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Defining safety culture The trend around safety culture originated after Chernobyl brought attention to the importance of safety culture and the impact of managerial and human factors on the outcome of safety performance (Flin et al. 2000; IAEA 1986). The term ‘safety culture’ was first used in INSAG’s (1988) ‘Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident’ where safety culture was described as: “That assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.” This concept was introduced as a means of explaining how the lack of knowledge and understanding of risk and safety by the employees and organization contributed to the outcome of the disaster. Since then, a number of definitions of safety culture have been introduced. The U.K. Health and Safety Commission developed one of the most commonly used definitions of safety culture, which describes safety culture as: “The product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization’s health and safety management” (HSC, 1993a, p. 23). Another widely used term, developed by Advisory Committee on the Safety of Nuclear Installations (ACSNI) (yr), describes safety culture as: “The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.” “Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.” Since the 1980s there has been a large amount of research conducted on safety culture, however the concept still remains largely “ill defined” (Guldenmund 2000). Within the literature there are a number of varying definitions of safety culture with arguments for and against the concept. The above-mentioned definitions, from the IAEA and UK Health and Safety Commission, are two of the most prominent and most-commonly used definitions (Yule, 2003). However, there are some common characteristics shared by other definitions. Some characteristics associated with safety culture include the incorporation of beliefs, values and attitudes that are shared by a group. Glendon et al. (2006) highlights that a number of definitions of safety culture depend on the individuals’ perceptions being shared within a group, organization, or societal context. For example, Cox and Cox (1991), HSC (1993a), Pidgeon (1991) and Schein (1992) all refer to ‘shared perceptions of safety’. Reason (1998, p. 295) highlights that safety culture “is a concept whose time has come”, stating that there is both a challenge and an opportunity to “develop a clearer theoretical understanding of these organizational issues to create a principled basis for more effective culture-enhancing practices.” There is a trend for safety culture to be expressed in terms of attitudes or behaviour. Glendon et al., (2006, p. 367) highlight that when defining safety culture the premise of some researchers is to focus on attitudes, where others emphasize safety culture being expressed through their behaviour and work activities. In other words, the safety culture of an organization acts as a guide as to how employees will behave in the workplace. Of course their behaviour will be influenced or determined by what behaviours are rewarded and acceptable within the workplace. For example, Clarke (2006, p. 278) states that the safety culture is not only observed within the “general state of the premises and conditions of the machinery but in the attitudes and behaviours of the employees towards safety”. It is important to identify the perception of the organization’s safety culture as it represents a critical factor influencing multiple aspects of human performance and organizational safety. One of the most succinct and usable definitions of safety culture can be found in von Thaden and Gibbons (2008): Safety culture is defined as the enduring value and prioritization of worker and public safety by each member of each group and in every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety; act to preserve, enhance and communicate safety concerns; strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes; and strive to be honored in association with these values. This definition combines key issues such as personal commitment, responsibility, communication, and learning in ways that are strongly influenced by upper-level management, but include the behaviors of everyone in the organization. It implies that organizations possess a safety culture of some sort, but this culture is expressed with varying degrees of quality and follow-through. Role of safety culture in incident investigation Although there is some uncertainty and ambiguity in defining safety culture, there is no uncertainty over the relevance or significance of the concept (Yule, 2003). Mearns et al., (2003) stated that “safety culture is an important concept that forms the environment within which individual safety attitudes develop and persist and safety behaviours are promoted”. Incidents like Piper Alpha and Kings Cross station have raised awareness of the effect of organisational, managerial and human factors on safety outcomes. As several reports of major disasters have identified, safety culture is a factor that decisively affected the outcome (Reason, 1990). Such reports include the Piper Alpha oil-platform explosion (Cullen, 1990), the 1987 Kings Cross underground station fire (Fennel, 1988), and the sinking of the Herald of Free Enterprise passenger ferry (Sheen, 1987). Although definitions vary there is a consensus towards safety culture being a proactive stance to safety (Lee and Harrison, 2000). Over the years, a lot of attention has focussed on the causes of occupational incidents (Haslam et al. 2005). When incidents occur in the workplace it is important to understand what factors (human, technical, organizational) may have contributed to the outcome in order to avoid similar incidents in the future. Through developing an understanding of why and how incidents occur, appropriate methods for incident prevention can be developed (Williamson and Feyer 2002). In the past, any attempt to improve workplace safety or to control workplace risks has focussed on technical aspects (i.e. design of safer systems) and on the direct influence of human behaviour (i.e. operator error) (Gadd and Collins 2002). However, a number of major disasters have brought attention to the impact of organizational factors (i.e. policies and procedures) on the outcome of safety performance, with numerous inquiries identifying safety culture as having a definitive impact on the outcome of the disaster (Reason, 1990). Such incident as Chernobyl, Kings Cross, and Piper Alpha are all examples of how organizational and human factors can have an impact on safety performance. Following the Piper Alpha explosion Lord Cullen said that, “it is essential to create a corporate atmosphere or culture in which safety is understood to be and is accepted as, the number one priority” (Cullen, 1990, p.300). In that same year a report into the Challenger Space shuttle disaster identified numerous “flawed” decisions on behalf of NASA and Thiokol management as contributing factors to the disaster.With every major disaster a large amount of resources are set aside in order to establish exactly what factors contributed to the outcome of the event. These inquiries pay particular attention to detail and prove to be an invaluable source of information in identifying factors that “make organizations vulnerable to failures” (Gadd and Collins, 2006 p. 3). From such inquiries, there are some clear observations that can be drawn, for example, organizational