ffshre areas nt therwise regulated under these jint federal-prvincial accrds, under the Canada Oil and Gas Operatins Act (COGOA). The Accrd Acts reflect the technical prvisins f COGOA. As a result, all f the ensuing regulatins prmulgated under these Acts have essentially the same technical basis. This makes regulatin f the il and gas industry, in all areas f the frntier and ffshre, technically cnsistent and similar frm regin t regin. 2

4 behavirs ultimately drive safety utcmes and perfrmance. A strng safety culture is ne in which: leaders demnstrate that safety is their verriding value and pririty; everyne is aware f knwn hazards while remaining vigilant t new threats; every emplyee feels empwered and rewarded fr making safe decisins; emplyees feel encuraged t reprt safety hazards, including instances where they have cmmitted an errr and intrduced a threat themselves; the mst junir emplyee wuld nt hesitate t take actin in respnse t a safety cncern withut fear f disciplinary actin r reprisal; the supervisr des nt have t be present fr smene t d the right thing; and the rganizatin is cntinually learning frm its wn and thers experiences with the gal f advancing safety. Leadership is key t establishing, fstering and maintaining a healthy safety culture. The attitudes f executive and senir management, their actins and decisins serve t shape crprate culture. Leadership uses its management systems plicies, pririties, prcesses, and prcedures t frmally cmmunicate its values and expectatins. Thrugh these mechanisms, executive management establishes the initial framewrk f the crprate culture. Where an rganizatin is strngly in tune with establishing and maintaining a psitive safety culture, it scrutinizes, as a nrmal business functin, every decisin t ensure that risk is cnsidered and managed apprpriately. It sets perfrmance measures that prvide a cmplete picture f the rganizatin s current state in rder t identify areas f weakness and t practively manage safety in advance f an incident. Majr Accidents in High Hazard Industries and the Rle f Safety Culture 3 In high hazard industries such as il and gas, there are tw kinds f accidents: accidents that happen t individuals and accidents that happen at an rganizatinal level. Individual accidents are mre frequent and f limited cnsequence, althugh the cnsequences can be significant t thse affected (e.g., wrker injury r fatality). Organizatinal accidents are rare but the utcmes can be widespread and catastrphic. In the il and gas industry, these accidents typically invlve prduct releases r spills, blwuts, explsins and fires. These accidents have multiple causes and cntributing factrs, and invlve many peple perating at different levels within the respective cmpanies. Organizatinal accidents pse the greatest risk t the safety f peple and the envirnment. 3 Reasn, J. (1997). Managing the risks f rganizatinal accidents. Burlingtn, VT: Ashgate Publishing Cmpany. 3

5 James Reasn, a well-respected psychlgist wh studies accident causatin, has develped a mdel cmmnly referred t as the Swiss Cheese mdel (Figure 1). It is widely used t explain hw an accident trajectry frms prir t an rganizatinal accident. Reasn s mdel cntends that defense against rganizatinal accidents requires several layers f verlapping and mutually supprting prtectin. Prtectin layers are technical, rganizatinal and peple-based cntrls such as technical devices, physical barriers, prtective equipment, system design, regulatry surveillance, rules and prcedures, training and supervisin. The risk f a majr accident ccurring is determined by the quality f an rganizatin s prtective layers. When rganizatinal deficiencies develp, the resulting hles impair the safety system s integrity ver time. These vulnerabilities can lead t the system being breached by varius hazards r threats. A number f seemingly insignificant failures and breaches in each prtective layer may create an accident trajectry resulting in catastrphic lsses (human and envirnmental). An rganizatin s safety culture is the ne element that influences the quality f all prtective layers in the safety system. Safety Culture Framewrks There are many cnceptual framewrks used t describe safety culture and its characteristics. James Reasn describes three characteristics f a psitive safety culture 4 : 1. The rganizatin has a gal f maximum safety 2. The rganizatin is nt cmplacent and demnstrates a cntinual respect fr threats t its defenses 3. The rganizatin sustains a state f intelligent and respectful wariness thrugh gathering the right kinds f data This means [crprate leadership] creating a safety infrmatin system that cllects, analyses and disseminates infrmatin frm incidents and near misses, as well as frm regular practive checks n the system s vital signs. All f these activities can be said t make up an infrmed culture ne in which thse wh manage and perate the system have current knwledge abut the human, technical rganizatinal and envirnmental factrs that determine the safety f the system as a whle. 4 Reasn, J. (1998). Achieving a safe culture: thery and practice. Wrk and Stress, vl.12, n. 3, pp

