A Pilot Project—Introducing a System for Transmitting Information on Safety and Technological Problems Within a Critical Infrastructure Company

Chernov, Dmitry; Ayoub, Ali; Sansavini, Giovanni; Sornette, Didier

doi:10.1007/978-3-031-30772-0_4

Dmitry Chernov⁵,
Ali Ayoub⁶,
Giovanni Sansavini⁷ &
…
Didier Sornette⁸

755 Accesses

Abstract

At the end of 2021, the first author of this handbook began a pilot project for an industrial company that is a world leader in its field. By agreement with this company, the following information must remain confidential and not be disclosed to the general public: the company name, the nature of its operations, the countries where it operates, the specific sites included in the project and the names of employees.

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At the end of 2021, the first author of this handbook began a pilot project for an industrial company that is a world leader in its field. By agreement with this company, the following information must remain confidential and not be disclosed to the general public: the company name, the nature of its operations, the countries where it operates, the specific sites included in the project and the names of employees.

The pilot project tested various methods for significantly improving the quality and speed of reporting information about safety and technological problems within the organization. These methods were formulated based on: (I) the recommendations of 100 leaders representing critical infrastructure companies from around the world (Chap. 3) and (II) analysis of the causes of dozens of industrial accidents in different countries of the world, which revealed numerous occasions where information about risks and problems had been concealed or misreported (Sects. 2.1 and 2.2).

The project involved more than 400 employees of the company, from senior management to shop floor employees. During the first few months of the project, shop floor employees and line managers disclosed seven critical risks to senior management that they believed had the potential to lead to accidents resulting in either the death of personnel, long-term decommissioning of production facilities or significant environmental issues. All these risks were quickly addressed by senior management and production site leaders. In several cases, these prompt disclosures and interventions prevented serious incidents from developing. Within the first few months of the introduction of the project, employees disclosed to senior management 104 other safety and technological problems that were compromising the industrial safety of four of the company’s production sites. Most of these issues have also now been resolved.

The success of the project indicates that, with suitable information transmission systems in place, shop floor employees and line managers are willing to disclose serious safety and technological problems in their area of responsibility to senior management in order to prevent emergencies.

This chapter provides a description of the key features of this pilot project, which was carried out over a period of 10 months from December 2021 to October 2022. Rather than taking a chronological approach, the findings of the pilot project are described from a system-based viewpoint, focusing on factors that have shown to improve the quality of risk information transmission. The project findings are, therefore, presented as a catalogue of initiatives and recommendations that can be adopted by any critical infrastructure company looking to fundamentally improve the quality and speed of risk information transmission up the corporate hierarchy.

I.
THE MAIN OWNER PRIORITIZES SAFETY OVER PROFIT AND PRODUCTIVITY

Prior to the pilot project, the company experienced several serious accidents that had a negative impact on its finances. In response, the main owner replaced part of the senior management team responsible for production and industrial safety. He set them the following task: “Further accidents are unacceptable to me, so I am willing to give you the resources and money you need to prevent them. I do not want the company to be focused on achieving production targets at any cost. The most important thing for me is to prevent further injuries or deaths to the workers, and make sure there are no more serious accidents at our production sites”.

The results of the survey of 100 managers from around the world (Sect. 2.3) show that the main reason (cited by 58% of respondents) why managers are reluctant to receive information about safety and technological risks is the high cost of resolving these problems, and the fact that owners and shareholders prioritize financial and operational performance over safety issues.

In this company, it was the main owner who established safety as his priority and undertook to provide senior management with both the finance and the time to control risks. The owner and senior management have repeatedly emphasized to their subordinates that safety is the most important priority across the entire company’s operations. Permission was granted to stop production and carry out scheduled, preventive or emergency repairs. The production plan can always be adjusted—the central goal is to control risks, and so prevent accidents and injuries.

Almost certainly, it was the owner’s clear statement that he prioritizes safety that encouraged the senior management to adopt a very positive attitude to improving the systems for reporting critical safety and technological problems at the industrial sites entrusted to them.

However, according to senior management, there is a persistent corporate culture among line managers and workers, who continue to believe that the most important goal is to meet the production plan, whatever fine remarks about safety the senior management may say to the contrary. It is possible that some middle managers (heads of production sites and their deputies) are still telling their subordinates that they should not listen to the words of senior management about the priority of safety—“they are just saying what they know they have to say”. Instead, workers are encouraged to focus on the implementation of the production plan and hitting their targets. As in many large industrial organizations, the employees and managers of this company grew up in a paradigm where the work focus has always been meeting production targets. Such deeply ingrained beliefs are very difficult to shift in a short time. It will take many years of targeted action by senior management to demonstrate that things have really changed, and that safety truly does take priority over financial and production objectives—or at least that there is a corporate mechanism to ensure an acceptable balance between safety, finance, and production.

Results of responses to anonymous surveys within the framework of the pilot project: The fulfillment of the production plan is not the main priority of a company—the highest priority is the safety of work and production processes in order to prevent emergency situations and accidents.

What is the level of awareness of these priorities among managers and employees at various levels in the company?

	Very high awareness of these priorities	Many are aware of these priorities	Some are aware of these priorities	Few are aware of these priorities	No one is aware of these priorities	Difficult to answer	Number of respondents
All survey participants	22.4%	42.0%	16.6%	8.3%	0.3%	10.4%	326
Senior management, heads of departments and directors of sites (middle managers)	43.9%	39.0%	12.2%	4.9%	0.0%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	27.8%	48.1%	10.2%	8.3%	0.9%	4.6%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	14.1%	39.0%	21.5%	9.0%	0.0%	16.4%	177

Interpretation of responses: there is a very significant difference between the answers of senior management and those of shop floor employees, which suggests that the message from the owner and senior management about the priority of the safety of work processes over the execution of the production plan is not yet received/ understood/ accepted by lower-level employees.

Results of responses to anonymous surveys within the framework of the pilot project: The fulfillment of the production plan is not the main priority of a company—the highest priority is the safety of work and production processes in order to prevent emergency situations and accidents.

How do things work in reality when choosing priorities in the company?

	Priority is always given to the safety of work and production processes	Priority is usually given to the safety of work and production processes	Priority is usually given to the execution of the production plan	Priority is always given to the execution of the production plan	Difficult to answer	Number of respondents
All survey participants	23.0%	28.8%	31.8%	8.9%	8.0%	326
Senior management, heads of departments and directors of sites (middle managers)	41.5%	24.4%	19.5%	12.2%	2.4%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	27.8%	26.9%	35.2%	5.6%	4.6%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	15.8%	31.1%	31.6%	10.2%	11.3%	177

Interpretation of responses: the responses from senior management suggest they (unconditionally or usually) give preference to the safety of work and production processes when making decisions, while people at the bottom of the hierarchy are placed in such a position that, regardless of the stated priority of safety, they are often forced to prioritize the production plan.

Lessons learned (from this experience for other critical infrastructure companies that want to fundamentally change the quality and speed of risk reporting within their organization): before implementing any changes, it is necessary to obtain the following agreements from owners and key shareholders: (I) they agree to view their investment in a company as long-term; (II) they are willing to be informed of serious technological and operational problems; (III) they are willing to devote significant resources to solving these problems when they are reported, in order to reduce the likelihood of major accidents and increase the reliability of critical infrastructure in the long term.

If senior management have support from owners and shareholders, then executives will be grateful to receive disclosures from their subordinates about serious risks and problems. For senior management, this information will be viewed as “good news”, as it will allow timely identification and mitigation of risks, which in turn will have a positive impact on a company’s finances.

If owners and shareholders consider their investments in an organization as short-term and are unwilling to reduce the profit margin of the business—which is clearly likely to occur when accumulated critical risks are addressed—then it is not recommended to launch a similar project there. In the absence of full support from owners and shareholders, implementation is likely to fail and have negative impacts. If senior management are not given enough resources to mitigate any serious risk or problems that their subordinates identify, then employees will quickly lose trust in the new system. They will soon revert to their previous long-standing behavior and keep quiet about safety and technological problems.

II.
THE COMPANY HAD PREVIOUS NEGATIVE EXPERIENCE ARISING FROM DELAYED TRANSMISSION OF RISK INFORMATION

The company had experienced a serious accident in the past. In the early hours of the accident, the managers responsible underestimated the scale of the problem. As a result, they timely informed their superiors about an incident, but not about the accident. There was no evidence that key information was deliberately concealed: it was simply that in the beginning, the line managers involved were confident that the incident was local, and that they could manage the situation independently. The real scale of the accident and the significant resources required to manage the escalating consequences only became apparent a day afterwards. It was then that senior managers were informed about real scale of the accident. If the real scale of the accident had been promptly reported to them, then the consequences of the accident would have been much less serious because appropriate decisions could have been made and resources deployed more rapidly.

This company then had a further serious accident where line managers again underestimated the scale of the evolving situation and failed to inform their superiors promptly enough. The result again was a major accident.

Fortunately, neither accident resulted in deaths, but nevertheless they had a significant impact on the company’s finances. In critical infrastructure companies, it is almost always much cheaper to deal with risks before they cause an accident, rather than to manage the fall-out from a serious incident.

These previous experiences motivated senior management to find ways to improve communication and action coordination between different levels of management, both before and during an emergency. They openly acknowledged the problem: “We, as leaders, do not know what is happening at the bottom of the corporate hierarchy. We need to improve critical risk communication”.

Results of responses to anonymous surveys within the framework of the pilot project: Imagine that employees at an industrial site detect a serious technological risk. Based on your experience, what do you think employees will do when this risk is discovered?

	Employees will immediately report the risk to their supervisor, who, in turn, will quickly inform the site management. A special group will be promptly established to carry out a risk analysis. If the risk is deemed unacceptable, then production work will be halted, and measures implemented to control the identified situation	Employees will report the risk to their supervisor, but this information will not be transmitted further up the hierarchy. Employees and their manager will try to independently address the risk using their own resources; it is possible that work will be stopped or reduced at the site	Employees will not report the risk to their immediate supervisor, but will try to eliminate the identified risk on their own, and production work will not be stopped	Employees will ignore the risk as they work in a dangerous industrial production facility, where there are already many serious hazards; employees simply do not have time to respond to all potential risks, because they need to keep working and fulfill the production plan	Difficult to answer	Number of respondents
All survey participants	38.6%	48.9%	3.9%	2.5%	6.1%	280
Senior management, heads of departments and directors of sites (middle managers)	41.7%	44.4%	8.3%	2.8%	2.8%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	43.3%	44.2%	4.8%	2.9%	4.8%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	34.3%	53.6%	2.1%	2.1%	7.9%	140

Interpretation of responses: a significant proportion of the respondents across all three groups believe that a serious risk will be promptly transmitted up through the entire management hierarchy of the company. Nevertheless, most lower-level employees believe that information about the risk will not go beyond the level of their immediate supervisors. They, together with their subordinates, will try to address the situation on their own, and not bother their superiors.

Lessons learned: company managers should analyze any previous serious incidents that have occurred within their organization. This will help establish whether there were incidents that occurred after warnings from subordinates had been ignored, and whether there were delays in transmission of critical information up or down the hierarchy after the onset of an emergency. It is also important to analyze a company’s successful experiences: times when efficient communication about risks, both before and during emergencies, made it possible to tackle problems before they became too serious. A retrospective analysis of both successful and ineffective management of risk situations within a company will provide invaluable data for all the participants of the new project: it should help them identify specific weaknesses in the current system, and practices that can be expanded where risk transmission worked well, and serious incidents were avoided. It is also recommended to create a special pool of employees and managers who can share positive examples from their own practice that other participants can then develop for their own situation.

III.
HOLDING A SPECIAL SEMINAR ON COMMUNICATION AND DECISION MAKING IN THE EVENT OF ACCIDENTS AT LARGE TECHNOLOGICAL FACILITIES

In July 2021, the first author of the handbook received an offer from the company to conduct a seminar on management decisions and communication in the event of major infrastructure accidents. The company’s leaders wanted to improve the quality of their team’s response to emergency situations and make their communication with external audiences more efficient during emergencies.

