One of the most fascinating ideas in incident investigation is defining the aspects of organisational culture that contributed to the failure. These are the collective practices of the group that preceded the event; the conditions, practices and inactions that were accepted or allowed, even promoted—including, especially, the things that went wrong.
Only after defining the organisational culture can we truly effect change to it—but this concept of culture change is actually much harder than most people think.
There are two prevailing schools of thought with regard to how organisational behaviour and culture is affected. One is due to the direct process of behaviour modification i.e. setting up procedures, rules and systems as antecedents to desired behaviour, and the other is to impact values—a deeper process of attitude and belief modification.
The Trap – Impacting Values Alone
There is a lot of research to indicate that the latter approach is fraught with danger, particularly in the context of mature adults who don’t readily change their very personal values at the behest of external forces, and most specifically, enthusiastic employers.
Acknowledging this point helps us understand that the best way to impact culture from the values perspective it to recruit (and then train appropriately) the right people in the first place.
The Way Forward – Adjusting “Collective Practices”
If trying to impact values (a very personal thing) is fraught with danger and/or eventual frustration, the methods of adjusting the collective practices at two levels potentially gives us more room to move and hope for a solution.
Collective practices can be observed by either the actions of individuals (the way we do things around here) or by the interaction of individuals with organisation systems which cannot be “reducible to individual practices,” for instance, the design and use of reporting systems.
The organisation, with some thought and intent in and of design, can create systems that will capitalise on opportunities to investigate failures to report and at the same time find inventive ways of rewarding good reporting behaviours. It can prove its interest in this area—and employees aren’t silly; they’ll endeavour to conform to what the organisation really wants by virtue of the level of its commitment to the end goal.
The Bridge to Great Culture
The final frontier in becoming a High Reliability Organisation (HRO) is addressing practices, not attitudes. And all the systems in the world do not create congruence in collective practices. It appears that mindful organisations rely on and produce mindful individuals and vice versa, so can it be deduced that the organisation’s culture is the sum of all stakeholders impacting on it in function with its systems?
Furthermore, it can be said that what separates the HRO from an also-ran is their ability to initiate strong responses to weak signals of problems. They “organise themselves in such a way that they are better able to notice the unexpected in the making and halt its development.”
Achieving great culture is a detailed science in itself with many convoluted factors impinging on it. It is interesting that, in the case of the BP Texas City Refinery disaster, BP had not taken seriously the very matters that would have proved their commitment to becoming a HRO—not the least of which a lack of commitment to process safety at the highest level, that of CEO, Lord John Browne.
Organisations, like individual people, get back what they’re prepared to actually invest. They reap what they sow. It may in some ways be an oversimplification but I think we get the basic point.
 Andrew Hopkins, Failure to Learn: the BP Texas City Refinery disaster (
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 See the Jim Collins’ study and book in Good to Great: Why Some Companies Make the Leap... and Others Don’t (
 Ibid, p. 145.
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 Ibid, p. 148.