6 Reasn s framewrk suggests that a psitive safety culture is an infrmed culture in which everyne understands and is wary f hazards in the perating envirnment. In rder t have an infrmed culture, an rganizatin must als have several supprting sub-cultures (briefly described belw). 1. Reprting Culture - A reprting culture is ne where peple have cnfidence t reprt safety cncerns withut fear f blame. Emplyees knw that cnfidentiality will be maintained and that the infrmatin they submit will be acted upn. 2. Learning Culture - A learning culture is ne where the rganizatin is able t learn frm its mistakes and adverse events (and thse f thers) and take apprpriate actin t address lessns. 3. Just Culture - A just culture is ne where errrs and unsafe acts are nt punished if the errr was unintentinal. Hwever, thse wh act recklessly r take deliberate and unjustifiable risks will be subject t disciplinary actin. In additin t an infrmed culture, Reasn suggests that a psitive safety culture requires a flexible culture where the rganizatin and the peple in it are capable f adapting effectively t changing demands. The rganizatin must have mechanisms in place t manage cmplex technlgy, and t cnstantly meet the fluctuating demands n its industry. All rganizatins in high hazard industries have a safety culture t sme degree r anther. While sme may have healthy and psitive cultures, thers may have pr r degrading cultures. Negative safety culture dimensins attack the rganizatinal safety system s cntrls and increase the likelihd that there will be weaknesses and resulting failures. In recgnitin f this phenmenn, Reasn identifies a series f cultural threats that act t degrade existing safety defenses. Specifically, he references wrk pressure, cmplacency, nrmalizatin f deviance, and tlerance f inadequate systems and resurces. These cultural threats are nt simply the absence f psitive safety culture dimensins but unique and separate dimensins that increase the risk f an rganizatinal accident ccurring. A recent study by Dr. Mark Fleming, wh hlds the CN Prfessrship in Safety Culture, and Natasha Sctt f St. Mary s University used Reasn s framewrk t review 17 majr petrchemical accidents that ccurred between It nted that pr safety culture cntributed t 14 f the 17 accidents and identified several recurring cultural threats, including: Tlerance f inadequate systems and resurces (identified ten times) Nrmalizatin f deviance (identified nine times) Cmplacency (identified eight times) Wrk pressure (identified fur times) 5. This review emphasized the imprtance f nt nly nurturing and advancing psitive cultural dimensins within an rganizatin, but als the need t practively identify and cmbat the negative cultural dimensins that impair safety perfrmance. A pr r degrading safety 5 Fleming, M. & Sctt N. (2012) Cultural disasters: Learning frm yesterday t be safe tmrrw. Oil and Gas Facilities, Vl 1, N 3 (June). Sciety f Petrleum Engineers. Hustn, Texas 5