As a result, a two-day seminar was held in October 2021, bringing together more than 100 leaders of this company. The research presented demonstrated that the first step to effective emergency management is prompt and reliable reporting about any incident from heads of production sites to senior management at headquarters. This should include detailed, accurate, and transparent information: where, when, and how the incident occurred; an objective analysis of the current and possible extent of the emergency; and their ideas on the best response to the situation, including resources required, production shutdowns and time required before the emergency is under control. The first part of the seminar was devoted to the problems of transmitting risk information up the hierarchy during the early minutes and hours after an accident. Examples of relevant accidents within critical infrastructure organizations were given.^{Footnote 1}^,^{Footnote 2}^,^{Footnote 3} It was emphasized that, when site managers understated the scale of an emergency or concealed information about the reality of the situation at their facility during reporting to a company’s headquarters, the situation was made worse. Such concealment of the truth typically leads to: (I) a delayed and inadequate response by senior management and the entire company to the developing crisis; (II) absence of key senior managers and specialists at the scene of the emergency; (III) critical delay of top-level decisions on the allocation of emergency resources for controlling the situation; (IV) an “information vacuum” around the accident, which is filled by rumors, misinformation and panic at the site and further afield, for example among people living close to the site and the media. It later transpired that this issue was of particular concern to the senior management of this company, after the already mentioned negative experience of two previous serious incidents.

As part of the seminar, an anonymous survey was conducted to hear the opinions of employees regarding the current situation of risk information transmission within the company. The survey showed that in the overwhelming majority of cases, senior management expected that the reports of their subordinates on existing risks would contain distorted or concealed information. This served to further confirm their belief that significant problems existed in the reporting of objective risk information up the corporate hierarchy.

When discussing the results of the seminar and the anonymous survey, the first author of the handbook suggested to senior managers (the Senior Vice President in charge of production at the key industrial site of the company [SVP], and the Vice President in charge of HSE) that they launch a pilot project to radically improve the quality and speed of reporting about safety and technological risks from shop floor employees to senior management. In November 2021, senior management gave the green light for the implementation of this pilot project.

Results of responses to anonymous surveys within the framework of the pilot project: In your experience, how often are employees afraid of expressing disagreement with their superiors?

	Constantly	Often	From time to time	Very rarely	Never	Number of respondents
All survey participants	4.9%	42.3%	39.3%	10.7%	2.8%	326
Senior management, heads of departments and directors of sites (middle managers)	2.4%	39.0%	36.6%	22.0%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	2.8%	12.0%	44.4%	35.2%	5.6%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	5.1%	47.5%	36.7%	7.3%	3.4%	177

Interpretation of responses: 86% of all survey participants (all those who responded “Constantly”, “Often”, “From time to time”) considered that employees of the company are afraid to disagree with the opinion of their superiors. This supports the idea that the usual communication model in large industrial organizations is a top-down monologue from managers who make decisions that they expect to be carried out by their subordinates without comment or question. This model discourages a culture of openness when raising any problems and difficulties that employees face in implementing management decisions. Fear of disagreeing with superiors is strongest among shop floor employees, while their immediate superiors (lower management) have a worrying misapprehension that their subordinates are not afraid to raise objections and issues with them. In reality, rank-and-file employees simply prefer not to object to their bosses’ decisions and will dutifully implement them to the best of their abilities, although they may disagree with them. This suggests that shop floor employees will even remain silent when they observe risk issues in their own area of responsibility. This is especially true if the problems arise directly because of poor decisions by their immediate supervisors and senior management.

Results of responses to anonymous surveys within the framework of the pilot project: In your experience, how often do employees hesitate to report problems, risks, and minor incidents to their superiors in their area of responsibility?

	Constantly	Often	From time to time	Very rarely	Never	Number of respondents
All survey participants	3.1%	30.1%	40.2%	23.6%	3.1%	326
Senior management, heads of departments and directors of sites (middle managers)	2.4%	46.3%	22.0%	26.8%	2.4%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	4.6%	31.5%	34.3%	27.8%	1.9%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	2.3%	25.4%	48.0%	20.3%	4.0%	177

Interpretation of responses: 73% of all survey participants (all those who responded “Constantly”, “Often”, “From time to time”) admitted that employees hesitate to disclose the problems and risks they observe in their area of responsibility. These results indicate that the company has significant problems in the effective reporting of risk information. Senior management response suggest that they believe their subordinates often distort the real situation in the field, while most lower-level employees believe that this distortion occurs much less frequently. This can be interpreted as follows: most shop floor employees sometimes distort information about observed problems when reporting to superiors. Meanwhile, senior managers are getting information from many departments with hundreds or even thousands of employees—all of whom sometimes distort information. As a result, they often see a discrepancy between reports they receive from their subordinates and what they observe at industrial sites. Therefore, the higher the respondents are in the hierarchy of the company and the more employees they have responsibility for, the more often they will see problems, risks and minor incidents being concealed by their subordinates.

Results of responses to anonymous surveys within the framework of the pilot project: Who bears most of the responsibility for creating an internal corporate climate where discussion of organizational problems and existing risks is not welcome?

	Managers	Shop floor employees	Number of respondents
All survey participants	87.5%	12.5%	326
Senior management, heads of departments and directors of sites (middle managers)	95.1%	4.9%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	80.6%	19.4%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	91.0%	9.0%	177

Interpretation of responses: Answers from the most senior managers (95.1%) correlate well with the responses from the 100 critical infrastructure executives from around the world interviewed between 2018–2021 (Sect. 2.3). In these earlier interviews, 97% of respondents felt that managers bear most of the responsibility for creating a climate in which discussion of organizational problems and existing risks is not welcome.

Results of answers to anonymous surveys within the framework of the pilot project: It is beneficial within the company not to inform about risks: no one bothers with additional questions, and there are no penalties for concealing risks.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	7.5%	25.7%	37.5%	25.0%	4.3%	280
Senior management, heads of departments and directors of sites (middle managers)	8.3%	13.9%	41.7%	36.1%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of the HSE services at sites	5.8%	20.2%	39.4%	32.7%	1.9%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	8.6%	32.9%	35.0%	16.4%	7.1%	140

Interpretation of responses: it is noteworthy that senior management, middle and lower managers insist that the company does not benefit from hiding information about risks, whereas a significant proportion of shop floor employees (more than 40%) believe the opposite. The higher the position of respondents in the hierarchy of the company, the less inclined they are to agree with the statement that it is beneficial for the company not to inform about risks; the lower their position, the more likely they are to support this statement. However, most respondents at all levels of management believe that it is unprofitable to hide information about risks from superiors and colleagues.shown the analysis of dozens of industrial.

Lessons learned: the experience of conducting seminars on how to respond to emergency situations, together with surveys of the participants, shows that the problem of reporting accurate information before and during emergencies is not always obvious to many managers and employees. Prior to the seminars, some did not fully understand the critical importance of communicating objective risk information across the company’s hierarchy. Significant number of the seminar participants only began to appreciate the severity of the problem after being made familiar with its consequences in the development of major industrial disasters. Therefore, prior to launching a project to transform a company’s culture around communication, it is very beneficial to hold special seminars for key managers and staff to convince them of the critical importance of information transmission, and to illustrate the disastrous consequences of hiding information. It is also recommended that, as part of these seminars, anonymous surveys are run to assess the current situation within the company and across its production sites in regard to the transmission of risk information.

IV.
RANKING THE COMPANY’S CRITICAL RISKS TO AID THE SELECTION OF SPECIFIC SITES AND PROJECT PARTICIPANTS

When the decision was made to launch a pilot project, four production sites were selected (from among dozens of possible company plants) where an accident could have catastrophic consequences for the overall production process and the company’s finances. The sites were also selected to cover different parts of the production process so that:

the anonymous surveys of project participants could be analyzed according to the production site they work at, to see if there were significant differences in their corporate cultures. It was also important to identify if there were different reasons for concealing risk information at particular sites.
it was possible to test different solutions within the pilot project to determine which of them proved effective and which did not. This information was important in selecting the practical solutions that could then be successfully rolled across all the various sites of the company during the subsequent scaling up of the project.

A total of 422 company representatives participated in the project. Approximately 10% of these were senior managers, heads of departments and directors of production sites selected for the pilot project. The other 90% were drawn from different levels of management across the four production sites and included lower-level managers and shop floor employees who regularly managed critical facilities, where failure could inflict serious losses for the company.

Participants were selected from the four production sites as follows:

general director of the site (head of the plant);
all deputies of the general director of the site supervising production, industrial safety, logistics, procurement and warehouse;
head of the HSE services at the site, as well as their subordinates;
heads of key production workshops and their deputies, and heads of sections of these workshops;
engineers, foremen and shop floor employees operating critical infrastructure in these workshops.

Approximately 5% of the combined workforce of the four production sites became participants in the project.

Lessons learned: there is a danger of excessive information noise when shop floor employees and line managers are reporting data about safety and technological risks to senior management. When setting up similar pilot projects, in order to reduce information noise to a minimum, it is recommended to choose for reporting those production sites in which accidents can have the most serious consequences for a company. The number of managers and employees who operate and manage the most critical infrastructure is limited. By selecting around 5–10% of the whole workforce of the selected production sites, senior management will not be overwhelmed by having to engage with thousands of employees. Executives will be able to meet the participating employees face to face, and quickly establish the process of getting a faster and more accurate flow of information about critical and serious risks up through the company’s hierarchy.

When scaling up solutions across a company, it is also recommended to start with only 5–10% of the employees who manage the most dangerous production processes across an organization. It is not recommended to scale up too rapidly by trying to immediately include every employee. There is a serious threat that this would overwhelm a company’s capacity by triggering a huge wave of messages about various technological risks and problems—the criticality of which will, for the most part, be low. The priority is to get the most critical and serious risks under full control. Only then will it work to gradually expand the circle of employees and managers who have the authority to report information about risks in their area of responsibility to senior management through specially established direct channels.

V.
IN-DEPTH INTERVIEWS WITH SENIOR MANAGERS AND MANAGERS OF PRODUCTION SITES SELECTED FOR THE PILOT PROJECT

In December 2021, the project leader began conducting in-depth interviews with the company’s senior managers to understand why the company had problems with internal risk communication, and how they imagine a successful intra-organizational risk communication system would look as a result of the project. In-depth interviews allowed the project leader to immerse himself in the company’s culture and activities, and understand the hopes and expectations that the managers had for the project.

Lessons learned: from the outset, it is important to determine the main senior managers who will be involved in the project for many months. At this initial pilot stage, only a proportion of the senior managers were involved, and had a key influence on how the project unfolded. Retrospectively, it became clear that it would have been better to draw in all the most senior managers who, in one way or another, could influence how the project evolved in the future. They should all be invited to the initial launch meeting, attend the introductory educational seminars, participate in in-depth interviews, and so on. If some are excluded from the discussion and decision-making during the pilot project, they are more likely to oppose the ideology and direction of the project in the longer run, when it is rolled out company-wide. The experience of the pilot project showed that any managers not involved from the outset might well continue to behave as they always have done—reinforcing the old fear among employees about bringing “bad news” to their superiors, so that risk information continues to be concealed. This can seriously undermine the entire project, and the problems of risk communication within the organization will simply resurface.

Therefore, a list of all senior managers who could potentially be included in the project should be discussed with the head of a company. If the project later requires the involvement of some new senior managers, then they must undergo special training and be brought up to speed so that they share the ideology of the project before being authorized to make any decision affecting it.

VI.
HOLD A LAUNCH MEETING WITH SENIOR MANAGEMENT AND MANAGERS OF PRODUCTION SITES SELECTED FOR THE PILOT PROJECT

When in-depth interviews with senior managers have been completed and the main sticking points within the company have been identified, the next step is to hold a launch meeting of all senior managers included in the project, as well as the managers of the production sites selected for the pilot.