accidents are not a result of ‘operator error’, chance environmental or technical failures alone. Rather, the disasters are a result of a break down in the organization’s policies and procedures that were established to deal with safety. The Piper Alpha disaster, for example, was a fatal combination of failure of individuals to perform their duties, breakdown in documented systems and managerial failure. There is now a move to apply the concept of safety culture at the individual level. Mearns et al., (2003) highlight that although safety culture was a concept originally used to describe the inadequacies of safety management that result in major disasters, it is interesting that the concept is now being applied to explain accidents at the individual level. As worker’s behaviour is influenced by the safety culture of an organization, such culture could become a determinant of worker injury involvement (Glendon et al., 2006). Although the culture of an organization may have an impact on the behaviour of employees, much research has focussed on the impact of more localised factors (i.e. supervisors, interpretation of safety policies). Glendon et al., (2006) refer to this as the “Local safety climate, which is more susceptible to transition and change” (p. 367). This would also suggest that safety climate operates on a different level than safety culture. Though Mearns et al. (2006) emphasize, “The validity of the safety culture concept with regard to individual accidents is yet to be ascertained” (p. 643). Characteristics of a positive safety culture Several papers have aimed at identify specific safety management practices that act as a predictor of safety performance (Mearns et al., 2003). Through examining organizations with good safety performance, it was intended to identify common features that are associated with good safety performance. Some examples of studies that have examined the safety performance of organizations include: Cohen (1977) reviewed four organizations; Shafai-Sahrai (1971) examined 11; Cohen et al. (1975) and Smith et al. (1975) examined 42; Shannon et al. (1996) conducted a postal survey of over 400 manufacturing companies; Shannon et al. (1997) reviewed 10 studies Reason (1998) considers an ideal safety culture to be “the ‘engine’ that drives the system towards the goal of sustaining the maximum resistance towards its operational hazards” (p. 294) Reason maintains this goal should be achieved irrespective of the organizations leader or current commercial concerns. What drives the system is a constant level of respect for anything that may bypass organizational safety systems. In other words, it is important to remember what can go wrong. It is very dangerous to think that an organization is safe because no information is saying otherwise. Reason (1998) believes in periods of good safety performance, the best ways to stay cautious is “to gather the right kind of information”, which means creating an informed culture. An informed culture requires safety management to be aware of the numerous factors that have an impact on the safety systems (i.e. human, technical, organizational, and environmental). In this sense, reason believes “an informed culture to be a safety culture” (p. 294). An organization’s safety culture is ultimately reflected in the way in which safety is managed in the workplace. Though it is important to note that an organizations safety management system does not just consist of a set of policies and procedures on a bookshelf. The safety management system is the manner in which safety is handled in the workplace and how those policies and procedures are implemented into the workplace (Kennedy and Kirwin, 1998). Kennedy and Kirwan, (1998) also assert that the nature by which safety is managed in the workplace (i.e. resources, policies, practices and procedures, monitoring, etc.) will be influenced by the safety culture/climate of the organization. The Health and Safety Executive (2000) believe that safety management should be integrated into the organizational system and management practice (HSG65, HSE 2000). Certainly in high-risk industries, safety should be considered number one priority. It is easy to see how the management system and culture of an organization is closely related. It is argued “a ‘good’ safety culture might both reflect and be promoted by at least four factors” (Pidgeon and O’Leary 1994). These four factors include “senior management commitment to safety, shared care and concern for hazards and a solicitude for their impacts on people, realistic and flexible norms and rules about hazards, and continual reflection upon practice through monitoring, analysis and feedback systems (organizational learning)” (Pidgeon and O’Leary 2000). It has also been argued that fundamentally leadership is the key to affecting a safety culture (Burman & Evans 2008). Shannon et al., (1997) conducted a review of ten studies that examined the relationship between organizational factors and injury rates. Studies were only included if they had made comparisons between at least 20 workplaces (Shannon et al., 1997 p. 201). In order for a variable to be considered ‘consistently’ related to the injury rate, the relationship had to be: Statistically significant in one direction in at least two thirds of the studies in which it was examined, and Was not found to be significant in the opposite direction in any other study. Variables were categorized into Joint Health and Safety Committee, Management Style and Culture, Organizational Philosophy on OHS, Post-Injury Factors, Work Force Characteristics, and Other Factors. In all 17 variables were found to meet the criteria of being consistently related to lower injury rates. Some of those variables included: The amount of training the Joint Health and Safety Committee received, Good relations between management and workers, Unsafe work behaviours monitored, Low turnover of staff, and Safety controls on machinery (Shannon et al., 1997; p. 213) Taking into account the nature and number of accidents that have occurred as a result of poor safety management (Reason, 1998) it is important that audit tools are developed to ensure that safety management practices are successful (Parker et al., 2006; Hudson et al., 1994). Mearns et al., (2003) asserts that the evaluation of safety management practices should compliment the assessment of safety climate. However Burman & Evans (2008) discuss the limitations of safety management systems (SMS) in relation to culture and show how leadership has a more direct affect on safety that management. They also define the difference between the two. Broadbent has quoted Barling et als (2002)contribution to the safety culture literature, in which they demonstrate a direct mathematical relationship with the application of Transformational Leadership and the frequency of workplace injuries. In a later development Broadbent (2004) showed how specific safety leadership items could assist organisations map their prevailing safety culture and safety leadership. This development was the creation of The Transformational Safety Culture and Leadership Assessment Systems. It is important to remember that an organizations culture develops over a period of time and cannot be created instantly. “Organizations, like organisms, adapt” (Reason, 1998). The safety culture of an organization is develops as a result of history, work environment, the workforce, health and safety practices, and management leadership (Reason, 1998). ad