7 culture is ne f the greatest latent threats needing t be managed if the rganizatin s prtective layers are nt t be undermined. A secnd well-accepted framewrk related t safety culture is that f High Reliability Organizatins (HROs). HROs such as air traffic cntrl peratins, naval aircraft carriers, and nuclear pwer peratins enjy a cntinuusly high level f safety perfrmance in perating envirnments that are characterized by uncertainty and threat. HROs cnsistently demnstrate a: Preccupatin with failure; Reluctance t simplify interpretatins; Sensitivity t peratins; Cmmitment t resilience; and Deference t expertise 6. These tw mdels prvided the fundatin fr the draft safety culture framewrk prpsed by the NEB, C-NSOPB, and C-NLOPB. The key elements f each are captured in the framewrk and augmented with ther ntable features. Develping the Draft Framewrk Safety culture framewrks serve t simplify and cmmunicate a cmplex cncept int distinct dimensins in rder t supprt its understanding and assessment. It is generally agreed that safety culture is a multidimensinal cnstruct, but there is less agreement abut its specific cmpnents. Sme framewrks cntain many dimensins (e.g. BSEE identifies nine) while ther mdels have fewer dimensins (e.g. Internatinal Atmic Energy Agency (IAEA) has five). This can be cnfusing and lead peple t cnclude that ne mdel is mre cmprehensive than anther. In general, the available framewrks are very similar, even when the number f dimensins varies cnsiderably. A clser review f several mdels used in the energy sectr reveals that the dimensins relate directly t ne anther. Fr example the BSEE dimensins envirnment fr raising cncerns and inquiring attitude are equivalent t the IAEA dimensin safety is learning driven (see Appendix A fr a cmparisn f varius framewrks). There is n ne crrect mdel, s it is imprtant t select a mdel r framewrk that wrks best fr the cntext in which it is t be used. Mdels with fewer dimensins tend t be mre generic and applicable t a wider range f situatins and are preferable if the mdel will be applied t different types f rganizatins (e.g. large and small). As the prpsed framewrk is intended t apply t several different types f cmpanies with peratins f varying size, scpe, and cmplexity, the prpsed number f dimensins was kept relatively limited. The draft safety culture framewrk is explained using three levels f detail: 6 Weick, K. & Sutcliffe, K. (2007). Managing the unexpected: Resilient perfrmance in an age f uncertainty. San Francisc, CA: Jssey Bass. 6

8 a) Dimensins represent high level safety culture characteristics; b) Attributes are intended t succinctly articulate the mst critical themes fund within each dimensin; and c) Descriptrs are detailed examples f hw the themes may be expressed within an rganizatin. Understanding and being able t recgnize bth psitive and negative dimensins f safety culture prvides great insight int a cmpany s vulnerability fr a catastrphic event. Fr this reasn, the prpsed framewrk includes bth psitive and negative cultural dimensins, attributes, and descriptrs. Draft Safety Culture Definitin and Framewrk The NEB, C-NLOPB, and C-NSOPB prpse the fllwing draft safety culture definitin fr public cmment: Safety culture means the attitudes, values, nrms and beliefs, which a particular grup f peple shares with respect t risk and safety 7. The draft safety culture framewrk being prpsed fr public cmment is cmprised f eight cultural dimensins. There are fur negative dimensins that act as threats t existing rganizatinal safety defenses: prductin pressure, cmplacency, nrmalizatin f deviance, and tlerance f inadequate systems and resurces. On the ther side f the spectrum, there are fur psitive dimensins that act as cultural defenses against these threats: cmmitted safety leadership, vigilance, empwerment and accuntability, and resiliency. These dimensins are shwn in the table belw. NEGATIVE DIMENSIONS (CULTURAL THREATS) Prductin Pressure Cmplacency Nrmalizatin f Deviance Tlerance f Inadequate Systems and Resurces POSITIVE DIMENSIONS (CULTURAL DEFENSES) Cmmitted Safety Leadership Vigilance Empwerment and Accuntability Resiliency 7 Mearns, K., Flin, R., Grdn, R. & Fleming, M. (1998). Measuring safety culture in the ffshre il industry. Wrk and Stress, 12(3), Safety includes safety f wrkers and the public, prcess safety, peratinal safety, facility integrity, security and envirnmental prtectin. 7

9 The draft framewrk can be best articulated by cnsidering the wrk f the dimensins in the cntext f James Reasn s Swiss Cheese mdel. In Figure 2, we see these negative dimensins acting as cultural threats that breach r degrade the prtective layers within the safety system. Figure 2. Safety Culture Mdel: Negative Cultural Threats Breaching Safety System Cnversely, in Figure 3, we see the psitive safety culture dimensins acting as verarching defenses, which act t deflect the cultural threats and reduce the risk that latent cnditins r active failures will impair the safety system. Figure 3. Safety Culture Mdel: Psitive Cultural Defenses Deflecting Cultural Threats 8