At this launch meeting in December 2021, the company’s SVP^{Footnote 4} told the audience why the company had decided to support the pilot project. The SVP also outlined the key project goals and expectations, and asked his subordinates to assist the project leader in making the project a success. The pilot project leader then presented the work plan for the coming months. Questions were taken from the audience, which were answered by the SVP of the company and the project leader. From that moment on, the pilot project was officially launched.

Lessons learned: prepare the key points of the project and have the head of a company present them. This is important, since the entire management team will see that the implementation of this project is a priority for the company’s top brass. This will have a positive impact on the successful implementation of the project, since lower-level managers will try to follow the direction that has been set by the company’s head.

VII.
HOLD A SERIES OF SEMINARS FOR SENIOR MANAGEMENT, MANAGERS AND EMPLOYEES OF THE SITES SELECTED FOR THE PILOT PROJECT

In the opinion of the authors of the handbook, holding a full day interactive educational seminar is the most effective way to convey the main principles of the project to the participants. It also provides an ideal opportunity to hear first-hand why the participants think risk information is concealed in the company, and what they think can be done to improve the quality and speed of risk communication and thus reduce accidents. During an in-depth interview, one senior manager of the company said: “People really appreciate that they are being listened to. Listening is key. It’s great that you [the pilot project leader] will go to the workforce and ask them what they think is the best thing to do to change the situation regarding the reporting of risk-related information. I hope that at the very least people will open up a bit—this in itself would be a great achievement—but if we can change how they think—well, that would be a real breakthrough. This project is a unique experiment. Our company has never talked to its employees like this before. We have always just told them what to do, and never been interested in hearing what they had to say”.

As part of the pilot project, the project leader conducted 15 seminars for 422 participants:

3 seminars for senior management, heads of departments of the company and heads of production sites selected for the pilot project (10% of participants);
5 seminars for lower-level managers: deputy directors, heads of workshops, and heads of HSE services at the selected sites (25% of participants);
7 seminars for engineers, foremen and shop floor employees who operate critical infrastructure at the selected sites (65% of participants).

Below is the structure of this interactive full day seminar. It ran from 9 am—6 pm with an hour’s lunch break and two 20 min coffee breaks. For the seminars, a 300-page presentation was prepared, which included the following sections:

1.
Demonstration of the relevance of the problem of concealing information about risks in critical infrastructure companies
- Major management errors recorded in recent large-scale industrial accidents. Drawing on 15 years of research by the first author of the handbook on management decisions and communication in emergencies, ten major management errors have been identified that are seen over and over again in many disasters, regardless of the country. One of these is the suppression of objective information about emergencies reported by subordinates through the corporate hierarchy of a company—including communication with external audiences, such as regulatory authorities, local populations, media, and so on. Examples were given of large and well-known accidents where it has been established that information about the true scale of the incident and the real state of affairs at the scene of the emergency were concealed.^{Footnote 5}
- Examples of information about risks being concealed before a disaster. Some of these accidents were then discussed in more detail. The reasons risk information was suppressed were analyzed, as well as how this failure in communication had led to the accidents.^{Footnote 6} To highlight the relevance of the problem, the accidents discussed were selected from the same industry as the pilot project company. Naturally, this helped the seminar participants engage with the discussion: they were studying the negative experiences of comparable organizations, facing similar kinds of production pressures and problems as their own company.
- Negative experience of this company in reporting information about critical risks before and during emergencies. The presentation then turned to the two incidents that had recently occurred in this company, where problems had been identified with the transmission of risk information (the details of these were mentioned earlier).
2.
Parting words of the company’s SVP

The company’s SVP recorded a special video message shown to all the pilot project participants at the seminars:

“Dear colleagues!

We operate a critical industrial infrastructure.

It is important for all of us to work together to prevent emergencies by avoiding a critical build up of negative events. We need to be proactive and control serious risks as effectively as we can so as to prevent accidents occurring.

The safety of employees and the reliability of our critical infrastructure is the most important priority for our company.

The implementation of the production plan should only proceed when the safety of employees and production processes has first been secured.

The company owners and shareholders have provided me and the heads of the production sites with the necessary authority and resources to adjust production plans in order to prevent critical problems from developing. We are also ready to take prompt action to stop production if the safety of workers and production processes cannot be guaranteed. All this is aimed at preventing emergencies and accidents occurring at our production facilities.

I also want to say, personally as well in my role as the director of your facility, that we actively want to hear any information you have about safety, technological, and production issues that you observe in your area of responsibility, however difficult or serious the problem might appear.

This project is aimed at improving the quality and speed of the transmission of critical risk information from employees at production sites to the company’s executives.

We need to ensure that we, as executives, are informed early on about problems on the ground so that we can respond to them promptly. We do not want delays in receiving this information as the longer a problem is left, the harder it becomes to solve. We are all determined to work together to stop critical events developing and prevent emergencies.

I would like to make it clear that nobody will be penalized for voluntary disclosure of information about critical risks. On the contrary, we will be grateful to you for these communications, and guarantee to assist in solving the problems you have helped identify. All the senior managers who participate in this project will also praise rather than punish any subordinates reporting problems on the ground, and will help employees tackle the issues. All senior and site managers are committed to providing local managers with the resources they need to tackle any safety problems and production issues that their subordinates report to them.

I ask you to work proactively, learn to identify risks at an early stage, then report them promptly to me personally or to your line managers, so that critical situations do not have a chance to develop. Never be afraid to disclose risks in your area of work to your superiors—you can be confident that your reports will be welcomed and carefully analyzed, and you will then be given the necessary authority and resources to solve the problem you have helped to identify.

I ask that you take an active part in this seminar. Provide an honest and objective assessment of the state of affairs in your own area of responsibility. Do your best to share any ideas that you think could improve the quality and speed of transmitting information about risks so that together we can prevent serious incidents and emergencies from occurring.

Thanks a lot! I wish you fruitful work!”.

This appeal contained several key messages from senior management to subordinates:

owners and senior management agree that safety is the most important corporate priority;
owners and senior management are ready to stop production in order to prevent accidents if a critical risk is detected;
senior management and site managers (middle management) actively want to receive accurate, objective information about existing risks and problems that could lead to a serious problem;
senior management have the resources available to address critical and serious issues reported by project participants;
senior management promise not to penalize any employee for disclosing information about risks but on the contrary to praise them.

3.
Anonymous survey No. 1—the reasons why risk-related information is concealed within the organization

As part of this seminar, an anonymous online survey was conducted to understand: (I) why employees and managers at various levels in the company have difficulty transmitting risk information to their line managers, and (II) why managers at various levels have difficulty receiving information from their subordinates about risks and problems.

Participants were asked to scan a QR code into their smartphones or follow a link to an online survey page, where they were asked to answer 40 questions about why risk-related information was concealed within the organization:

1.
In your experience, how often are employees afraid of expressing disagreement with their superiors? (Constantly | Often | From time to time | Very rarely | Never)
2.
In your experience, how often do employees hesitate to report problems, risks, and minor incidents to their superiors in their area of responsibility? (Constantly | Often | From time to time | Very rarely | Never)
3.
Some employees appear reluctant to inform managers about problems such as equipment failure, mistakes in their work or inability to achieve their targets. Why is this happening?
1. 3.1.
  The income of some employees is linked to reaching production targets. Reporting risks to management can jeopardize things here, as production will probably be halted, delaying the payment they usually receive when the targets are reached. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
2. 3.2.
  Fear of blame and punishment from supervisors. Employees believe they will be held accountable for any problem they report to their supervisors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
3. 3.3.
  Employees are afraid of losing income and spoiling their career prospects (including being fired) because they could look incompetent if they report a problem in their area of responsibility to their superiors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4. 3.4.
  In many organizations it is simply not customary to discuss risks and problems with managers. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5. 3.5.
  Fear of destroying relationships with colleagues or line managers. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
6. 3.6.
  Additional burden and responsibility. Some employees fear that managers will require them to take responsibility for any problem they report, in addition to their current workload. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
7. 3.7.
  Employees do not fully understand risks in their area of responsibility and lack the training or experience to accurately assess the criticality of the situation. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
8. 3.8.
  Employees believe it is pointless to transmit information about risks to managers, because all similar previous warnings have failed to produce any kind of response. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
9. 3.9.
  Employees are afraid to appear disloyal to a company, be labeled as troublemakers who are”rocking the boat”, or give the impression that they think they are better than everybody else. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
10. 3.10.
  Some employees are over-confident in their own abilities and believe they can solve the problem on their own, without requesting the support of their superiors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
11. 3.11.
  Industrial safety indicators and the bonus system within a company work to keep risks and problems concealed when reporting to superiors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
12. 3.12.
  Employees are afraid to take the initiative as it can produce unpredictable and risky results: “why stick your face into a hornet’s nest”, “don’t put your head above the parapet unless you want it shot off”, “slow and steady wins the race”. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
13. 3.13.
  Some employees only want to show themselves in the best possible light to their superiors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
14. 3.14.
  Unwillingness to upset superiors by reporting negative news about risks within an organization: “superiors can take information like this very personally… it is like the employee is blaming them for the problem because of earlier bad decisions they made”. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
15. 3.15.
  Some employees are indifferent to any risks they might notice, being simply too lazy to take positive action, and like to believe that with a bit of luck nothing serious will come of it anyway. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4.
Why do you think managers often do not want to hear bad news from employees about matters like observed risks and problems in an organization and the need for additional investments, like equipment upgrades, to create safer production processes?
1. 4.1.
  Shareholders set tough and ambitious financial and operational goals for the management, which do not make any allowance for the additional—often high—costs that may be necessary to deal with problems identified by employees. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
2. 4.2.
  The income of some managers is tied to the implementation of production plans. An adequate response to most risks requires a halt to production. This threatens the successful implementation of the production plan, as targets are difficult to adjust downwards, however necessary the stoppage. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
3. 4.3.
  When a manager receives information about a problem that requires additional resources to rectify, he will have to report this bad news to his superiors. If he cannot sort the problem out at his level, he may find this has a negative impact on his career. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4. 4.4.
  Excessive bureaucracy interferes with the practical solution of any identified problems. Managers face complex corporate procedures when going through budgeting and investment committees, so issues are resolved very slowly. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5. 4.5.
  There are limited resources available for managers to solve problems. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
6. 4.6.
  Leaders are afraid of being seen as incompetent and being held accountable for their previous bad decisions that created the current problems. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
7. 4.7.
  Managers believe that once a problem has been reported to them, they are automatically responsible for solving it. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
8. 4.8.
  Managers expect employees to solve problems on their own when they occur in their area of responsibility. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
9. 4.9.
  Managers prefer not to be made aware of identified risks so as not to become legally liable if these eventually lead to an incident. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
10. 4.10.
  Leaders do not want to deal with difficult issues that require them to step out of their comfort zone. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
11. 4.11.
  Managers are people too – they prefer to receive good news, not bad. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
12. 4.12.
  Managers consider problems reported by employees to be unimportant. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
13. 4.13.
  Managers have short-term contracts and are focused on achieving short-term results, so do not want to get involved in solving serious problems that require years of effort, because the results of these efforts will not be visible until several years after they have left their position. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
14. 4.14.
  The generally accepted culture of behavior for leaders permeates entire industries: leaders insist that employees bring them mostly good news about successes and achievements, and problems are solved by employees without bringing them to the attention of managers. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
15. 4.15.
  When employees bring information about problems to their managers that they should then disclose to regulators, this is likely to mean an immediate increase in the number of site inspections, which in turn means additional time, cost and stress to manage this extra burden. Managers can therefore be reluctant to pass the information on to appropriate regulators. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5.
Who bears most of the responsibility for creating an internal corporate climate where discussion of organizational problems and existing risks is not welcome? (Managers | Shop floor employees)
6.
How do you rate the level of trust of employees towards their managers in your enterprise? (Very high | Medium high | Medium | Low | None | Difficult to answer)
7.
How do you rate the level of trust of managers towards their employees in your enterprise? (Very high | Medium high | Medium | Low | None | Difficult to answer)
8.
Do you think that the managers and employees in your company are in a hurry? (Rarely | Sometimes | From time to time | Often | Constantly | Difficult to answer)
9.
In your organization is there a lot of pressure on managers and employees to implement the agreed production plan? (No | Some pressure | Yes | Difficult to answer)
10.
Middle and lower managers have the power to stop the work of a workshop, and even the entire operation of a plant, if critical risks are identified. Employees are given the right to refuse to perform unsafe work. In your experience, how often do managers and employees exercise these rights? (Very often | Often | Occasionally | Rarely | Never | Difficult to answer)
11.
The fulfillment of the production plan is not the main priority of a company—the highest priority is the safety of work and production processes in order to prevent emergency situations and accidents.
1. 11.1.
  What is the level of awareness of these priorities among managers and employees at various levels in the company? (Very high awareness of these priorities | Many are aware of these priorities | Some are aware of these priorities | Few are aware of these priorities | No one is aware of these priorities | Difficult to answer)
2. 11.2.
  How do things work in reality when choosing priorities in the company? (Priority is always given to the safety of work and production processes | Priority is usually given to the safety of work and production processes | Priority is usually given to the execution of the production plan | Priority is always given to the execution of the production plan | Difficult to answer)
3. 11.3.
  Have you been made aware of the main critical risks of your enterprise? (High awareness | Medium awareness | Low awareness | No awareness | Difficult to answer)

