Culture Change Process Industries. There has been much discussion in recent years as to how to develop new and improved cultures within the process industries. There appears to be an implicit assumption in these discussions that ours is the first generation to wrestle with the problem of creating a new culture. Nothing could be further from the truth. Indeed, it can be instructive to examine how previous generations affected cultural change with respect to industrial safety and environmental performance, and to consider how their techniques and approaches may apply to our times.
For example, those working in the process industries now take it for granted that safety matters, even when their own organization has a poor safety record or management is merely paying lip service. No one ever says, "Safety doesn't matter". However, such an attitude was not the norm two hundred years ago. A culture change was needed. And that change was achieved, at least in part, through use of a weapon that is rarely used now by process safety professionals: satire. And the master of the genre was Charles Dickens (1812-1870).
Hard Times (1854)
In his book Hard Times, published in the year 1854, set in the fictional Coketown, Dickens satirically condemned the industrialists who failed to acknowledge that safety and clean air mattered.
They [ the industrialists ] were ruined when they were required to send labouring children to school; they were ruined when inspectors were appointed to look into their works; they were ruined, when such inspectors considered it doubtful whether they were quite justified in chopping people up with their machinery; they were utterly undone, when it was hinted that perhaps they need not always make quite so much smoke . . .
It [ Coketown ] was a town of red brick, or of brick that would have been red if the smoke and ashes had allowed it; but, as matters stood it was a town of unnatural red and black . . . It was a town of machinery and tall chimneys, out of which interminable serpents of smoke trailed themselves for ever and ever, and never got uncoiled. It had a black canal in it, and a river that ran purple with ill-smelling dye . . .
Whenever a Coketowner [factory owner] felt he was ill-used - that is to say, whenever he was not left entirely alone, and it was proposed to hold him accountable for the consequences of any of his acts - he was sure to come out with the awful menace, that he would "sooner pitch his property into the Atlantic." This had terrified the Home Secretary within an inch of his life, on several occasions. However, the Coketowners were so patriotic after all, that they never had pitched their property into the Atlantic yet, but, on the contrary, had been kind enough to take mighty good care of it.
In response to such writings, and pressure from many other sources, safety and environmental standards gradually did improve such that, by the year 1954 - a hundred years after the publication of Hard Times - it would have been a rare factory owner who would have declared that, "Safety does not matter". Culture can be changed.
House of Lords Fire (1834)
Although Hard Times is probably the best known of Dickens' satirical attacks on unsafe working conditions, his approach is also illustrated in his writing about the fire in the year 1834 that burned down both the House of Lords and the House of Commons in London. The following is a brief synopsis of this fascinating event (in which there were - amazingly - no fatalities).
Votes in the House of Lords in mediaeval times were recorded through the use of tally sticks - sticks with notches in them. Although no longer in use the old tally sticks were still being stored in the palace. It was decided to get rid of the sticks by burning them in the heating furnaces of the House of Lords. (They could have had an outside bonfire but the smoke might have bothered the people in the neighborhood - an early environmental decision). Richard Weobley, Clerk of the Works (what we would call Facility or Plant Manager) delegated the task to two laborers: Joshua Cross and Patrick Furlong. They threw sticks into the furnaces all day, even though the copper-lined brick flues, which had not been swept for a year, were getting very hot. Weobley, well aware of the fire risk, had warned the two men not to overfill the furnaces or stoke the fires too high but his instructions were ignored.
The first indication that something was wrong came that afternoon when the housekeeper, Elizabeth Wright, was showing round a party of visitors. She complained that the House of Lords chamber was full of smoke; her visitors noted the exceptional amount of heat coming up through the floor. Nonetheless neither they nor anyone else followed up. Cross and Furlong clocked off in the late afternoon, having completed their task. Mrs. Wright locked up the Lords chamber at 5 p.m. Within an hour it was discovered to be ablaze.
Emergency response was hampered by lack of co-ordination between the different forces which turned up to assist. Chief among these was the London Fire Engine Establishment, formed in 1833, which was joined at the fire by its mascot, a dog named Chance. The volunteers who undertook the physically demanding task of pumping water for the engines were paid in beer.
After the event the Prime Minister declared the disaster, "one of the greatest instances of stupidity upon record", thereby making it clear that he, as leader of the country and of the Houses of Parliament, had no personal responsibility for the fire.
