Back in January I wrote briefly about safety culture and in particular about Exxon's journey along the pathway to a sustainable safety culture. The occasion was a statement given by Rex Tillerson, Chairman and CEO of ExxonMobil to the U.S. National Commission on the BP Deepwater Oil Spill and Offshore Drilling on November 9th, 2010, in which Tillerson outlined ExxonMobil's approach to safety, operational integrity and risk management. Tillerson made the point that safety had to become a value to be embedded in the organization's culture. Expanding on this, he outlined three key criteria for a safety culture:
1. A culture of safety is born within an organization. You can't buy a culture - you have to make it yourself.
2. Creating a strong, sustainable safety culture is a long process.
3. Leadership by example and thoughtful, honest and objective self-assessment are essential.
Today there was some news from a fellow energy company that sits at the opposite end of the spectrum with respect to valuing safety and a safety culture. The NY Times reported on the release of the West Virginia Governor's Independent Investigation Panel charged with examining the April 5th, 2010 explosion at the Massey Energy Upper Big Branch Mine. The explosion killed 29 miners - the worst disaster in U.S. mining in 40 years. The report, released today, doesn't seemed to have pulled many punches:
"an independent team of investigators has put the blame squarely on the owner of the mine, Massey Energy, concluding that it had “made life difficult” for miners who tried to address safety and built “a culture in which wrongdoing became acceptable .... echoed preliminary findings by federal officials that the blast could have been prevented if Massey had observed minimal safety standards ... but it was more pointed in naming Massey as the culprit, using blunt language to describe what it said was a pattern of negligence that ultimately led to the deaths of 29 miners on April 5, 2010, in the worst American mining disaster in 40 years."
The culpability of Massey in the disaster is certainly the most important part of the story and one that the NY Times tells well. However, when I linked to the report itself and read through it, I was struck by the contrasts between the approach to safety articulated by Tillerson and Massey's moral failure. The report discusses the process of "normalization of devience"by which, in the push to to produce coal, the operating culture of the mine made allowances for a laundry list of unacceptable problems and failures. For example:
- Chronic low airflow;
- Illegal ventilation changes, made with a blatant disregard for worker safety and the law;
- Lack of an effective engineering design with engineering staff disconnected from the mine management decisions;
- Continual problems with high water, routinely sending men into chest-high water;
- Lack of safety equipment;
- Failure to carry out basic safety measures (e.g. rock dusting to reduce risk of coal dust explosions);
- Ineffective and even fraudulent safetyboss (i.e. safety managers) practices;
- Failed equipment;
- Disabled safety mechanisms.
The report goes on to detail how, far from promoting a safety culture, Massey conspicuously valued production over safety and created a climate in which intimidation of employees, institutional secrecy, deliberate law-breaking and more were routine. One would have to ask, where were the regulators that were responsible for ensuring mine safety? Massey had systematically used its wealth to undermine the political and regulatory process and to undermine the legitimacy of the regulators in the eyes of the workforce. The question that emerges from this report is not "How could it happen?", rather it is "How didn't it happen more often and on a greater scale?"
In a way this report reinforces the message from Tillerson. A positive safety culture isn't something that just happens. In fact it’s possible to create the complete opposite - a Frankenstein culture if you will.