This second issue of ACS Chemical Health & Safety once again offers a variety of articles to invigorate the mind and stimulate dialogue among safety professionals, practitioners, and researchers. As with most safety literature, the topic of culture is inevitably going to surface, and included in this issue is a fascinating account from several contributors of how an organization’s culture for safety was shaped by a catastrophic event.(1) The efforts of Texas Tech University are commendable, and reading about their experiences, as well as reflecting on my own from the investigator’s perspective, drops me down into a proverbial rabbit hole of thought. Please be my Alice and follow me down ... As a former investigator for the U.S. Chemical Safety & Hazard Investigation Board (CSB), I can tell you that it is not surprising to see a company take daring initiatives and implement changes once a catastrophic incident happens. Sadly, all too often, it takes a dramatic and consequential event to trigger safety change. It is persuasive in the moment. Those that existed and worked within the organization preincident often are amazed at the step change in safety that results, and they can provide anecdotal examples of the depth and breadth of that change. But are these examples “evidence” that demonstrate a collective transformation of an organization’s safety culture? As the Texas Tech article offers, one can see commonalities and yet nuanced differences in the retelling of the aftermath of that fateful day by the authors, contingent upon their role at the time and the context within which they were operating at the University. No perspective is wrong—inherently, it cannot be, as it is their perspective—and yet each may define Texas Tech’s culture of safety differently. How do they know the culture for safety is present and, if it is, where it needs to be to prevent the next event? How do they know the culture for safety is present and, if it is, where it needs to be to prevent the next event? Having participated in numerous investigations of devastating industrial incidents in my 14+ year stint at the CSB, I have been given the luxury of contemplating “culture” and, specifically, an organization’s “culture for safety” at length. Time and again I’ve been forced to redefine what a “culture for safety” means, and more importantly, what it looks like. How do we examine something that is often difficult to know intimately without immersing oneself within the organization? Often, as investigators, we would seek out evidence by examining the presence and importance of safety considerations throughout the life cycle of a given process or work program. Do the hazard analyses go deep enough to clearly articulate the barriers, and who is accountable to ensure they work when called upon? How well can personnel from each level within the organization speak to the hazards and the controls meant to mitigate them? Are the major hazards discussed in safety briefings and pretask analyses to a level of detail that those in the meeting know how to recognize changing conditions that may increase hazard risk? If there are recognized gaps between work-as-imagined and work-as-done, how is the organization collectively working to narrow that gap? In asking these questions, what often became clear to me was the following:

• The answers depend on whom you ask or the documentation you choose to look at;
• Perspectives are just as valid as “fact” when it comes to managing safety; and
• Context is everything.

The answers depend on whom you ask or the documentation you choose to look at; Perspectives are just as valid as “fact” when it comes to managing safety; and Context is everything. Assessors of culture are out there, and I look forward to future pieces that seek to educate us on measuring culture. I, myself, have seen some assessments that spent too much time examining how often safety is mentioned in the paperwork without enough comparison on whether anyone’s perspective matches what’s written. I have seen others make valiant efforts to capture the perspectives of significant samples of an organization’s population. I have also seen an assessment that purported fantastic strides in safety culture improvements only to witness a catastrophic event months later. Interestingly, that company likely did make significant improvements, but perhaps had not moved far enough along the “culture for safety” spectrum to have in place effective, well-understood, and sufficiently maintained controls to prevent the event. They saw themselves experiencing a shift in their culture of safety. Yet it was not enough. Everything, even culture, appears to be relative. And ever-changing. As the old adage goes, “The only thing that’s permanent is change.” Which, to quote Alice, makes me “curiouser and curiouser.” Once organizations put in place systems, programs, and influential individuals to enact change, how do they keep it going long-term? Considering the reality that, eventually, influencers of safety move on to new roles and even new employers, how does an organization sustain the collective drive and engagement to maintain its culture of safety? Underlying the success stories, I wager, are powerful efforts to encourage dialogue and clarity of communication about the hazards (and their associated controls) up and down the organizational ladder. I look forward to future articles that enlighten me, and other readers, further. How does an organization sustain the collective drive and engagement to maintain its culture of safety? Views expressed in this editorial are those of the author and not necessarily the views of the ACS. This article references 1 other publications. This article has not yet been cited by other publications. This article references 1 other publications.