10 Detailed Draft Safety Culture Framewrk Cultural Threat #1: Prductin Pressure Prductin pressure ccurs when there is an imbalance between prductin and safety as leadership verly values prductin, such that the emphasis is placed upn meeting the wrk demands, schedule r budget, rather than wrking safely. Organizatinal gals and perfrmance measures are heavily weighted twards cmmercial and prductin utcmes ver prtectin and safety. Business strategy, plans, resurcing and prcesses fail t adequately address safety cnsideratins. Prductin Pressure Attributes: Leaders making decisins based upn shrt-term business bjectives withut sufficient cnsideratin f lng-term impact t safety utcmes Leaders failing t see the impact f their actins in erding safety as an rganizatinal value Descriptrs: 1. There are time and wrklad pressures because nt enugh time r resurces are assigned activities. 2. There are excessive budgetary pressures. 3. Leaders are less strict abut adherence t prcedures when wrk falls behind schedule. 4. Prject deadlines are set based upn verly ptimistic assumptins. 5. There are frequent prject verruns. 6. The cnstant tensin between prductin and safety results in a slw and gradual degradatin in safety margins. 7. Shrtcuts are necessary t meet unrealistic deadlines. 8. Rewards and incentives are heavily weighted twards prductin utcmes. Cultural Threat #2: Cmplacency Cmplacency ccurs when there is a widely held belief that all pssible hazards are cntrlled and the rganizatin has frgtten t be afraid resulting in reduced attentin t risk. The rganizatin views itself as being uniquely better (safer) than thers and as a result, des nt need t cnfrm t industry standards r best practices. This can be the result f an verreliance n ccupatinal injury data that leads them t errneusly believe that they are nt at risk fr a majr accident. The absence f a safety failure ver a perid f time results in a reductin f rganizatinal vigilance. Cmplacency Attributes: Overcnfidence in the safety system and its perfrmance The rganizatin s inattentin t critical safety data The rganizatin failing t learn frm past events 9

11 Descriptrs: 1. Safety data gathering is inadequate and may fcus n the wrng indicatrs r a limited set f indicatrs. 2. Perfrmance management, incentives and rewards are related t a limited set f safety indicatrs (e.g. ccupatinal injury rates). 3. Cntrl f risks is weak and/r reactive. 4. There is a sense f invulnerability at varius levels f the rganizatin. 5. Supervisrs d nt perfrm frequent checks t cnfirm that wrkers (including cntractrs) are beying safety rules. 6. The rganizatin nly seeks infrmatin t cnfirm its superirity. 7. The rganizatin discunts infrmatin that identifies a need t imprve. 8. There is n interest in learning frm ther rganizatins r industries. 9. Thse wh raise cncerns are viewed negatively. 10. Respnse t safety cncerns fcuses n explaining away the cncern rather than understanding it. 11. Investigatin f incidents is superficial with a fcus n the actins f individuals. 12. Failures are viewed as being caused by bad peple rather than system inadequacy. Cultural Threat #3: Nrmalizatin f Deviance Nrmalizatin f deviance ccurs when it becmes generally acceptable t deviate frm safety systems, prcedures, and prcesses. The rganizatin fails t implement r cnsistently apply its management system acrss the peratin (reginal r functinal disparities exist). Safety rules and defenses are rutinely circumvented in rder t get the jb dne. Nrmalizatin f Deviance Attributes: The rganizatin failing t prvide adequate r effective systems, prcesses, and prcedures fr wrk being perfrmed The rganizatin failing t prvide necessary financial, human, and technical resurces Impracticable rules, prcesses and prcedures, which make cmpliance and achievement f ther rganizatinal utcmes mutually exclusive Emplyees finding wrkarunds in respnse t peratinal inadequacies The rganizatin failing t prvide emplyees with effective mechanisms t reslve peratinal inadequacies Descriptrs: 1. Operatinal deviatins are nt managed using change and risk management prcesses. 2. Sme safety rules and peratinal prcedures are nt practical in the perating envirnment. 3. There is an extended time between reprting f safety issues (hazards, inspectin and audit findings, ther deficiencies, etc.) and their reslutin. 4. There is a backlg f scheduled maintenance activities. 10

