I have recently been considering the impact of culture on the safety of complex systems, specifically chemical operations covered by the Process Safety Management standard. My supposition is that engineering and procedures factors are important building blocks to safe operations of complex systems but the culture of the group controlling the equipment is the final and powerful factor.

“While strong engineering practices are undoubtedly crucial in operations, it’s clear that a culture prioritizing the proactive identification, understanding, and management of risks consistently delivers the best outcomes.” –Chet Brandon

Examples of Negative Impacts of Culture

The Columbia Space Shuttle disaster of 2003 provides an insightful study on how culture can negatively affect complex operations. NASA’s organizational culture was a major contributor to the catastrophe. The most significant cultural element was the downplaying of the risk of space flight over time by leadership.

Other elements identified as contributors were:

• Lack of communication: NASA’s organizational issues made it difficult for people to communicate candidly.  
• Management practices: Management techniques discouraged dissenting views on safety issues.  
• Acceptance of flaws: NASA’s mission managers accepted flaws in the shuttle system as normal.  
• Missed opportunities: NASA managers missed opportunities to evaluate possible damage to the shuttle’s heat shield.  
• Lack of national vision: There was no agreed national vision for human space flight.  

A central recommendation was the need to maintain a culture that values open and frank communication of risks and failures. See the full investigation report at: https://sma.nasa.gov/SignificantIncidents/assets/columbia-accident-investigation-board-report-volume-1.pdf

Union Carbide’s risk-taking nature is another example of a negative culture. I was a senior EHS leader for two of Union Carbide’s former divisions, Metals and Carbon. These divisions were able to develop effective EHS processes after separating from UCC. However, I could still see the vestiges of the old UCC culture in the DNA of the organizations. This included a high tolerance for risk and overconfidence in existing controls and processes. The company was born from experimental and entrepreneurial origins and was not able to grasp the larger picture of risk created by its rapidly up-scaling industrial operations. Everything UCC built was BIG and complex! Leadership was not able to recognize the risk from these operations and include effective processes and actions in their management systems to control the risks.

Examples of Positive Impacts of Culture

A standout example of a manufacturing organization emphasizing safety and reliability is ExxonMobil, particularly within its chemical and refining operations. ExxonMobil’s “Operations Integrity Management System” (OIMS) exemplifies its dedication to systematically managing risks associated with complex industrial processes. This framework integrates safety into all aspects of operations, requiring regular audits, rigorous employee training, and detailed incident reviews to ensure continuous improvement. The organization’s strong emphasis on leadership accountability and an ingrained culture of reporting and learning from near-misses enable employees to proactively address risks, fostering an environment where operational reliability and safety are paramount.

Another notable example is Dow, a global leader in materials science and chemical manufacturing, which emphasizes safety and operational reliability through its “Dow Safety Academy” and “Operational Discipline” principles. Dow’s approach integrates robust risk management frameworks, employee training, and cutting-edge technologies to maintain safe and efficient operations. The organization emphasizes collaboration across teams to identify and mitigate risks proactively, supported by initiatives such as behavior-based safety programs and real-time monitoring systems. By fostering a culture of accountability and continuous improvement, Dow ensures the safety of its workforce and the reliable functioning of its intricate manufacturing processes. It is important to recognize that Dow was one of Union Carbide’s primary competitors and ultimately acquired UCC. Dow’s sustainability focused culture of clearly led it to the future while UCCs high risk tolerance condemned it to extinction.

My final example of an organizational culture that was highly successful operating complex systems is NASA during the Apollo missions. The Apollo mission control organization serves as a quintessential example of High-Reliability Organization (HRO) principles in action, demonstrating how complex systems can achieve exceptional safety and reliability. HRO theory emphasizes mindfulness, resilience, and a commitment to error prevention in high-stakes environments, all of which were central to NASA’s mission control approach during the Apollo program. Mission control operated with a clear prioritization of safety and a culture that empowered team members at all levels to voice concerns. This mirrors HRO principles such as “deference to expertise,” where decisions are based on the knowledge of the most informed individual rather than hierarchical rank. For example, during the Apollo 13 crisis, engineers and mission controllers collaborated across disciplines to innovate solutions in real time, showcasing adaptability and the value of diverse expertise.

Moreover, Apollo mission control adhered to the HRO principle of “preoccupation with failure,” anticipating potential failures and preparing contingencies. Rigorous simulations, redundant systems, and exhaustive checklists ensured readiness for various scenarios, fostering resilience in the face of unexpected challenges. Their “commitment to resilience” was evident in their capacity to recover and adapt rapidly during crises, such as the oxygen tank explosion on Apollo 13. The meticulous coordination of operations and an ingrained culture of learning from past missions align with HRO’s emphasis on continuous improvement and sensitivity to operations. This combination of proactive planning, adaptability, and collective accountability underscores the alignment between Apollo mission control and HRO organizational theory, highlighting the effectiveness of these principles in managing high-stakes, complex operations. A great read to learn more about this era of NASA is: Failure is Not an Option, by Gene Krantz https://www.amazon.com/Failure-Not-Option-Mission-Control/dp/1439148813

High Reliability Organization Theory as a Model Culture

High-Reliability Organizations (HROs) cultivate a culture designed to ensure the safe operation of complex manufacturing systems by embedding principles that prioritize vigilance, adaptability, and resilience. One foundational element is preoccupation with failure, which encourages organizations to remain consistently aware of potential risks, even when operations appear to be running smoothly. This mindset fosters a culture where employees are not complacent and actively seek out weak signals of potential issues, such as subtle changes in equipment performance or minor deviations from standard operating procedures. By identifying these early warning signs, HROs can address small problems before they escalate into significant failures, reinforcing the stability and safety of complex systems.

Another critical element is the commitment to resilience, which equips organizations to effectively respond to disruptions while minimizing impacts on safety and operations. Resilience is achieved through thorough training, clear protocols, and fostering a workforce that can adapt to unexpected challenges. This adaptability is supported by a culture that values learning from both successes and failures, ensuring continuous improvement. For example, when weak signals are detected—such as unusual vibration patterns in machinery—HROs mobilize cross-functional teams to analyze the root cause and implement corrective actions swiftly. This ability to detect and react to weak signals is vital in maintaining the reliability and safety of manufacturing systems, particularly in environments where small errors can propagate rapidly into catastrophic outcomes.

A third essential element is deference to expertise, which ensures that decision-making is guided by those with the most relevant knowledge, regardless of their hierarchical position. In complex manufacturing environments, this principle enables rapid and informed responses to weak signals, as specialists closest to the issue are empowered to act. For instance, if a technician notices subtle inconsistencies in system outputs, they are encouraged to escalate their concerns and collaborate with engineers or process experts without fear of dismissal. This collaborative approach not only enhances the organization’s ability to detect and address risks but also reinforces a culture of mutual respect and collective accountability. Together, these elements create an environment where the safe operation of complex manufacturing systems is not only achievable but sustainable, even in the face of evolving challenges.

This contrast between the two eras of NASA complex operations discussed above, demonstrates the elusive nature of HRO capability. High-Reliability Organization (HRO) capability is inherently elusive because it requires maintaining a delicate balance between operational discipline and adaptability, even in the face of competing demands, uncertainty and change. Achieving and maintaining this capability demands constant vigilance, robust communication, and an ingrained culture of learning, which are difficult to sustain over time. However, the benefit of persevering and cultivating HRO principles is immense: organizations achieve unparalleled safety and reliability, ensuring long-term success and resilience in managing complex systems.