It is worth noting that not all seminar participants took part in the anonymous online survey. Out of 422 people who attended the 15 seminars, 326 (77% of the seminar participants) answered these questions. This suggests that a significant proportion of managers and employees (a quarter of all respondents) are afraid or unwilling to express their opinion on difficult issues around relations between managers and employees in a company even within the anonymous online survey.

4.
Discussion on the reasons behind risk information concealment

The participants of the seminar were shown the analysis of dozens of industrial disasters conducted by the authors of this handbook between 2013–2022 (summarized in Sects. 2.1 and 2.2). In addition, they were shown a study of the reasons behind concealment of risk-related information based on in-depth interviews with 100 critical infrastructure executives conducted in 2018–2021 (Sect. 2.3).

After that, participants were presented with the results of anonymous survey No. 1 conducted earlier within this same group. This gave them an opportunity to examine the reasons for risk information concealment within various large industrial companies, and also to analyze the main reasons why proper risk information transmission was sometimes blocked or impeded in their own company.

5.
Group work No. 1—how the problem of risk information concealment can be solved in this company

The participants were divided into several small groups and moved to different areas of the seminar hall. They were asked the following questions, to answer as a group:

Paint an ideal picture of an effective process for communicating technological risks from shop floor to senior management within your organization.
What are the current barriers/challenges to rapidly reporting risk-related information from the bottom up in your organization? Where is information lost? Why is information lost?
What needs to be done to improve the quality of risk-related information that is reported from the bottom up in your organization? Offer practical solutions.
What barriers/problems currently exist to effectively mitigating technological risks identified in your organization?
What needs to be done to improve the quality of ongoing mitigation measures for technological risks identified in your organization?
Suggest how to build a high level of employee trust in managers—in other words, what should managers do to gain the trust of their subordinates?
Do you agree with the statement that preventing accidents by identifying technological risks and disclosing these risks to colleagues and management is the professional duty of responsible employees, so neither tangible nor intangible rewards are needed for disclosing risks?
If the company does decide on rewards for disclosure, what are the pros and cons of financial incentives for employees disclosing information about technological risks? Identify the pros and cons of non-material rewards for employees disclosing this information.
Describe what you think is the best way of rewarding employees for disclosing information about technological risks in your organization.
Instead of reporting a safety issue to the head of a production unit, employees shoot a video and upload it onto social networks. Who is to blame for this situation? How can management motivate employees to report risks to their managers, rather than exposing this sensitive information to the public?

The seminar participants were given approximately 40 min to answer these questions. The responses of the group members were recorded in writing on large sheets (flip-chart format). Then each group delegated a representative to present the group’s results to the seminar’s participants, and an audio recording was made of these presentations. The project leader later analyzed and collated all this data and created a list of possible solutions that should be explored within the project.

6.
How the “cover-up” problem can be solved: 10 key recommendations from in-depth interviews with 100 executives around the world

The seminar participants were shown the results of the 2018–2021 study described in detail in Chap. 3 of this handbook.

7.
How the problem of concealment can be solved: a thermodynamic model for the transmission of information about risks

The seminar participants were shown the thermodynamic model presented in Recommendation 5 of Chap. 3, which makes a direct link between the growth of employee trust in managers and an increase in the quality and speed of communication about risks. This model builds on the following recommendation: “Senior management should build an atmosphere of trust and security, so that employees feel safe to disclose risk-related information”.

After that, a video was shown to the project participants, presenting an appeal from the company’s SVP: “We all need to strive to build trusting relationships with our subordinates. This is the only way we can start the process of transmitting really important information about risks from the bottom up, from departments to senior management, and horizontally, between different departments. I say again: do not be afraid to bring me and your superiors information about serious problems—we will deal with these and calmly solve them together! I am ready to play my part in the analysis of the critical information that you will be reporting, and then making decisions to solve them. I will also personally thank everyone who voluntarily discloses serious safety and technological risks and thus helps prevent serious incidents”.

This message helped convince the project participants that senior management were focused on building trust in relationships with their subordinates, and ready to fully commit to finding effective solutions to safety and technological problems.

8.
Anonymous survey No. 2—how the problem of risk information concealment can be solved

The purpose of this survey was to understand what needs to be done to fundamentally change the situation in respect to communication of risk-related information at the pilot production sites, by creating simple, practical, and easily implemented solutions.

Seminar participants had to scan a QR code on their smartphones or follow a link to the online survey, where they had to answer next 40 questions on what practical steps could be taken to improve the quality and speed of risk communication in the company:

12.
How do you increase the level of trust of employees in managers, and motivate them to report risks upwards?
1. 12.1.
  A leader must be authoritarian (e.g. be the sole decision-maker and carry overall responsibility for a company’s performance) in order to meet the difficult challenges of managing a critical infrastructure company. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
2. 12.2.
  A leader should be more democratic (e.g. share decision-making, delegate some power to active employees, take joint responsibility for the results of the unit’s work with them). (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
3. 12.3.
  A trusting relationship between a manager and their subordinates is necessary to create an environment where if feels safe to share information about existing problems. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4. 12.4.
  It is beneficial within the company not to inform about risks: no one bothers with additional questions, there are no penalties for concealing risks. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5. 12.5.
  A high level of employee trust in managers leads to improved transmission of information about risks throughout a company; and conversely, low trust leads to a lack of willingness to transmit risk information to superiors. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
6. 12.6.
  In order for employees to trust managers, their actions should match their words. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
  
  You were shown the “Thermodynamic model of risk information transmission”. This explains how a company’s conscious policy of building trust between managers and employees leads to an increase in the quality and speed of communication about risks in the organization, while a low level of employee trust in managers negatively affects the quality of risk information transmitted through the corporate hierarchy.
7. 12.7.
  Do you understand the thermodynamic model of risk information transmission that has been presented to you? (Fully understand | Mostly understand | Don’t understand very well | Don’t understand at all | Difficult to answer)
8. 12.8.
  Do you agree with the principles of this model? (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
9. 12.9.
  What stage do you feel your organization is at in the framework of the “Thermodynamic Model of Risk Information Transmission”? (Steam (warm relationship) | Water (transition state) | Ice (cold relationship) | Difficult to answer)
  