中文翻译：

---

进入兔子洞—安全文化视角

ACS化学健康与安全第二期再次提供各种文章，以激发思想并激发安全专业人员，从业人员和研究人员之间的对话。与大多数安全文献一样，文化的话题不可避免地浮出水面，并且在本期中，有几篇有趣的文章讲述了组织的安全文化是如何由灾难性事件形成的。（1）德州理工学院的努力大学是值得称赞的，阅读他们的经历，以及从研究者的角度反思自己，使我陷入了一个众所周知的兔子洞。请成为我的爱丽丝，并跟我来...作为美国化学安全与危害调查委员会（CSB）的前调查员，我可以告诉您，一旦发生灾难性事件，看到一家公司采取大胆的举措并实施更改就不足为奇了。令人遗憾的是，要触发安全性更改通常要花费大量时间和精力。此刻具有说服力。那些在组织突发事件中已经存在并工作过的人通常会对所导致的安全性的逐步变化感到惊讶，并且它们可以提供这种变化的深度和广度的轶事示例。但是，这些例子是否“证据”表明了组织安全文化的集体转变？正如德州理工大学的文章所提供的那样，作者在讲述命运这一天的后果时所看到的共性和细微差别，取决于他们当时在大学中所扮演的角色和所处的环境。没有任何观点是错误的—从本质上讲，这不可能是正确的，因为这是他们的观点—但是每个人可能对德州理工的安全文化都有不同的定义。他们如何知道安全文化的存在，以及是否存在防止下次事件发生的地方？他们如何知道安全文化的存在，以及是否存在防止下次事件发生的地方？在我在CSB的14年多的时间里，参与了许多毁灭性工业事故的调查之后，我得到了深思熟虑的“文化”，特别是组织的“安全文化”。我一次又一次地被迫重新定义“安全文化”的含义，更重要的是，它的外观。如果不将自己沉浸在组织中，我们如何检查通常很难亲密了解的事情？通常，作为研究人员，我们将通过检查给定过程或工作程序的整个生命周期中安全注意事项的存在和重要性来寻找证据。危害分析是否足够深入，可以清楚地阐明障碍，并且谁应负责确保在受到呼吁时能够发挥作用？组织中各个级别的人员对危害和减轻危害的控制措施的满意度如何？安全简报和任务前分析中讨论的主要危害是否达到了使会议中的人员知道如何识别可能增加危害风险的变化情况的详细程度？如果在设想的工作与完成的工作之间存在差距，该组织如何共同努力缩小差距？在问这些问题时，我经常明白以下几点：

• 答案取决于您要求的人或选择的文档；
• 在管理安全方面，观点与“事实”一样有效。和
• 上下文就是一切。

答案取决于您要询问的人或选择查看的文档；在管理安全方面，观点与“事实”一样有效。上下文就是一切。文化评估员在那里，我期待着将来的一些作品，它们旨在对我们进行文化测量方面的教育。我本人已经看到一些评估，这些评估花费了太多时间来检查文书工作中提到安全的频率，而没有就任何人的观点是否与所写内容进行足够的比较。我已经看到其他人为捕捉组织人口中大量样本的观点而做出了英勇的努力。我还看到了一项评估，该评估据称在安全文化改进方面取得了巨大进步，只是见证了几个月后的灾难性事件。有趣的是，该公司有可能做进行了重大改进，但也许在“安全文化”方面还没有走得足够远，无法采取有效，易于理解和充分维护的控制措施来防止事件发生。他们看到自己的安全文化正在发生转变。但这还不够。一切，甚至文化，似乎都是相对的。并且日新月异。正如古老的谚语所说，“唯一永久不变的就是改变。” 用爱丽丝的话来说，这让我“越来越好奇”。一旦组织实施了系统，程序和有影响力的个人来实施更改，他们如何使更改长期进行？考虑到一个现实，即最终有影响力的安全因素会转移到新角色甚至新雇主上，组织如何维持集体动力和参与以维持其安全文化？我敢打赌，成功故事的基础是鼓励在组织阶梯上下对话有关危害（及其相关控制措施）的对话和沟通的清晰性。我期待将来能启发我和其他读者的文章。组织如何维持集体动力和参与以维持其安全文化？本社论中表达的观点只是作者的观点，不一定是ACS的观点。本文引用了其他1个出版物。本文尚未被其他出版物引用。本文引用了其他1个出版物。