12 5. Prcesses and prcedures are nt rutinely assessed fr accuracy, cmpleteness, r effectiveness. Cultural Threat #4: Tlerance f Inadequate Systems and Resurces Tlerance f inadequate systems and resurces ccurs when it becmes acceptable t wrk with inadequate systems and resurces, which ften ccurs when the rganizatin tries t d t much with t little. N allwance is made in business and peratinal planning fr unanticipated prblems and changing cnditins, which wuld include resurce cntingencies fr cmpletin f wrk. The rganizatin is slw t react t changing cnditins. Mst attempts t make the peratin safer thrugh enhanced systems and resurces happen fllwing an incident r regulatry actin. Tlerance f Inadequate Systems and Resurces Attributes: A pervasive belief that rganizatinal success r survival is dependent upn making d with what is available A reactive stance twards safety management The rganizatin stretching human and financial resurces in rder t manage csts The rganizatin s failure t prvide adequate skills and tls t manage risk Descriptrs: 1. The management system is incnsistently implemented. 2. Inadequate human and financial resurces are assigned t safety activities. 3. A single persn is assigned respnsibility fr multiple psitins/prtflis. 4. N cmpetent backup persnnel fr critical safety functins exist. 5. Pr wrking cnditins exist. 6. Operatinal wrkarunds are cmmn. 7. Degraded safety cnditins exist. 8. Maintenance backlgs exist. 9. Quality f dcumentatin is pr (incnsistent, inaccurate, ut-f-date, inaccessible, etc.). 10. Emplyees receive the minimum, inadequate r pr quality training. 11. Little r n training is prvided n system safety, risk and errr management strategies. 12. Change management prcess and prcedures are ineffective r absent. 13. Equipment needed t perfrm wrk safely is ften unavailable. 14. Equipment prvided fr wrk is nt fit fr purpse and/r nt serviceable. 15. Warning r alarm systems are nt fit fr purpse. 16. Practive maintenance f assets is verdue. 17. Extended time lapse exists between reprts f safety cncerns and their reslutin. 11

13 Cultural Defense #1: Cmmitted Safety Leadership Safety is an rganizatinal value demnstrated by a genuine leadership cmmitment and expressed by prviding adequate resurces, systems, and rewards t serve this end. Senir leaders recgnize that cmmercial gals and safety can cme int cnflict and take measures t identify and reslve such cnflicts in a transparent and effective manner. The strategic business imprtance f safety is reflected in the cmpany s strategy, business plans and prcesses. Cmmitted Safety Leadership Attributes: Direct participatin f leaders in the safety system Leader inquiry and understanding f threats Leaders taking actin t address hazards and deficiencies in the system Leaders valuing safety effrts and expertise Descriptrs: 1. The management system specifies an accuntable fficer (AO) with authrity and cntrl fr human and financial resurces. 2. The management system specifies direct reprting lines between key safety persnnel and the AO. 3. Leaders attend safety training and participate in safety reviews. 4. Timely actin is taken t mitigate hazards even when it is cstly t d s. 5. Safety psitins are accrded equal status, authrity, and salary t ther peratinal assignments. 6. Leaders are willing t stand up fr safety even when prductin is impacted. 7. Safety is cnsidered at high-level meetings n a regular basis (nt nly after an incident). Cultural Defense #2: Vigilance Vigilance refers t rganizatinal preccupatin with failure and the willingness and ability t draw the right cnclusins frm available safety infrmatin. The rganizatin implements apprpriate changes t address the lessns learned. It includes the cntinual cllectin and analysis f relevant data in rder t identify hazards (human, technical, rganizatinal and envirnmental factrs) and manage related risk. The rganizatin actively disseminates safety infrmatin in rder t imprve verall awareness and understanding f risks t safety. Peple are encuraged and willing t reprt safety cncerns (unsafe cnditins, errrs, nearmisses, incidents) withut fear f blame r punishment. Emplyees trust that the infrmatin they submit will be acted upn t supprt increased awareness, understanding, and management f threats t safety. Errrs and unsafe acts will nt be punished when these events are unintended; hwever, it is clear that thse wh act recklessly r take deliberate and unjustifiable risks will still be subject t disciplinary actin. 12