  Below are pairs of statements that have opposite meanings. Please rate which statement from each pair you most agree with (0—fully agree with the statement on the left, 10—fully agree with the statement on the right).
10. 12.10.
  Excessive caution when dealing with managers and colleagues does not hurt / Most managers and colleagues can be trusted
11. 12.11.
  Most managers and colleagues are willing to cheat if the opportunity presents itself / Most managers and colleagues try to be honest
12. 12.12.
  Most managers and colleagues care only about themselves / Most managers and colleagues are happy to help others
13. 12.13.
  Most managers and colleagues are very closed-minded / Most managers and colleagues are very open
14. 12.14.
  For the most part, work is stress, conflict and punishment / For the most part, work is good relationships with colleagues, cooperation and freedom from punishment
15. 12.15.
  Imagine that employees at an industrial site detect a serious technological risk. Based on your experience, what do you think employees will do when this risk is discovered? (1. Employees will immediately report the risk to their supervisor, who, in turn, will quickly inform the site management. A special group will be promptly established to carry out a risk analysis. If the risk is deemed unacceptable, then production work will be halted, and measures implemented to control the identified situation | 2. Employees will report the risk to their supervisor, but this information will not be transmitted further up the hierarchy. Employees and their manager will try to independently address the risk using their own resources; it is possible that work will be stopped or reduced at the site | 3. Employees will not report the risk to their immediate supervisor, but will try to eliminate the identified risk on their own, and production work will not be stopped | 4. Employees will ignore the risk as they work in a dangerous industrial production facility, where there are already many serious hazards; employees simply do not have time to respond to all potential risks, because they need to keep working and fulfill the production plan | 5. Difficult to answer)
16. 12.16.
  Based on your experience, can employees in the company come to their superiors and talk about problems in their area of responsibility, confident that they will not be punished for bringing this information, and that suitable resources—money, time, personnel—will be provided to address the issue? (1. Yes, employees can go to their superiors and calmly discuss problems without fear of punishment and get the resources to solve them | 2. Yes, employees can go to their superiors and disclose problems. They will not be punished, but they will not be given the required resources to solve them | 3. Yes, employees can come to their superiors and talk about problems—but they will be punished and will not be given resources to solve them | 4. No, nothing will be changed, no one will provide any resources, and employees will be forced to solve problems in their area of competence independently | 5. Difficult to answer)
13.
Information transmission channels
1. 13.1.
  What channels should be developed at your production site for transmitting information about risks from the bottom of the corporate hierarchy? (1. It is only necessary to develop a risk communication channel based on the traditional chain of command corporate hierarchy (employees report information to their supervisor, who reports to his/her line manager, and so on up the chain from shop floor to senior management) | 2. It is only necessary to develop an alternative channel (any employee can send information about risks directly to senior management, bypassing the traditional hierarchy, through smartphone apps, hotlines, mailboxes, meeting with executives, etc.) | 3. Both channels need to be developed (transmitting information about risks through the traditional hierarchy and through an alternative channel) | Difficult to answer)
2. 13.2.
  If a company decides that it is necessary to develop both channels—communicating information about risks through the traditional hierarchy and through an alternative channel—then which channel should be the main priority for development? (1. Greater priority should be given to the channel using the traditional chain of command | 2. Greater priority should be given to the alternative channel | 3. Develop both channels with equal priority | Difficult to answer)
3. 13.3.
  Alternative communication channels used to transmit risk information between shop floor employees and senior managers should keep the identity of the employee raising the issue secret—i.e. be anonymous. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4. 13.4.
  Alternative communication channels used to transmit risk information between shop floor employees and senior managers should identify the employee raising the issue—i.e. not be anonymous but include personal identification details. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5. 13.5.
  How do you feel about this system for cascading the transmission of risk information up the hierarchy? A shop floor employee observes a risk or problem and informs their immediate supervisor. If within a certain time there has been no response, then that employee has the right to contact their line manager’s superior. If this still fails to produce any feedback, then the employee has the right to inform the next level of management up—all the way up to the site director and even beyond to the CEO of a company. This system is intended to encourage the traditional management hierarchy to act more quickly to address problems raised by shop floor employees, without going straight to alternative (emergency) channels of communication between shop floor employees and senior management, where the traditional management hierarchy is immediately bypassed. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
6. 13.6.
  Do you want to receive information about serious incidents that have occurred across all of your organization’s facilities, including a brief analysis of the main reasons behind each one? (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
7. 13.7.
  Do you want to receive information about serious incidents (and their causes) that have occurred in your industry, in this country and across the world? (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
8. 13.8.
  As part of the pilot project, it is planned to create a smartphone app so that employees can quickly transmit information about observed risks up the corporate hierarchy to senior management. This raises a technical question: what operating system does your phone run on? (If you have several phones with different operating systems, then mark all the systems that are used on your phones.) (Google (Android) | Apple (iOS) | Huawei (HarmonyOS) | Microsoft (Windows Phone) | different operating system | I don’t have a smartphone)
9. 13.9.
  As part of the pilot project, it is planned to present the solutions developed by around 500 employees and managers who attended the seminars. What is the most convenient format for you to participate in this presentation? (1. Personal participation in a special event where senior management will talk about decisions within the project; opportunity for attendees to ask questions directly | 2. Receive a link to a video on your smartphone, which explains what solutions were developed within the project; online chat to answer any questions | 3. View specially prepared video with colleagues at the facility; ask questions to a representative of HSE service | 4. Difficult to answer)
14.
Rewards and punishments
1. 14.1.
  How do you view the adequacy of penalties at your enterprise for various misconduct offenses? (Excessively hard | Hard | Adequate/Fair | Soft | Excessively soft)
2. 14.2.
  Managers should not penalize employees for their mistakes, but look for systemic flaws in the work of an organization that may have created an unsafe situation for employees. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
3. 14.3.
  It is justified to penalize employees only if they have deliberately violated safety rules or neglected their duties. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
4. 14.4.
  When employees report a problem to a manager, they then share the responsibility for solving it. If employees keep a problem to themselves, they are taking full responsibility for whatever happens. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
5. 14.5.
  Managers should create a workplace climate where the voluntary admission of an error by an employee does not then result in them being penalized. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
6. 14.6.
  Any employee—worker or manager—found to have concealed important risk information should face serious consequences, including possible dismissal. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
7. 14.7.
  In a company where a voluntary risk disclosure to superiors is never penalized, employees or managers who deliberately hide information about risks in their area of responsibility should face dismissal. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
8. 14.8.
  Managers should reward employees publicly in the presence of their co-workers, but penalize them only in private conversation and with total confidentiality. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
9. 14.9.
  Managers should not offend or humiliate employees, as this can have a negative impact on productivity and damage communications. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
10. 14.10.
  Identifying safety risks and disclosing them to colleagues and management to prevent accidents is the professional duty of every responsible employee. Therefore, neither material nor non-material rewards for disclosure of risks are necessary. (Strongly agree | Rather agree | Rather disagree | Strongly disagree | Difficult to answer)
11. 14.11.
  There is a discussion within a company and the participants divide into two groups. The first believes that, to encourage employees to disclose dangerous actions by their colleagues (e.g. working at height without a harness), the management should offer material rewards (e.g. money, valuable gifts, and so on). The priority is to identify and prevent safety violations, by any means necessary. The second group believes that to encourage employees to disclose dangerous actions by their colleagues, the management should not provide material rewards. This may threaten the stability of the work teams—and in any case, reporting safety violations is the professional duty of any responsible employee, and should not require any financial incentives. Do you support the beliefs of the first group or the second group? (Fully support ideas of 1st group | Rather support ideas of 1st group | Rather support ideas of 2nd group | Fully support ideas of 2nd group | Difficult to answer)
12. 14.12.
  Choose what you believe to be the most appropriate methods of reward for disclosing information about safety and technological problems (choose only one answer). (Material rewards only | Non-material rewards only | Combination of material and non-material rewards | No rewards needed—disclosure is the professional duty of employees | Difficult to answer)
13. 14.13.
  If the company decides that it needs to combine material and non-material rewards for disclosing information about safety and technological problems, what should be prioritized? (Combination of mostly material and some non-material rewards | Combination of mostly non-material and some material rewards | Equal priority to material and non-material rewards | Difficult to answer)
14. 14.14.
  Choose what you consider to be the most appropriate and effective non-material rewards for employees disclosing information about technological risks (multiple answers can be selected).
  - Public commendation from senior management to an employee or work team
  - Letter of gratitude sent from senior management to an employee’s family acknowledging his/her contribution to the safety of the site
  - Award of diploma personally signed by senior management
  - Award of special honorary order (corporate medal)
  - Joint photo with senior management
  - Article in the corporate media featuring the employee/team who prevented a serious emergency
  - Inclusion in the list of best employees at the site
  - Lavish dinner for distinguished employee/team with senior management
  - Weekends at the corporate recreation center for all family members
  - Allocation of annual personal parking spot alongside top company executives.
  - Professional internships at other company enterprises or additional professional training (including abroad)
  - Videos featuring the outstanding contribution to company safety by the employee/team. Broadcasting these videos to other employees across all the company sites.
  - Tickets for all family members to attend major sporting events or concerts
  - Additional days off
  - Opportunity to become a mentor, passing on their successful experience to other employees within the company

After conducting these online surveys, results were immediately shared with all seminar participants.

9.
Group work No. 2—how the problem of risk information concealment can be solved in this company

The second group work session followed the same structure as the first. The seminar participants were asked the following questions:

How is it possible to “unfreeze” the corporate hierarchy and “melt the ice” in the interactions between managers and employees? The “Thermodynamic model of risk information transmission” would describe this as a successful transition from “cold” to “warm” relations. The goal of this thawing of relations would be to motivate employees to voluntarily disclose critical risks to their superiors.
The absence of penalties for the voluntary disclosure of technological risks is one of the fundamental principles for improving communication about risks within an organization. However, this can create problems. How can the organization avoid creating an atmosphere where employees feel they can act with impunity and where kindness (i.e. lack of punishment) is perceived as weakness? Offer practical solutions.
How can lower managers be motivated to actively address the problems that subordinates bring to them?
What is a simple step-by-step protocol (three to five steps) that all employees could follow when they discover a critical risk that may require an urgent coordinated response?
Alternative channels for transmitting information about risks are auxiliary channels. The main channel through which information about technological risks should be reported is the traditional hierarchy of management control. List the existing risk communication channels in the company that follow this traditional pattern. How can the quality of reporting using these channels be improved?
Part of this project will involve creating a special smartphone app to function as an alternative channel for transmitting information about technological risks. Is it also worth considering an app to support the existing channels for transmitting risk information along the traditional hierarchy? What are the pros and cons of this approach?
What do you think should be the criteria for the success or failure of this pilot project to improve the quality and speed of risk information transmission? How can these criteria be measured in practice?

The experience of conducting seminars for various levels of management showed that the most active participants in group work No. 2 were senior managers, and the least active were shop floor workers. After holding two out of the seven planned seminars for shop floor employees, group work No. 2 was excluded from the presentation, due to the obvious fatigue of shop floor employees towards the end of the session.

10.
Group work No. 3—reveal to senior management the most critical problems of your enterprise

Some senior managers of the company, who were interviewed as part of in-depth interviews at the very beginning of the pilot project, were skeptical that their subordinates would reveal anything serious or problematic during these special seminars. They were convinced that the workforce held a firm belief that it was better not to risk disclosing bad news to their superiors.

However, once employees during the seminars had seen the extreme emergencies that poor risk communication can cause in an industrial company, they seemed to have overcome this reluctance. As a result, participants across the board showed a willingness to share problems they had encountered within the company.

Group work No. 3 generated the most active and productive responses from shop floor workers and lower managers. They were asked to disclose to the senior management and the site director any serious problems and risks that: (I) they had observed within their specific area of responsibility, or in the wider production process; (II) had the potential to create a critical problem in the near/medium term; and (III) they believed should receive urgent attention from senior management.

Senior management promised the participants of the seminars that no one would be penalized for honestly disclosing any of this information, that a detailed analysis would be made of all the risks or issues raised, and that rapid corrective measures would be taken wherever they were needed. These statements were included in the following video message from the SVP to the seminar participants:

“Dear colleagues!

I am sure that the seminar has helped us all recognize the extreme importance of prompt and accurate reporting of risk-related information throughout the management hierarchy. This can prevent a critical development of events and avoid an emergency.

We will need time to evaluate the results of the work of the groups involved in these introductory seminars—and based on this analysis, to create effective practical solutions to improve the quality and speed of the transmission of risk information over the coming months.

However, I believe that we should not waste precious time! I would like to invite you all, right now in this seminar, to inform me and the site managers about any serious problems and risks that you are already aware of, anywhere across the production site or in your own workshops, that you think could have the potential to create a serious problem in the near future.

Tell us what the senior management should urgently pay attention to. Share this information in your group or personally with Dmitry [leader of this pilot project], who I have complete trust in. All this information will then be handed on to me personally.

Once again, I personally guarantee that no one, including your superiors, will be punished or blamed for sharing this information! A detailed analysis of all the disclosed risks will be carried out and, where necessary, corrective actions will be taken.

All this will help us save lives, increase the reliability of our production facilities, and also save our jobs and ensure the stability of your incomes for many years to come.

Thank you very much for your help, concern, and contribution to the safety of our company!”.

After listening to this message, the seminar participants divided into groups, went to different areas of the hall and began to discuss the risks that they wanted to disclose to senior management, writing them down on flip-chart papers.

There was no limit to the number of relevant issues that could be raised—all were welcome. However, it was crucial that the participants ranked the risks and problems raised in their group. They were ranked on scales of 5 down to 1, by criticality—how serious was the possible danger, 5 being highly critical and 1 least critical—and by urgency—how soon the problem could escalate, 5 being the most urgent and 1 the least. This helped senior management to immediately identify the most pressing issues, and where they should first direct their attention. An issue scoring 5 on criticality and 5 on urgency obviously required their immediate intervention!

Running this exercise over 15 seminars revealed seven critical and urgent risks, and a further 104 significant technological, production and organizational problems—all of which had an existing or potential negative impact on risk management and industrial safety across all four industrial sites.

Interestingly, several seminar participants stated the importance of having a seminar facilitator (the pilot project leader) who is an independent scientist, reporting only to the company’s SVP. After each seminar, the facilitator sent all the information about the disclosed risks to the SVP alone.

It is also important that separate seminars were held for various levels of management (i.e. shop floor employees did not attend a seminar with their line managers). This allowed seminar participants to disclose risks and problems they were aware of without fear of being identified by their superiors.

Six critical risks were revealed during this group work No. 3, while the seventh was revealed by one of the participants after the seminar had ended and everyone else had left. A lower-level manager approached the pilot project leader and said that he would like to disclose a critical risk, but did not want his colleagues to know. He explained that he is a new manager and does not want to endanger his relationships with his colleagues. The pilot project leader agreed, and the manager shared what he knew about the risk. Senior management arrived at the site the next day. The risk was indeed recognized as critical, and work began immediately to address it. As part of this corrective action, the peers of the lower-level manager who had disclosed the risk were faced with an increased workload because the situation was so urgent. Workers began to guess who had revealed the risk, but they had no evidence. The situation was successfully contained, to the satisfaction of the lower-level manager, his colleagues, the head of the facility, and senior management. No one was penalized for having allowed this critical risk to have developed. Instead, all the workers were told that situation like this must not happen again—risks need to be identified at an early stage and promptly reported to the head of the facility, and control measures need to be taken and/or referred up the hierarchy if additional support is required. Later, the manager involved was invited to receive an award at a special company ceremony (discussed below)—but he chose not to attend, preferring to maintain his anonymity.

It is worth comparing the results obtained during the seminars with the results of other channels for reporting risks and problems in the company. There were three such channels at the pilot plants: a problem-solving board, boxes for anonymous reporting of problems and risks, and a helpline. The last two channels were not popular with employees—the number of messages sent was minimal. Many more messages were sent through the problem-solving board, but these were also related to minor production problems. According to the manager who oversees these problem-solving boards, employees are mostly reporting problems with the cleanliness of industrial premises. No critical and serious risks have ever been reported through these three channels. By comparison, holding special seminars for a narrow circle of selected employees and managers who manage the critical infrastructure at the sites is a much more effective way to get information about critical and serious technological or production issues.

