Resisting Change in Organizational Culture - Chapter 11

Because of the many organizational accidents in the 1980s, the 1990s became the safety culture decade. Instead of focusing on the computer-based technologies (chemical processes, nuclear power etc.), the focus shifted to more traditional industries like infrastructure, mining and construction.

There are 3 ways in which a not accurately applied safety culture can negatively undermine a complex system’s protective layers (the slices of the Swiss Cheese Model):

  • A poor safety culture will increase the number of defensive weaknesses caused by active failures (errors and violations). This will happen more in organizations that are neglectful in identifying error traps. The more dangerous thing is that a poor safety culture will also encourage an atmosphere of non-compliance.
  • Inability to recognize and an inability to respect the operational hazards can lead to more long-lasting holes in the defensive layers. This can arise through underlying conditions during the maintenance, testing, adjustment, the wrong equipment or through downgrading the importance of training.
  • The reluctance of an organization to deal proactively with their known deficiencies.

If there is one phrase that captures the essence of an unsafe culture it should be the unwarranted insouciance.

What Makes a Safe Culture?

Karl Weick says that the power of a safe culture lies in instilling a ‘collective mindfulness’ of the many entities that can penetrate, disable or bypass the system’s safeguards. Weick calls reliability and safety dynamic non-events. This means that people assume nothing bad will happen today because they acted the same as yesterday, and yesterday nothing bad happened.

Gradations of Cultural Change

At any time an organization can be in the stages mentioned below. This is a continuum that presents the path along change. Only the last one mentioned is the one that involves a successful transition in change.

  • State 1: Don’t accept the need of change: The managers are happy with the status quo, they do not belief they have a problem and are satisfied with the way they are achieving their targets.
  • State 2: Accept the need for change, but don’t know where to go. There is a concern over a series of bad events. They recognize that the existing safety measures are not accurate, but the cultural deficiencies are not understood.
  • State 3: Know where to go, but don’t know how to get there. Acknowledge that the existing safety measures are less than adequate, and accept the cultural deficiencies but unsure how to make the necessary improvements.
  • State 4: Know how to get there, but doubt whether the organization can afford it. Current projects are overrunning the budget, so they are willing but not able.
  • State 5: Make changes, but do them only cosmetically. Making changes, but with short cuts.
  • State 6: Make changes, but no good comes of them. The model of the change in the origination is not realistic and does not align with the real world.
  • State 7: Model aligns today but not tomorrow. The change only brings limited benefits due to unforeseen changes.
  • State 8: Successful transition. The change in the organization keeps up with the dynamic world and brings benefits.

Vulnerable System Syndrome

It is usually bad luck when the holes in the defensive system align to create an error. However some organizations are especially prone to having accidents. These organizations are suffering from the Vulnerable System Syndrome (VSS) and have three interacting and self-perpetuating elements: blaming front-line operators, denying the existence of systemic error provoking features and the blinkered pursuit of the wrong kind of excellence. VSS is present in some degree in all organizations; it is a matter on how an organization is taking effective remedial action. Blame and denial are the more dangerous elements of the VSS and differ on organizational and personal level.

At the personal level of the dynamics of blame and denial, there are several factors that influence the level:

  • Fundamental attribution error: When someone else is performing less, we blame it on the person. When we perform less we attribute it to situational factors.
  • Illusion of free will: People (especially in the west) value the belief that we are in control of our own destinies.
  • ‘Just world’ hypothesis: This is the belief that bad things happen to bad people and vice-versa. This also means that the person is judged by the severity of the outcome.
  • Hindsight bias: The tendency to see past events as more foreseeable on the spot than they actually where at that time.
  • Outcome bias: The tendency to evaluate prior decisions according to the outcome. Another belief is that bad outcomes can only come from bad decisions, but history tells us that belief is not true.

At the organizational level of the dynamic of blame and denial, there also some factor that influence the level:

  • Shooting or discounting the messenger: Ron Westrum distinguished three kinds of safety cultures: pathological (organizations that shoot the messenger and ignore or deny the information), bureaucratic (the large majority of the organizations that listen to the messenger but don’t really know what it means) and generative (these organizations welcome the messenger and praise him for it and treat the message very seriously).
  • Principles of least effort: It is fairly easy to find a mistake that an individual made, which in some organizational causes the investigation into the error to stop early.
  • Principles of administrative convenience: By restricting the area of investigations to the persons that are directly in contact with the system, it is easier to blame someone.
  • Entrapment: Weck called the culture of entrapment “through repeated cycles of justification, people enact a sensible world that matches their belief, a world that is not clearly in need of change”.
  • Organizational Silence: A climate in an organization where people don’t speak up when they feel there is an issue.
  • Workarounds: When looking at the people working front-line, we see that for the most part they are solving local problems (daily tweaking, messaging, adjusting) to get the job done. When there is a problem they tend to work around it instead of fixing the underlying organizational problems.
  • The normalization of deviance: Certain defects become so commonplace and so apparently inconsequential that their risk significance is gradually downgraded, so they are more seen as routine wear and tear.

Cultural Strata

Patrick Hudson expended the typology of the organizational safety cultures (Ron Westrum). The identified stages that each have to be passed through to move on to the next level. The first stage is pathological where blame and denial are the cheaper and faster way to solve problems. The second stage is reactive where safety is only given attention after an event because there is concern about adverse publicity. The third stage is bureaucratic/calculative, where there are systems to manage safety but often only because there was external pressure and also strictly by the book. The fourth stage is the proactive stage. This stage entails the awareness of the error traps in the system and they then seek to eliminate them before they happen. The final stage is generative, in this stage risks are anticipated, respected and responded to. It is an adaptive, flexible and learning culture that strives for resilience.

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