The Sounds of Safety Silence: Interventions and Temporal Patterns Reduce Unique Thematic
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The London School of Economics and Political Science THE BEHAVIOURAL NATURE OF SAFETY VOICE: ADVANCING CONCEPTS AND MEASURES TO ENABLE THE PREVENTION OF HARM A thesis submitted to the London School of Economics and Political Science’s Department of Psychological and Behavioural Science for the degree of Doctor of Philosophy August 2020 THE BEHAVIOURAL NATURE OF SAFETY VOICE 2 DECLARATION I certify that the thesis I have presented for examination for the PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. I declare that this thesis consists of 75,840 words (excluding references and appendices). I consider the work submitted to be a complete thesis fit for examination. I authorise that, if a degree is awarded, an electronic copy of my thesis will be deposited in LSE Theses Online (in accordance with the published deposit agreement) held by the British Library of Political and Economic Science and that, except as provided for in regulation 61 it will be made available for public reference. I authorise the School to supply a copy of the abstract of my thesis for inclusion in any published list of theses offered for higher degrees in British universities or in any supplement thereto, or for consultation in any central file of abstracts of such theses. Statement of co-authored work I confirm that Articles 1-4 were jointly co-authored with Dr Reader and Dr Gillespie and I contributed 80% of this work. For all other sections I am the sole author. Statement of use of third party for editorial help I can confirm that my thesis (bar the articles) was copy edited for conventions of language, spelling and grammar by the Language Centre at the London School of Economics and Political science. THE BEHAVIOURAL NATURE OF SAFETY VOICE 3 ABSTRACT Background: The concept of ‘safety voice’ captures the extent to which individuals speak-up about safety. The behaviour is deemed important for preventing accidents, yet interventions are needed because people often fail to speak-up (‘safety silence’), thus contributing to harmful outcomes across safety-critical domains. However, the concept remains disintegrated and grounded in limited evidence and methodologies. Thus, the utility of ‘safety voice’ for safety management remains unclear, prohibiting effective interventions. This thesis therefore aims to evaluate how the behavioural nature of safety voice may be optimally conceptualised, assessed and intervened on. Approach: Four articles presented a systematic literature review (n = 48 publications), twelve experimental studies (ntotal = 1,222) and an analysis of Cockpit Voice Recorder (CVR) transcripts across 172 aviation accidents (1962- 2018; n = 14,128 conversational turns). Article 1 synthesised evidence from across theoretical domains. Article 2 presented the first experimental paradigm for safety voice (‘Walking the Plank’) to address nine methodological challenges. Article 3 observed safety silence in the laboratory to establish and conceptualise how the behaviour manifests in relationship to safety voice and interventions. Article 4 captured safety voice during real-life safety accidents, and investigated how risk, safety listening, power distance and CRM training impact on safety voice. Findings: Safety voice is a distinct concept that is highly ecological and situated, and that is important for understanding how safety voice contributes to accidents. A methodological reliance on self-reports and post-hoc methodologies was identified and addressed through the Walking the Plank paradigm. Safety silence, identifiable through assessing safety concerns, was scalable based on the degree of safety voice speech, with interventions uniquely impacting on five safety themes and hazard stages. Safety voice was found to occur frequently during real accidents, with the developed Threat Mitigation Model underscoring that safety concerns, safety voice and safety listening all contribute to preventing harm. THE BEHAVIOURAL NATURE OF SAFETY VOICE 4 PERSONAL STATEMENT In the spirit of my alma maters (i.e., the London School of Economics and Utrecht University), I care about conducting rigorous research in order to create a better world and address real-world problems. Conducting research on safety voice fits this personal mission. This is because by investigating the nature of the safety voice I can contribute new insights into how people may be enabled to prevent harm. The problem posed by people withholding safety concerns is not merely academic but has a very clear application for understanding and improving situations in which people encounter hazards: these situations can have serious outcomes such as injuries, accidents, or organisational decline. Whilst I acknowledge that mishaps are a normal part of social and institutional life (Perrow, 2011), I assume that at least a portion of adverse events are preventable through policies and behaviours that mitigate contributing causes (Nabhan et al., 2012). This assumption is important to me because it provides me with a hope that a better world is possible, one in which people can manage risks effectively, and that knowledge may be developed to support this. This drives me to investigate ways for people and institutions to create better outcomes, and motivates me to become a better researcher. Of course, I do not claim that creating a better world through solving real problems is the only worthy endeavour: arguably, pursuing knowledge is virtuous in and of itself. Yet, this simple motivation (to apply fundamental knowledge in order to enable people to do good) and hope (that harmful outcomes are preventable) drives me to investigate phenomena such as safety voice. Through investigating safety voice, I continue my line of work on the psychology of risk within social and organisational environments. As an under- and postgraduate student I researched the effect of threat perceptions (e.g., from immigrant or religious outgroup members) on the extent to which individuals adopt more social distance (unpublished undergraduate thesis at Utrecht University) and show prejudiced behaviour (unpublished THE BEHAVIOURAL NATURE OF SAFETY VOICE 5 postgraduate thesis at the LSE). Based on my interest in the psychology of risk, I took up a position as research assistant at the LSE (2012-2015) to work with Dr Tom Reader on a project investigating safety culture (i.e, “the norms, values, and practices shared by groups in relation to risk and safety"; Noort et al., 2016, p.516) across the European air traffic management industry. In this highly enjoyable period, Dr Reader introduced me to a wealth of knowledge on the intersection of social psychology, organisational safety and safety management, and he mentored me in becoming a better researcher. As a side-project I worked with Dr Bradley Franks and Dr Martin Bauer on how risk perceptions (e.g., in terms of threat, uncertainty, alienation) shaped sense-making amongst conspiracy theorists. Thus, I became a published scholar on safety and risk (Franks et al., 2017; Noort et al., 2016; Reader et al., 2015), and I deeply enjoyed the mixture of writing and travelling across Europe to facilitate focus groups on safety culture. To understand how safety culture operates in practice and gain hands-on understanding of safety management I worked at NATS (British air traffic control) in 2015-2016. Here, I was involved in projects involving safety management (e.g., safety culture, safety assurance for a new voice communication system, human performance assessment) and training (e.g., on human factors, Crew Resource Management). This period taught me two valuable lessons. First, that the world is safer with me handling theories and methods rather than planes (i.e., a hilarious simulation to familiarise myself with the work of air traffic controllers went painfully wrong). Second, that even within organisations with a strong safety culture people can withhold safety concerns. The management and operational staff I worked with (e.g., air traffic controllers, engineers, Royal Airforce Force personnel, pilots) demonstrated excellent commitment to safety, and I observed that air traffic controllers handled flights in one of Europe’s largest and most complex airspaces with skilled precision and excellent three- dimensional planning capabilities whilst using advanced technologies and following detailed THE BEHAVIOURAL NATURE OF SAFETY VOICE 6 protocols. In 2015-2016, these air traffic controllers handled 4,494,000 flights (i.e., aircraft taking off, landing, or passing through British airspace; NATS, 2018b, 2018a) yet only saw a single serious aviation incident that was attributable to the organisation (NATS, 2018b). However, conversations provided me with anecdotal evidence that people across the aviation industry were able to recall situations in which they were concerned but felt unable to raise this. I was puzzled by the possibility, though unverified, that even in organisations with the strongest safety records people may find it difficult to speak-up about safety. In