11.
Anonymous survey No. 3: feedback from seminar participants

At the end of each seminar, a final online survey (five answers) was conducted, aiming to assess how helpful and relevant the session had been for the participants.

Results of responses to anonymous surveys within the framework of the pilot project: Prior to this seminar, did you have a clear understanding that the problem of employees concealing risk information from their superiors is one of the main causes of serious industrial accidents?

	Clear understanding	Some understanding	No understanding	Difficult to answer	Number of respondents
All survey participants	51.0%	40.0%	8.0%	1.0%	252
Senior management, heads of departments and directors of sites (middle managers)	67.6%	29.4%	2.9%	0.0%	34
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	51.1%	40.0%	7.8%	1.1%	90
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	46.9%	42.2%	10.2%	0.8%	128

Interpretation of responses: the lower the respondents are in the company’s hierarchy, the less they realize that the problem of employees concealing risk information from their superiors is one of the main barriers to preventing serious industrial accidents. This shows that senior management need to constantly emphasize to their subordinates the importance of communicating objective information about any safety and technological problems they encounter in their area of responsibility. Leaders should also reassure the workforce that they very much welcome this information, and that nobody will be blamed or penalized for disclosing problems, however serious. On the contrary, they will have the management’s gratitude for taking prompt action that may well prevent an emergency, and resources will be made available to address the issues they have helped identify.

Results of responses to anonymous surveys within the framework of the pilot project: How relevant was the content of the seminar for you? (1 = totally irrelevant; 10 = 100% relevant)

	1 = totally irrelevant 10 = 100% relevant
	1	2	3	4	5	6	7	8	9	10	Average score	Number of respondents
All survey participants	0.0%	0.0%	0.4%	0.8%	2.4%	3.2%	10.7%	15.5%	12.7%	54.4%	8.9	252
Senior management, heads of departments and directors of sites (middle managers)	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	8.8%	8.8%	11.8%	70.6%	9.4	34
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	0.0%	0.0%	0.0%	0.0%	3.3%	3.3%	7.8%	21.1%	12.2%	52.2%	8.9	90
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	0.0%	0.0%	0.8%	1.6%	2.3%	3.9%	13.3%	13.3%	13.3%	51.6%	8.7	128

Results of responses to anonymous surveys within the framework of the pilot project: How ready are you to use the knowledge and skills that you have gained from this seminar in your day-to-day work? (1 = absolutely not ready; 10 = 100% ready)

	1 = absolutely not ready 10 = 100% ready
	1	2	3	4	5	6	7	8	9	10	Average score	Number of respondents
All survey participants	0.0%	0.0%	0.0%	0.4%	2.8%	4.0%	11.1%	13.5%	13.5%	54.8%	8.9	252
Senior management, heads of departments and directors of sites (middle managers)	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	8.8%	2.9%	14.7%	73.5%	9.5	34
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	0.0%	0.0%	0.0%	0.0%	3.3%	6.7%	8.9%	14.4%	10.0%	56.7%	8.9	90
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	0.0%	0.0%	0.0%	0.8%	3.1%	3.1%	13.3%	15.6%	15.6%	48.4%	8.8	128

Results of responses to anonymous surveys in the framework of the pilot project: It is necessary to run explanatory trainings and seminars, to explore the consequences of distorting risk information transmitted through the corporate hierarchy. Many employees simply do not realize that this is one of the key problems within industrial safety, and do not understand what catastrophic consequences it can have. Special seminars can advance the understanding of this urgent problem and offer managers and employees opportunities to “break the ice” around improving communication on difficult topics.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	57.0%	38.0%	2.0%	0.0%	2.0%	252
Senior management, heads of departments and directors of sites (middle managers)	88.2%	11.8%	0.0%	0.0%	0.0%	34
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	54.4%	41.1%	2.2%	0.0%	2.2%	90
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	50.8%	43.8%	1.6%	0.8%	3.1%	128

Results of responses to anonymous surveys within the framework of the pilot project: I am ready to recommend this seminar to work colleagues. (1 = not ready at all; 10 = 100% ready to recommend)

	1 = absolutely not ready 10 = 100% ready
	1	2	3	4	5	6	7	8	9	10	Average Score	Number of respondents
All survey participants	0.4%	0.4%	0.0%	1.2%	2.8%	1.2%	5.6%	11.1%	14.3%	63.1%	9.1	252
Senior management,heads of departments and directors of sites (middle managers)	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	8.8%	17.6%	73.5%	9.6	34
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	0.0%	0.0%	0.0%	1.1%	4.4%	1.1%	7.8%	12.2%	13.3%	60.0%	9.0	90
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	0.8%	0.8%	0.0%	1.6%	2.3%	1.6%	5.5%	10.9%	14.1%	62.5%	9.0	128

The results of anonymous survey No. 3 show that conducting interactive seminars is a very effective method of (I) demonstrating the significance of the widespread problem of employees suppressing and distorting information about risks; (II) getting feedback about the reasons why this problem occurs in a given company; (III) getting first-hand feedback about possible solutions to the problem; (IV) obtaining information on a wide range of existing safety and production risks within the organization, which can then be rated for criticality and urgency.

Lessons learned: Based on a survey of 100 critical infrastructure executives, a recommendation was made that senior management should regularly visit industrial sites to identify and address serious safety and technological problems (see Chap. 3, Recommendation 7: “Use multiple channels for obtaining risk information”). Conducting seminars like this, prior to a site visit by executives from headquarters, allows senior management to have an up-to-date list of the most serious current problems of the facility. This will help them to be properly prepared for visiting the facility: executives can demonstrate to their subordinates that they are already aware of the most critical issues, and immediately announce suitable remedial measures to address them. Senior managers visiting the facility are unlikely to meet with all employees at the site but should focus their attention on a selected 5–10% of the workforce who manage the critical facilities. If these employees have already undergone special training by participating in these seminars, they will already understand the vital importance of communicating honest and accurate risk information to their superiors. Therefore, they should be primed and ready to share this with the top brass. This will make the visits much more productive and efficient and improve safety management across the production process. Trained employees should also be granted access to a special corporate smartphone app that will enable them to promptly inform their superiors about any operational risks that come to their attention during their daily work (the development of this smartphone app will be discussed later).

It is important to mention that these seminars are essential at the start of the project. At this stage, hundreds of senior managers and their subordinates need to be shown the importance of prompt and accurate upward risk reporting, and trained in a new way to respond if they detect critical or serious risks. During the subsequent implementation of the project over several years, the emphasis will shift. The main alternative channels for reporting risk-related information will now be the special smartphone app (distributed among staff trained by means of such seminars), and direct communication between senior management and production site workers during their visits. In these later years of the project, new seminars should be organized only at new production sites, or for the initial training of new personnel at the existing pilot sites.

VIII.
TAKE ACTION ON ALL IDENTIFIED CRITICAL AND URGENT RISKS

When the pilot project began, its main objective was formulated as follows: to encourage shop floor employees to promptly transmit information about safety and production risks to senior management, so that remedial action can be taken before a serious situation can develop. The focus was on improving the speed and quality of risk reporting up the corporate hierarchy.

Therefore, from the very beginning of the project, there was a separation of tasks. The project leader concentrated on ways of improving the quality and speed of communication about risks and problems (in other words, how to motivate employees and line managers at the pilot sites to disclose this information to senior management), while senior management took responsibility for providing solutions to the identified risks and problems.

From the outset, it was agreed that when participants disclosed problems at the seminars, it would be the responsibility of the project leader to document the issues raised and send this information directly to the SVP of the company, who would then decide with other executives on the best course of action for each problem. Accordingly, immediately after each seminar, the project leader emailed the company’s SVP a list of the identified critical risk issues. The following day, he would send a second list detailing risks and issues of a lower level of criticality and urgency.

Through this process, senior management were able to take swift control of seven critical and/or urgent situations. In some cases, their prompt intervention solved problems that could very quickly have resulted in a major incident. In two of the seven cases, the relevant site directors had not previously been aware that such a problem even existed at their facility.

Summing up, the pilot project immediately proved its effectiveness and value by bringing these serious critical risks to the attention of senior management so that remedial action could be quickly taken, preventing the problems escalating into an emergency.

Lessons learned: from the retrospective analysis of how these critical problems were solved, it appears very important that the project leader visits production sites together with senior managers, and that they assess critical risks revealed during the last seminar. By personally taking part in this inspection, the project leader can observe firsthand the communication between senior management and the employees who had reported critical risks during the seminar.

This realization came a few months after the seminars began, when the project leader accidentally became aware that one of the senior managers—a highly qualified expert in the production process—was asked by the company’s SVP to analyze one identified critical risk at the pilot plant. For unknown reasons, this senior manager had not been included in the initial list of the pilot project participants. As a result, he had not undergone the specific project training, and was unaware of the project’s ideology and the newly introduced methods of risk communication. Arriving at the plant and assessing the situation (which was indeed very critical), he proceeded to condemn the lower-level manager who had uncovered this critical risk and requested urgent assistance from senior management to address the situation.

The truth was that an external contractor had aggravated the problem, and the lower-level manager judged that he lacked the resources to tackle this unexpected issue in his area of responsibility. To make matters worse, the head of the plant was on vacation when the problem came to light. Therefore, following what he had learnt at the seminar, the lower-level manager decided to approach the company’s SVP directly and without delay to request assistance in tackling the problem. As a result of his actions, the critical risk was promptly mitigated, and a potential accident averted. As it turned out, this risk was the most serious of the seven identified in the pilot project seminars. But instead of receiving positive feedback and recognition, the manager was publicly criticized by the senior manager for failing to do his job properly.

By simply blaming the lower-level manager, rather than making a detailed analysis of the true causes of the problem, the senior manager endangered the successful implementation of the pilot project across the entire site. For a start, the lower-level manager who disclosed the risk would be sure to keep quiet about any safety issues in his area of responsibility in the future, and try and tackle them on his own. But the damage did not stop there: the dressing-down given by the senior manager was also witnessed by the lower-level manager’s colleagues. It is likely that they drew similar conclusions about the dangers of informing their superiors about production problems, despite the SVP’s pledge not to blame employees for communicating difficult issues. Once the head of the plant had returned from vacation and conducted his own investigation, he personally thanked the lower-level manager for his courage and promptness in revealing a serious risk and preventing an accident. He also urged him not to be fearful of disclosing further problems, but to continue to be proactive in caring about safety. Nevertheless, this incident appears to have had a negative impact on the willingness of the head of the plant to disclose new risks and problems to headquarters. One indication of this is the fact that, under various pretexts, the head of the facility did not allow the pilot project leader to organize further seminars at his plant. Finally, he explained his reluctance by saying that further seminars would likely lead to the disclosure of new problems: this would just attract more attention from senior management with no guarantee that the information would be well received and might well leave his plant workers being blamed and criticized again.