Based on the above narrative a modern professional would write a lengthy and earnest report looking at risk management techniques such as LOPA, the need for coordinated emergency response and the importance of maintaining high hazard equipment such as furnaces.
By contrast, here is the "report" that Charles Dickens wrote. Its focus is on political issues, but it also can be read in terms of safety culture.
Ages ago a savage method of keeping accounts on notched sticks was introduced into the Court of the Exchequer, and the accounts were kept, much as Robinson Crusoe kept his calendar on the desert island . . . Official routine inclined to these notched sticks, as if they were pillars of the constitution, and still the Exchequer accounts continued to be kept on certain splints of elm wood called "tallies." In the reign of George III. an inquiry was made by some revolutionary spirit, whether pens, ink, and paper, slates and pencils, being in existence, this obstinate adherence to an obsolete custom ought to be continued, and whether a change ought not be effected.
All the red tape in the country grew redder at the bare mention of this bold and original conception, and it took till 1826 to get these sticks abolished. In 1834 it was found that there was a considerable accumulation of them; and the question then arose, what was to be done with such worn-out, worm-eaten, rotten old bits of wood . . . It would naturally occur to any intelligent person that nothing could be easier than to allow them to be carried away for fire-wood by the miserable people who live in the neighbourhood. However, they had never been useful, and official routine required that they never should be, and so the order went forth that they were to be privately and confidentially burnt. It came to pass that they were burnt in the House of Lords. The stove, overgorged with these preposterous sticks, set fire to the paneling; the paneling set fire to the House of Lords; the House of Lords set fire to the House of Commons; the two houses were reduced to ashes; architects were called in to build others; we are now in the second million of the cost thereof; the national pig is not nearly over the stile yet; and the little old woman, Britannia, hasn't got home tonight.
There are five features that distinguish Dickens' "report" that make it surprisingly modern.
- He does not investigate the 'elements of PSM' such as the lack of training for Mrs. ("there's no smoke without fire") Wright; the "mechanical integrity" of the unswept flues; or the absence of visitor control procedures. He focuses immediately on what we now call inherent safety. The root cause of the fire was the presence of the tally sticks. If the sticks had been disposed of years earlier the fire would not have occurred.
- He directs his criticism at what we now call senior management, i.e., the politicians and senior civil servants who ran the parliamentary system. He does not blame the workers, the firefighters or even the facility manager, Richard Weobley.
- He comes up with what we would now call a "no cost, win-win" solution: give ?these preposterous sticks? to the poor people of Westminster. It costs nothing, it improves the safety of Westminster Palace and it allows the poor to be warmed on a chilly October evening.
- He maintains a sense of humor - something that would not be permitted now.
- His magnificent rhetoric such as "It came to pass . . ." - reminiscent of the speeches of Dr. Martin Luther King - is an integral part of his message.
The fire had one good outcome. Having prevaricated for many years about the need to replace the cramped House of Commons chamber, MPs had the decision made for them. The veteran Radical Joseph Hume - a strong advocate for a new building - declared that the motion for a new House is carried without a division.
Another example of culture change is that led by William Wilberforce (1759-1833). He dedicated his political life to an even more profound cultural cause than factory safety: the abolition of slavery. And he succeeded. The House of Commons (in the old building) passed the Slavery Abolition Act, just three days before his death.
The changes brought about by Wilberforce and Dickens (and the others involved in their causes) were possessed of a very simple feature; they spoke to a very great wrong that could be stated in just a few words: "Slavery is evil", "Safety matters".
The original title for Dickens' book was Hard Times for These Times. He later shortened it, but still, it is useful to consider what lessons Dickens, Wilberforce and so many others have for the times we live in now, particularly as many of the current culture initiatives are trying to make changes to systems that are already quite good.
Such initiatives cannot generally be summarized in just a few words. For example, the core of the draft Safety Culture Policy from BSEE contains nine subheads and 205 words. It provides useful guidance but it lacks punch. Maybe this is because the issue we face now is not, "How do we implement a new safety culture"? but, "How do we make the safety culture we already have - which is actually quite good - work more effectively"?
Charles Dickens was not a safety professional - he was a writer and a parliamentary reporter. He had only a layperson's knowledge regarding building and furnace design. Yet his analysis immediately identifies issues such as Inherent Safety and management responsibility. As we seek to improve the safety of our process facilities maybe we should open our discussions to persons who may not possess technical expertise, but who are capable of cutting to the heart of the matter.