No theory forbids me to say "Ah!" or "Ugh!", but it forbids me the bogus theorization of my "Ah!" and "Ugh!" - the value judgments. - Theodor Julius Geiger (1960)

Broad (multilevel) safety research and strategy

Le Coze, JC. 2021. Broad (multilevel) safety research and strategy. A sociological study. Safety Science.

Sociologists' analyses of technological disasters provide good examples of a broad view, where they conceptualize the interplay between:

  • Technology
  • Tasks
  • Structure
  • Strategy
  • Environment
  • Culture
  • Power.

HRO (high-reliability organization) studies daily operations and builds an empirical understanding through observations and interviews. The main outcomes of this research include:

  • redundant tasks
  • underspecified structure
  • strong socializing processes
  • a culture that emphasizes safety
  • learning without fear of blame
  • a leadership that takes a broad perspective.

While the core facets and dimensions of safety have remained stable, there have been evolutions in understanding. In the literature on disasters, the role of strategic decisions by executives and top management is a crucial aspect in the analysis of case studies. The authors have different perspectives on the role of strategy, with Perrow approaching it critically, Hopkins seeing it as a failure of centralized structures, and Vaughan emphasizing its influence on engineering practices. Farjoun and Starbuck have linked strategic decisions to safety and view strategy as balancing exploration and exploitation. Despite the emphasis on the role of executives, there is a need for more empirical research to understand their role alongside other factors such as technology, tasks, culture, and environment.

Le Coze advocates a comprehensive approach to safety that takes into account the role of decision makers and their strategies. He presents a case study of a plant with hazardous industrial processes and multiple safety incidents over a few months. The analysis shows that common managerial, organizational, and strategic issues contribute to a vicious circle, which is sustained by the inability of the plant manager to fully comprehend the situation. Le Coze highlights the importance of considering the role of powerful actors in safety and recommends changes in organizational structure, management style, training, and supervision to break the vicious circle.

The study views safety in sociotechnical systems from a broad/multilevel perspective. Safety is the result of the interaction between artefacts, people, organizations, and institutions in specific contexts. The study advocates for a broader understanding of safety in safety-critical systems, considering multiple facets such as technology, tasks, structure, culture, strategy, and environment. It recognizes the non-deterministic and combined influences of these facets, with strategy being the pivotal one. The study focuses on the importance of in-depth qualitative data through ethnographic work to understand the combination of these facets and their impact on safety outcomes. The study argues that a micro-level focus on workers' practices alone is not enough, and a broader, multilevel approach that considers the influence of top managers and their business orientations is crucial. The study also considers the views of various researchers on the role of top managers in ensuring safety, with some seeing them as sacrificing safety for production, some as responsible for complying with legal duties and good practices, and others as dealing with complex sociotechnical systems and taking risks in tough environments.

The methodology of the study is an ethnographic approach, which involves collecting data through interviews, observations, and document analysis. The researcher is not neutral but fully immersed and engaged, and the data-theory connection is seen as an interplay between evidence collection, prior knowledge, and interpretation. Ethnography is a long-standing tradition in anthropology and sociology, which is used here to understand a specific situation and the relationship between key dimensions in safety, such as technology, task, structure, culture, leadership, strategy, and environment.

The paper presents a case study of a production department in a plant where safety problems were the focus of the analysis. The approach consisted of observing and interviewing workers, shift supervisors, foremen, engineers, managers, and other actors in the department and their interactions with other departments and collective actors to identify patterns of interactions and dynamics that contributed to the recurring safety problems. The study took place over a period of six months and consisted of two phases: first, observing work practices and informal interviews with workers, shift supervisors, and foremen, and second, planning and conducting formal interviews with managers of various departments, including the plant manager. The goal of the study was to gain a comprehensive understanding of the production department, its processes, work principles, and interactions between workers, managers, and other actors.