14 Vigilance Attributes: Knwing what is ging n, thrugh a practive surveillance prcess Understanding safety infrmatin thrugh analysis and interpretatin Everyne practively reprting errrs, near-misses, and incidents Sharing infrmatin and interpretatin t create cllective understanding f current status f safety and anticipated future challenges Descriptrs: 1. Sphisticated infrmatin systems are used t cllect and analyze data frm a range f surces (e.g. incidents, hazard reprts, inspectins, audits, and reviews). 2. Safety perfrmance indicatrs are tracked, trended, evaluated and acted upn. 3. Safety infrmatin and perfrmance data is cmmunicated upwards and acrss the rganizatin withut distrtin. 4. Prspective analysis is cnducted t identify future threats. 5. Staff frm a wide variety f departments and levels attends meetings relating t safety. 6. A questining attitude prevails at all levels f the rganizatin. 7. Leaders seek t identify and understand active failures and latent cnditins that lead t accidents. 8. Hazards and risks are explicitly captured, reviewed regularly, and updated. 9. Reactive and practive safety perfrmance is tracked ver time. 10. Safety data gathering includes third parties, such as cntractrs. 11. Safety risks and related cntrls are cmmunicated thrughut the rganizatin and beynd (cntractrs, ther cmpanies). 12. Staff have nn-technical knwledge and skills related t human factrs, team perfrmance and errr management techniques. 13. Plicies are in place t encurage everyne t raise safety-related issues. 14. High reprting levels are viewed as a psitive cultural signal. 15. Prcesses are in place t ensure visibility f risk prduced by a single decisin/actin and aggregate risk that results frm multiple decisins/actins that cllectively exceed safety margins. 16. High quality and timely feedback is prvided t staff fllwing receipt f a reprt/cncern. 17. Emplyees are clear that they will be treated fairly if they are invlved in a near-miss r incident. 18. Disciplinary plicies are based n an agreed distinctin between acceptable and unacceptable behavir. 19. Safety mistakes, errrs, lapses are treated as an pprtunity t learn rather than find fault r blame. 20. Incident investigatin aims t identify the failed system defenses and imprve them. 21. Incidents are thrughly reviewed at tp-level meetings. 22. Lessns learned are implemented as glbal refrms rather than lcal repairs and cmmunicated effectively t emplyees. 23. Lessns are learned frm incidents that ccur acrss the industry and in ther high hazard industries. 24. Lessns learned frm internal data cllectin are shared with thers acrss the 13

15 industry. 25. Leadership seeks t exceed the minimum established regulatry expectatins with regards t safety. 26. Leadership takes wnership and respnsibility fr safety standards and perfrmance and des nt rely n regulatry interventins t manage the rganizatin s peratinal risk. Cultural Defense #3: Empwerment and Accuntability Management benefits frm the expertise f frntline wrkers in rder t achieve better slutins t meet safety challenges. Emplyees feel that they can stp any activity when they ntice a ptential hazard in rder t reprt it even when it may have an impact n prductin r csts. Accuntabilities and respnsibilities fr safety are clearly established and dcumented at all levels f the rganizatin. Ownership fr safety utcmes is present at all levels and functinal areas f the rganizatin. Empwerment and Accuntability Attributes: Emplyee participatin in safety management activities Organizatin-wide safety wnership and cmmunicatin Willingness t d what is right in regards t safety Breaking dwn f rganizatinal sils Descriptrs: 1. Emplyees participate in setting safety standards and rules. 2. Emplyees participate in the investigatin f accidents and near-misses. 3. A persn s safety perfrmance is cnsidered when hiring, retentin, and prmtin decisins are being made. 4. Cntractr safety perfrmance is given same weight as ther criteria in prcurement activities. 5. Psitive labur relatins exist. 6. Emplyees (regardless f psitin) express cncern if safety prcedures are nt being fllwed. 7. Perfrmance management systems include a wide range f safety criteria. 8. Emplyees are held accuntable and rewarded fr a demnstrated cmmitment t safety. 9. Nn-peratinal staff recgnizes their business decisins may impact safety. 10. Emplyees cmmunicate with ther departments t understand safety implicatins f decisins. Cultural Defense #4: Resiliency Resiliency is the capability t respnd effectively t changing demands in rder t manage ptential r emerging risk. There are rganizatinal mechanisms in place t manage cmplex activities, and t cnstantly meet the fluctuating demands f a high hazard industry. There is a 14