This incident offered valuable lessons:

At the beginning of the project, the pilot project leader underestimated how important it is to oversee the process of addressing any serious problems that come to light. If the project is to succeed, it is essential that, as well as improving the process of risk information transmission, the process of solving the problems should be well prepared and organized. It was impossible to immediately delegate the latter process exclusively to the company’s management. Due to corporate inertia and habit, managers may well simply repeat the negative behaviors that had led to risk communication problems in the first place. In other words, the project must be perceived as a concrete opportunity for new ways of addressing problems across the entire company. At its outset, this new approach should be agreed upon and formalized with senior executives, making it clear to them how they are now required to respond to subordinates who report risks and problems.
All managers who have a role in mitigating identified risk problems must undergo special training and accept the ideology of the project—especially the stipulation that any employee voluntarily disclosing risks in their area of responsibility must always receive positive feedback from their superiors. It is absolutely essential that employees feel safe to disclose risks to their superiors and are motivated to continue doing so.
The project leader must travel with the team of senior managers to production sites where critical risks have been identified. This should be continued until the project leader has confidence in the senior management to properly analyze the reasons why any risks have arisen, give positive feedback to those who disclosed the information, and conduct their interactions in a way that reduces employees’ fears about risk reporting and encourages them to inform their superiors if they become aware of further problems.
To counteract the misguided negative feedback, it would have been enormously helpful to organize an urgent visit by the company’s SVP to the production site. This would have allowed him to thank the lower-level manager personally and publicly for his correct and courageous actions, and encourage all workers to follow this example and willingly disclose risks to their managers. A visit could also have reassured the head of the site that promptly identifying and reporting critical risks would help and not hinder career prospects—while on the other hand, suppression of risk information is going to be dealt with very severely. Unfortunately, the project leader did not become aware of this incident until a few months afterwards, so no such visit was possible. However, the lower-level manager who identified the concerned critical risk was one of the employees that the SVP selected to publicly commend during the pilot project’s inaugural event (discussed below).
After this incident, the project leader found the opportunity to briefly speak to the senior manager involved, to share the ideology and objectives of the project, and explain the damage that negative feedback could inflict on its overall success. The senior manager agreed to attend a special full day senior management seminar led by the project leader. But when it came to it, citing a heavy workload, he was unfortunately only able to attend about 40% of the seminar. This experience suggests that only managers who have completed the special training, and fully support the project’s ideology and principles, should be involved in solving the problems that are identified through the seminars. The training of lower-level employees should only begin when all involved senior managers have completed theirs.

IX.
PROGRESS IN ADDRESSING LESS CRITICAL PROBLEMS

In addition to critical and urgent risks, more than a hundred less serious issues became known during the seminars.

When employees show trust by reporting risks or problems in response to requests from their senior management, they act in the belief that prompt action will be taken to solve, or at least reduce, these problems. If senior management cannot do so, they must explain this to their subordinates, and reassure them that—for the time being at least—shop floor workers can continue to work safely even though such risks are present. Employees need to see progress in dealing with the problems they have helped identify. If not, eventually they will stop believing that things are changing and will revert to their old habits of concealing risks and problems to avoid trouble landing on their own heads.

As part of the pilot project, it was important to understand the limits of the existing corporate management system to successfully address these various issues.

The management system may be able to show at the pilot stage that it can quickly and effectively solve all the problems that come up, regardless of their level of criticality. In that case, when it comes to scaling the project up to include additional production sites, it will be safe to encourage employees to disclose all production risks and problems they are aware of, and not restrict this to just the most serious.

Conversely, if the company cannot address all the problems reported during the pilot project, then, it is advisable not to promise future project participants that any issue they identify at their sites will be quickly dealt with. Indeed, this has the potential for raising unrealistic expectations. The SVP’s message to the participants of the seminars contained the following clause: “A detailed analysis of all the disclosed risks will be carried out and, where necessary, corrective actions will be taken”. The project initiators were careful not to guarantee seminar participants that every problem would be dealt with. Instead, a more realistic approach was taken. They were assured that any issue raised in the seminars would be brought to the attention of senior management and carefully analyzed, but that only the most critical and urgent would be resolved straight away.

During the pilot project, the following problem-solving issues were encountered at the four sites.

After each seminar, information about the risks and issues disclosed was passed on to the company’s SVP. He acquainted himself with this list of identified problems, and then delegated actions to his HSE deputy. The HSE department studied the problems in more detail, collecting any additional information they required, and then began to plan and execute appropriate remedial action plans.

As it turned out, many of the problems identified were related to the production department of the company. Gradually, departments responsible for production, logistics, and procurement became involved in addressing the various problems. The number of seminars held at the production sites grew as the number of problems identified inevitably increased. The project leader held a special educational seminar for 20 heads of departments. Here he outlined in detail the principles and objectives of the project and called on them to get closely involved in addressing the problems that had now been identified at four production sites. Eventually the number of problems identified by employees grew so large (in total, 104 were raised during the 15 seminars) that it was decided to create a special working team of company executives and production unit managers. This included various senior managers (some of whom did not receive the special project training), along with the relevant department heads, and all the site managers at the selected sites (all of whom did attend the training).

Functions of the special working team:

comprehensive assistance to production sites to tackle identified problems;
prompt and expert assessment of critical and urgent problems: members of the team visited the location; all equipment involved was examined to determine the potential risks from its continued operation; equipment was decommissioned when necessary; the company’s senior officials and any relevant departments were immediately informed about the presence of critical and urgent issues;
creation of temporary joint working groups to manage specific identified problems (e.g. equipment repair programs; scaling back of production targets and plans; resolving employment of workers operating the faulty equipment in cases of lengthy shut downs; repairs and replacements etc.);
securing additional finance and other resources when required;
conducting a qualitative analysis to determine the reasons a problem had occurred;
maintaining a database of identified problems and actions and coordinating this information with the company’s database of safety and technological risks.

To conclude, the company management system was able to quickly and effectively respond to seven extremely critical risks (where serious accidents were likely to be imminent) and address a further 25 major risks across the four pilot facilities. The heads of the sites were able to resolve most of the moderate risks (approximately 50) using each facility’s own resources. However, more than six months after the start of the project, about 25 serious problems remained unresolved. It became apparent that a considerable proportion of these hold-ups were the result of accumulated malfunctions within the company’s organizational and technological structures over many years. The “treatment” of these deep-seated problems would require painful decisions at the highest level, restructuring of the entire organization, many years of efforts by senior management, and the allocation of significant extra resources.

In the opinion of the project leader, there were also other reasons why these problems were still not addressed more than six months after the launch of the pilot project:

A.
The company’s SVP participated in all key meetings of the project, but with the exception of the special working team meetings where solutions to the identified problems were discussed. Retrospective analysis suggests that, if the SVP had participated regularly in these meetings and immersed himself in delivering solutions, then this would have increased the involvement of the entire senior management team in resolving these issues—which, while not being urgent or critical, were still important in the medium or longer term.
B.
Not all production-related issues can be resolved quickly. The head of one production site (middle management) offered the following explanation: “Many heads of the facilities are aware of existing risks, but we cannot immediately address all the problems and minimize the risk of accidents, because our resources are limited. Therefore, we can only make repairs sequentially. We are manually redirecting resources to rectify the most critical risks, but other important risks have to wait their turn. My colleagues and I really do want to reduce all the risks at once, but this is simply impossible, because all production cannot be stopped at one go—we can only withdraw a part of the production capacity at a time. I don’t want to continue working while risks are there: in fact, I don’t want risks to exist at all. I want everything to be working perfectly, everything in harmony, nothing worn or defective. However, everything depends on resources: time, money, the availability of contractors to carry out the repairs, logistics of new equipment and the existence of a realistic production plan allowing us to temporarily shut down some production processes for the repairs. In the end, we have no option but to constantly prioritize what needs to be repaired first, and this is a never-ending process”.
C.
Senior managers are extremely busy with regular responsibilities. As result, it is difficult for them to find additional time to address significant organizational and production problems that have accumulated over many years and, to some extent, have been tolerated. Their rectification requires time and effort, and often only produces safety improvements in the longer term. Most of the unresolved major problems revealed during the project, however, required long-term solutions.

Results of responses to anonymous surveys within the framework of the pilot project: Do you think that the managers and employees in your company are in a hurry?

	Constantly	Often	Sometimes	Rarely	Difficult to answer	Number of respondents
All survey participants	19.9%	23.0%	32.5%	18.1%	6.4%	326
Senior management, heads of departments and directors of sites (middle managers)	26.8%	24.4%	36.6%	9.8%	2.4%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	20.4%	28.7%	27.8%	12.0%	11.1%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	18.1%	19.2%	34.5%	23.7%	4.5%	177

Interpretation of responses: the higher the respondents are in the company hierarchy, the more they feel overloaded and always in a hurry. They feel they just do not have the time to analyze problems and risks in detail, so they and their subordinates often ignore them. The authors of this handbook examined 20 major accidentsFootnote
Dmitry Chernov, Didier Sornette, Giovanni Sansavini, Ali Ayoub, Don’t Tell the Boss! How poor communication on risks within organizations causes major catastrophes, Springer, 2022, https://springerlink.fh-diploma.de/book/10.1007/978-3-031-05206-4.
where intra-organizational concealment of information about risks was established as a major factor in causing disaster. The analysis showed that, in 12 out of 20 disasters (60%), managers and employees were reported to be constantly in a hurry. In the organizations where these accidents occurred, employees were often urgently required to implement a range of tasks, which forced them to ignore many of the risks that were shown later to have caused serious incidents.

D.
Some senior managers and department heads were overwhelmed by current production tasks. Instead of giving the production sites the comprehensive assistance they had promised, they were forced to delegate the job of solving some risk issues to their subordinates. As a result, responsibility for a sizable proportion of these problems shifted to the heads of the pilot production sites, who did not have the additional resources required to correct these issues. Such downward delegation went against a central principle of the project: the guarantee that senior management would assist the production sites to address their problems, so that employees and lower managers would not be afraid to report problems in their area of responsibility. As a result, these problems became a real headache for the heads of the sites. Some of them did not understand why they should risk disclosing problems at their sites to senior management as part of a pilot project, if in the end they were left to tackle these problems alone, without practical or financial support from executives. Meanwhile, some dutifully tried to follow their bosses’ instructions and tackle the problems the project had brought to light. But with senior management now preoccupied with “more important” matters, the site managers were very reluctant to admit to the leadership that (I) a significant number of their production site problems could only be solved with the direct involvement of senior managers; (II) they had neither the resources nor the authority to deliver effective solutions; (III) it was at best misguided, and at worst a dereliction of duty, for senior managers to be delegating responsibility back down to site level for tackling such serious production problems.

Results of responses to anonymous surveys within the framework of the pilot project: Why do you think managers often do not want to hear bad news from employees about matters like observed risks and problems in an organization and the need for additional investments, like equipment upgrades, to create safer production processes?

Managers expect employees to solve problems on their own when they occur in their area of responsibility.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	16.3%	46.6%	25.2%	7.4%	4.6%	326
Senior management, heads of departments and directors of sites (middle managers)	14.6%	48.8%	19.5%	14.6%	2.4%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	19.4%	40.7%	27.8%	8.3%	3.7%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	14.7%	49.7%	24.9%	5.1%	5.6%	177

E.
The main reason the leaders of the company are reluctant to receive information about risks and problems from their subordinates is the excessive bureaucracy involved in getting anything done about them. The very serious issues identified during the seminars required extraordinary efforts from senior management to get the remedial plan through the bureaucracy of this very large industrial company.

Results of responses to anonymous surveys within the framework of the pilot project: Why do you think managers often do not want to hear bad news from employees about matters like observed risks and problems in an organization and the need for additional investments, like equipment upgrades, to create safer production processes?

Excessive bureaucracy interferes with the practical solution of any identified problems. Managers face complex corporate procedures when going through budgeting and investment committees, so issues are resolved very slowly.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	42.6%	35.9%	12.9%	1.5%	7.1%	326
Senior management, heads of departments and directors of sites (middle managers)	48.8%	29.3%	19.5%	2.4%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	46.3%	36.1%	10.2%	1.9%	5.6%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	39.0%	37.3%	13.0%	1.1%	9.6%	177

Interpretation of responses: a very large rate of agreement to this question across all groups indicates that this company has an excessively bureaucratic system of budgeting, procurement, repairs, ordering internal corporate services, and so on. This has a negative impact on both the speed of response to identified risks and the quality of decision-making. Another factor that has a negative impact here is the geographical remoteness of the company’s production sites, so delivering new equipment for example can be very slow. Curiously, this reason was not mentioned even once during the interviews of the 100 critical infrastructure executives conducted in 2018–2021. This suggests that each critical infrastructure company may have some unique combination of factors that have a negative impact on the willingness of managers to hear about and respond to risks.