The data analysis for the study is based on a combination of sociological lenses and inputs from various safety research traditions, examining patterns of interactions between different aspects. The principle used in the study is that technology, task, structure, and other dimensions are not deterministic influences on their own, but are instead the result of a combination of interactions between people across different hierarchies and departments. Tasks, for example, depend not only on technology and its design, but also on workforce training and supervision, team relationships, production targets, and social relations. The study includes a historical view of the plant, a description of problems in the production department, an explanation of the problems through an organizational and managerial perspective, a description of the complex interactions between people, and a strategic analysis of the situation.

The safety narrative describes the history of a plant that was on the verge of shutting down but was saved by a new investor who invested millions over several years to upgrade and modernize the plant. It was part of a national group with a strong industrial expertise but was sold twice in the past fifteen years to multinationals with different visions for the plant. The new investor brought the plant back to life and increased production. Five years later, one of the three production departments was in the red due to a series of events, including a fire and a leak of chlorine, which were linked to managerial and organizational problems. These problems were related to insufficient training, coordination problems, low morale, and design and maintenance issues. The regulators were aware of the most visible events but did not take any action. The plant spends resources to comply with legal requirements and regularly submits analyses to the authorities. From the perspective of health and safety inspectors, there have been no casualties that would trigger a thorough investigation of working practices.

The workers in the plant are represented by powerful unions with 70% of the workers being members. The unions have historically been involved in violent strikes, but under the new plant manager the has become more peaceful. The unions still have influence in decision making processes and are represented by members in the production departments, including a powerful operator in the production department. This creates a challenging situation for the production department manager and foreman, who may be pressured by the plant manager based on union inputs. The power of the union is also felt in health and safety, with an active health and safety committee run by union members and a worker dedicated full time to the committee. The plant manager finds the committee to be a useful channel for gathering information on health and safety issues. Members of the unions and the health and safety committee, along with managers of other departments, are complaining about the latent problems of the production department.

The study found that there is a consensus among workers, members of unions, engineers, and managers in the operational department that there are problems with safety, quality, and engineering projects, and that these issues are related to deeper managerial and organizational problems. The study confirms the causal connections between these events and deeper issues, but these connections are unstructured in people's minds. The problems in the department started a few years prior, when the strategic increase in production volume meant opening processes that had been shut down and required new workers, which led to issues with the quality of training and coordination between departments. The department was understaffed and the production manager and foreman were overloaded, leading to unresolved tensions and problems. Despite meeting production targets, the motivational cost is high, morale is low, and the likelihood of a serious accident is a concern for many. The HSE department plays a role in regulatory compliance but is a small unit with limited expertise and a control-based approach that is not well perceived by operational personnel. Despite these problems, the production department manages to reach its target due to the collective expertise of its workers and supervisors, who are able to compensate for coordination problems and rely on their networks of relationships and experience.

The narrative describes a situation in which the imperfections in the plant are maintained by a vicious circle of interactions among various actors such as the company owner, plant manager, production department manager, unions, regulators, supervisors and workers, and human resources managers. The imperfections result from a lack of workforce qualification, inadequate organizational structure, and pressure from the plant manager to solve problems in the production department. The situation creates a dynamic of circular causality and complex patterns of interactions. This leads to a strategic blind spot with strong implications for safety. The situation improves after a year of implementing measures such as changes in the production department structure, management style, and increase of workforce expertise with the help of a consulting firm.

The production department at the plant was facing various performance issues including safety events, quality problems, and a negative climate within the department. Despite these issues being discussed in management committees, the underlying problems were not fully exposed and proposed solutions only scratched the surface. The plant manager recognized the need for change, particularly in organizational structure and resources, but only after external analysis. He had a managerial style that relied on department managers to translate the new investment strategy and avoided intervening too much, anticipating problems, and criticizing managers. This style was successful with most departments but proved to go together with a blind spot in addressing the problems of the production department. A more thorough analysis was needed to expose the problems and find a suitable solution.

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