16 reluctance t simplify prblems and situatins in rder t arrive at a slutin. The rganizatin allws decisins t be made by frntline emplyees and allws authrity t migrate t the emplyees with the mst expertise, regardless f their level in the cmpany. The rganizatin is cmmitted t develping capabilities t detect, cntain, and rebund frm errrs that may ccur. Resiliency Attributes: Recgnizing the intrductin f new r changing threats in the perating envirnment Ensuring emplyees (at all levels) have adequate knwledge and skill related t errr management The rganizatin having the capacity, diversity and redundancy t manage risk The rganizatin respnding t unanticipated r changing cnditins in a timely and effective manner Descriptrs: 1. Adequate financial and human resurces t manage risk and perfrm peratinal activities safely. 2. Authrity t make decisins lies with the mst qualified emplyees. 3. Rbust change management practices include safety cnsideratins. 4. Timely crrective and preventive actins are taken when deficiencies and hazards are detected. 5. Crss-functinal and interdisciplinary teamwrk is present in safety reviews and analyses. 6. Cntingencies are in place t fill vacated rles with cmpetent staff. 7. There is an nging mnitring f the peratin and its envirnment fr changing cnditins and related risks. Cnclusin The NEB, C-NSOPB, and C-NLOPB put safety and envirnmental prtectin at the frefrnt f their respnsibilities in prtecting Canadians. The Bards achieve this by taking a leadership rle t imprve awareness and drive fundamental change when and where it is needed. Safety culture is an emerging discipline in the il and gas sectr that requires greater understanding and cnsideratin. The draft safety culture definitin and framewrk is intended t prmte learning and shared understanding f safety culture. It is als articulates the expectatin that cmpanies regulated by the Bards shuld build and maintain a psitive safety culture while remaining vigilant t ptential cultural threats. The Bards will cntinue t wrk with the PHMSA and BSEE while cnsulting with thers as part f their nging safety culture regulatry cllabratin. Public Cmment Perid Each Bard will release this discussin paper and invite public cmment n the draft safety culture definitin and framewrk. Cmments and questins may be submitted t the NEB 15

17 until 30 January 2014 using the fllwing methds: Mail: Safety Culture Cnsultatin Attentin: Claudine Bradley Natinal Energy Bard 444 Seventh Avenue SW Calgary, Alberta T2P 0X8 Fax: r (tll free) 16

18 IAEA Leadership fr safety is clear JAMES REASON Appendix A: Cmparisn f Safety Culture Framewrks HIGH RELIABILITY ORGANIZATIONS BSEE PHMSA NEB/CNLOPB/ CNSOPB Leadership Safety Values and Actins Leadership is clearly cmmitted t safety Cmmitted Safety Leadership Prductin Pressure Safety is learning driven Learning Preccupatin with failure Cntinuus Learning Organizatin practices cntinuus learning Vigilance Safety is a clearly recgnized value Infrmed Reprting Cmplacency Preccupatin with failure Reluctance t simplify interpretatins Sensitivity t peratins Leadership Safety Values and Actins Prblem Identificatin and Reslutin Decisins demnstrate safety is priritized ver cmpeting demands Reprting systems and accuntability are clearly defined Cmmitted Safety Leadership Prductin Pressure Vigilance Cmplacency Nrmalizatin f deviance Nrmalizatin f deviance Infrmed Just Cmplacency Preccupatin with failure Envirnment fr Raising Cncerns Inquiring Attitude There is a safety cnscius wrk envirnment Vigilance Cmplacency Nrmalizatin f deviance Nrmalizatin f deviance Accuntability fr safety is clear Just Deference t expertise Persnal Accuntability Emplyees feel persnally respnsible fr safety Empwerment and Accuntability Vigilance 17

19 Infrmed Deference t expertise Effective Safety Cmmunicatin Open and effective cmmunicatin acrss the rganizatin Vigilance Just Deference t expertise Respectful Wrk Envirnment Just Preccupatin with failure Envirnment fr raising cncerns withut fear f retaliatin, intimidatin, harassment, r discriminatin Mutual trust is fstered between emplyees and the rganizatin Organizatin is fair and cnsistent in respnding t safety cncerns Vigilance Vigilance Safety is integrated int all activities Infrmed Flexible Tlerance f Inadequate Systems and Resurces Cmmitment t resilience Wrk Prcesses Training and resurces are available t supprt safety Vigilance Resiliency Tlerance f Inadequate Systems and Resurces Prductin Pressure 18