23
Chapter 2
Autonomous SHE
The safety of the people shall be the highest law.
Marcus Tullius Cicero
Ancient Roman statesman, 10643 BC
2.1  The Path toward Autonomous 
Safety/Autonomous SHE
A safety culture is not a program that can be acquired and simply bolted
onto an existing organization. It is not a simple process input that can be
supplied whenever needed. Instead, safety culture is the complex out-
come of the values, beliefs, norms, and numerous actions and interactions
of organizational members over time. A safety culture lies at the core of
an organization, and is an enduring fundamental force that influences
how organizational members think, behave, and perform their work.
Analysis of several well-publicized catastrophic accidents has indicated
that a weak safety culture, or lack of a safety culture, is a key underly-
ing cause of safety failures. For example, the study of NASAs Challenger
explosion revealed that it was not simply the result of a technical O-ring
failure, but rather the outcome of a dysfunctional organizational safety
culture that resulted in faulty decision making and the downplaying of
risk.
1
The 1988 explosion and resulting re on Occidental Petroleum’s
North Sea Piper Alpha offshore oil rig, which tragically killed 167 people,
24 ◾  Lean Sustainability
has also been attributed to breakdowns in organizational safety culture.
Pate-Cornell’s accident analysis of this disaster reveals that it was not a
random act of God, but instead a “self-inicted” tragedy resulting from a
series of management errors that were fostered by a dysfunctional safety
culture.
2
More recently it has been argued that British Petroleum’s recur-
ring history of catastrophic safety failures including refinery explosions,
Alaskan oil pipeline spills, and the explosion and massive oil spill of the
Deepwater Horizon oil rig in the Gulf of Mexico are symptomatic of a
woefully deficient safety culture. The U.S. Chemical Safety Board and
the Baker Safety Review Panel indicated that BP had “a corporate safety
culture that may have tolerated serious and longstanding deviations from
good safety practice.
3
Building a strong safety culture takes consistent and sustained
organizational effort, but once established it is a key determinant in the
organizations safety success and overall performance. In other words,
the journey toward SHE excellence involves a dramatic transformation of
an organizations culture that not only improves safety, health, and envi-
ronmental performance, but also the overall organizational functioning.
A well-developed safety culture is a determining factor in the safety perfor-
mance of a wide variety of organizations from the petrochemical industry to
healthcare.
4
As an organizational safety, health, and environmental culture evolves
and matures it tends to go through several distinct phases that improve the
functioning of the enterprise’s SHE systems and result in progressively lower
accident and incident rates. DuPont
5
and Hudson
6
have developed safety
culture continua or maturity models that describe some of the key steps in
the evolution of an organizational safety culture. Figure 2.1 provides another
perspective on the evolution of an organizational safety, health, and environ-
mental culture that proposes that higher levels of SHE culture maturity and
sustained levels of outstanding SHE performance can be realized by incor-
porating and leveraging Lean principles. The initial stage in this SHE culture
continuum is termed the “uncaring culture.” In this pathological and reactive
stage, safety, health, and environmental management is neither an organi-
zational value nor a priority. Organizations at this stage have little interest
in workplace safety, health, and environmental issues, seeing protection of
employees and the environment as a business burden and unnecessary cost.
Typically the business places a lower value on people and views labor as
an expendable resource that can simply be replaced when accidents hap-
pen. Ironically, as the organization worries about the cost of SHE programs,

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