F.
The geopolitical turbulence in 2022 caused economic difficulties in many countries around the world. This company also faced serious new challenges, which required immediate decisions from the top brass. Senior managers may have decided that they had to prioritize these challenges because the company’s immediate survival depended on a quick response. They could not simultaneously devote time and resources to addressing the chronic safety and technological problems the seminars had revealed—and the benefits from solving these chronic problems may not be apparent for years.
G.
This geopolitical turbulence also put pressure on the company to initiate massive cost reductions, so some risk issues were left unresolved due to the company’s financial situation.
H.
The reluctance of some managers to acknowledge that safety and technological problems really do exist, may indicate that earlier managerial mistakes were made. This may threaten their authority in the eyes of their superiors, subordinates and colleagues, casting doubt on their competency and other leadership decisions.

Real-life examples of refusing to acknowledge serious problems can be revealing. In one of the pilot facilities, all three seminar groups highlighted the same major problem caused by recent innovations in production management. At the company-wide level, these changes were generally recognized as a bad decision. At some production sites, the return to the previous management model—which had worked successfully for decades—was already under way. However, one of the senior managers, responsible for a particular aspect of the production innovations, refused to admit that they had caused any problems—even when all three seminar groups independently raised the same issue. This manager had invested much time and effort into introducing the change, so it was hard for him to face the safety and efficiency problems that the change had also introduced. Rather than admitting the problem, he simply deleted it from the list of urgent issues identified during the seminars. Nevertheless, during a meeting of the special working team, he promised to run a promotion campaign among his subordinates that would show the benefits of the new production system, and convince them to stop demanding a return to the previous model. Clearly, he was finding all the public discussion of the problems caused by the new model, and the complaints it generated among lower-level employees, very threatening. When the project will be scaled up across other company sites where he has significant control, the company’s SVP and many of his fellow managers would be there—and, of course, they would see the dissent among employees against his wish to push the new model through. He decided he would deal with this by writing to the pilot project leader: in future, when scaling the project to other enterprises under his control, he himself would organize the seminars. This really showed just how far he was prepared to go to control and limit the risk information that employees could report to the company’s SVP, bypassing the traditional hierarchy in general and himself in particular. It might also indicate his wish to be the first to receive risk information, so that he could control which problems he would allow to be sent higher up the corporate hierarchy. It would seem that the fear of having their own previous mistakes made public can make senior managers completely refuse to admit the existence of serious problems—even when they are raised by the majority of their subordinates. This, of course, will make any attempt to mitigate those problems impossible.

Another group of middle managers from one of the production sites selected for the pilot project were also eager to show their senior managers that there were no serious problems at their site. They underestimated the criticality and urgency of some of the problems that their employees had highlighted. They dismissed some problems as irrelevant and crossed them off the list of issues to be addressed immediately, despite the objections of various departments of the company arguing that they were important. This experience suggests that the special working team of the project, although it will consist mostly of senior managers, must also include highly qualified employees in the field who are independent of site management. These employees will keep top managers informed about the real situation in a production site, through constant communication with those who have disclosed risks. This is necessary to provide senior management with a second opinion on the criticality and urgency of reported problems and feedback on how the management of a production site is progressing in solving them.

Results of responses to anonymous surveys within the framework of the pilot project: Why do you think managers often do not want to hear bad news from employees about matters like observed risks and problems in an organization and the need for additional investments, like equipment upgrades, to create safer production processes?

Leaders are afraid of being seen as incompetent and being held accountable for their previous bad decisions that created the current problems.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	16.0%	36.2%	31.6%	7.4%	8.9%	326
Senior management, heads of departments and directors of sites (middle managers)	17.1%	43.9%	29.3%	9.8%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	13.9%	27.8%	38.9%	13.0%	6.5%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	16.9%	39.5%	27.7%	3.4%	12.4%	177

Interpretation of responses: Senior and middle managers are most sensitive to the fact that problems reported to them by their subordinates may have been caused by their previous poor management decisions.

I.
Tackling serious production problems may also create conflict with other senior managers, because public discussion of such problems within the company is likely to call into question the wisdom of previous management decisions. For this reason, some managers who were delegated the responsibility for tackling serious problems identified in the pilot project were unwilling to really delve into what had caused these problems and how they might be solved.
J.
Some leaders appeared unwilling to take personal responsibility for tacking serious problems, due to the threat to their own careers if they made mistakes. Responsibility for coordinating solutions to issues identified within the project was constantly being handed on from one senior manager to another during the first six to eight months after the launch of the pilot. This continued until the SVP chose one senior manager as the main person responsible for coordinating the solution of all the problems that had arisen.

Results of responses to anonymous surveys within the framework of the pilot project: Why do you think managers often do not want to hear bad news from employees about matters like observed risks and problems in an organization and the need for additional investments, like equipment upgrades, to create safer production processes?

Managers believe that once a problem has been reported to them, they are automatically responsible for solving it.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	16.3%	47.9%	23.0%	5.5%	7.4%	326
Senior management, heads of departments and directors of sites (middle managers)	17.1%	46.3%	24.4%	12.2%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	17.6%	43.5%	25.0%	11.1%	2.8%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	15.3%	50.8%	21.5%	0.6%	11.9%	177

Interpretation of responses: A high percentage of agreement among all levels of respondents suggests that managers feel overwhelmed by their workload and would rather not receive information about problems from the field, so they do not have to take responsibly for solving them. Leaders would much prefer that employees in the field somehow find a way to solve these issues on their own, without attracting the attention of their superiors.

K.
Unwillingness to take responsibility for addressing specific risk problems—some senior managers were clearly reluctant to take on the responsibility for investigating and implementing solutions to the problems identified during the seminars.

Summing up, within the framework of the pilot project, the company’s existing management system coped effectively with finding ways of reducing or removing the seven critical production risks that came to light. However, the company was not fully prepared for the very large number of less critical but still serious production and organizational problems that the pilot project seminars revealed. Some of these had been building up for years, and the overall corporate response to these was much less successful, with some left unresolved.

The authors believe that the best way to scale up a similar project across new company sites is to begin by asking all participants for information they have about existing risks and problems but include a warning that not all these problems can be tackled at once. Major problems that do not actually pose a direct threat to operational safety cannot always be resolved quickly. An honest dialogue between executives and employees about corporate priorities, and the unavoidable limitations on addressing every problem, is essential to avoid unrealistic expectations.

There is a more radical solution—restructuring the company’s entire management system to enable it to tackle all the identified problems. However, such a big decision would require huge investment by the leadership. This would only be justified if the company found itself unable to respond adequately even to critical risks identified during the project.

Lessons learned: During the pilot project, the majority of the risks identified by the project participants were addressed. Some further conclusions can be drawn:

Expand the project’s objectives. The central goal remains: “to ensure prompt transmission of information about critical safety and technological problems from shop floor employees to senior management, in order to prevent emergencies from arising”. However, a further crucial goal needs to be added: “to create a corporate mechanism for promptly dealing with all significant safety and technological problems disclosed to senior management”.
From the onset of the project, the company involved should have in place a mechanism for dealing with all the risks and problems that are reported. This should include:
- a list of the leaders who will take responsibility for dealing with safety and technological problems into the future;
- specific training for senior managers;
- creation of a pool of technical experts who can rapidly diagnose the relative criticality of any safety and production risks;
- access to additional resources to enable solutions to be swiftly and properly implemented;
- agreeing on specific regulations to govern how managers must act when addressing production risks and communicating with the employees who revealed the issues.
When conducting seminars at production sites, it is advisable to be very specific about how disclosed risk information will be managed and recorded:
- seminar participants are asked to disclose any information they have about critical and urgent safety and production risks that could escalate out of control and cause accidents and emergencies. It should be explicitly understood that, by requesting this information, senior managers are assuming full responsibility for taking action to bring these risks under control;
- seminar participants are also asked to disclose any information they have about major (but less critical) production and organizational problems that could have a negative impact on the labor protection and industrial safety within their facility and across the whole company. It is also recommended to discuss both the positive and negative experiences of the company in solving similar problems in the past. It should be openly acknowledged that not all the issues raised can be resolved, but that senior managers will use this information to improve their understanding of more critical safety issues;
- Identify and list the less critical problems at the facility that the production site managers can solve without assistance from headquarters.
A gradation of risks and problems by severity and urgency allows the company to prioritize and immediately begin the process of addressing the issues that have been disclosed:
- critical safety and production risks will be taken under the immediate control of senior management due to their potentially catastrophic consequences;
- major problems will be analyzed, and priority given to tackling the most dangerous ones as quickly as possible;
- moderately serious problems can be made the responsibility of site directors and addressed promptly.
Resolving as many issues as quickly as possible will:
- demonstrate to staff that risk issues they raise can be swiftly dealt with;
- convince employees that senior managers are serious about solving problems and improving everyone’s safety and security;
- encourage employees to continue to disclose new risks to their superiors.
It is important that a company CEO takes part in the initial discussion around safety and technological problems at a given site, in order to show the entire management hierarchy that this issue is now a priority for the leadership. The message is made clear: “If the head of a company is personally involved in tackling the problems identified by the employees, then managers at every corporate level should also take an active part and do all they can to reduce these risks”. Immediately after each project seminar, it is advisable to call a meeting with senior managers, the special working team of the project, and the site heads. The project leader uses this opportunity to present the collective feedback of the seminar participants. The meeting then moves on to discuss the identified problems in detail, looking at priorities, practical solutions, and responsibilities. After that, the CEO delegates roles and allocates additional resources to relevant executives and production sites. Regular monthly follow-up meetings under the leadership of the CEO may also be needed to review progress in solving the identified issues and making necessary adjustments.

X.
PROCESSING THE RESULTS OF RESPONSES TO THE ANONYMOUS SURVEYS

Responses to the 85 questions included in the three anonymous surveys were collected during all 15 pilot project seminars. The responses were then grouped and processed.

The first analysis was based on where respondents were located—whether at one of the four selected production sites or at headquarters. This made it possible to analyze responses by site to see if there were any differences in their attitudes and corporate cultures.

The second analysis was based on the respondent’s position within the company’s hierarchy: (I) senior management, heads of departments and directors of sites (middle managers); (II) deputy directors of sites, chief engineers of sites, heads of workshops, heads, and representatives of HSE services at sites (lower managers); (III) engineers, foremen, and shop floor employees who operate critical infrastructure at sites. In the opinion of the authors of this handbook, this was the most informative breakdown, as it gave a good indication of the predominant opinions at each level of the hierarchy, including preferred solutions for managing the issues (some results of this second analysis are presented in the handbook).

XI.
CREATION OF A SMARTPHONE APP AS AN ALTERNATIVE CHANNEL FOR TRANSMITTING INFORMATION ABOUT RISKS

The participants’ survey responses helped give a sense of what kinds of methods and systems should be developed as part of the pilot project, to improve the transmission of risk-related information from shop floor employees to senior management.

Results of answers to anonymous surveys within the framework of the pilot project: What channels should be developed at your production site for transmitting information about risks from the bottom of the corporate hierarchy?

	It is only necessary to develop a risk communication channel based on the traditional chain of command (employees report information to their supervisor, who reports to his/her line manager, and so on up the chain from shop floor to senior management)	It is only necessary to develop an alternative channel (any employee can send information about risks directly to senior management, bypassing the traditional hierarchy, through smartphone app, hotlines, mailboxes, meeting with executives, etc.)	Both channels need to be developed (transmitting information about risks through the traditional hierarchy and through an alternative channel)	Difficult to answer	Number of respondents
All survey participants	20.4%	7.1%	67.5%	5.0%	280
Senior management, heads of departments and directors of sites (middle managers)	13.9%	0.0%	86.1%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	25.0%	5.8%	60.6%	8.7%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	18.6%	10.0%	67.9%	3.6%	140

Results of responses to anonymous surveys within the pilot project: If the company decides that it is necessary to develop both channels—communicating information about risks through the traditional hierarchy and through an alternative channel—then which channel should be the main focus of development?

	Greater priority should be given to the channel using the traditional chain of command	Greater priority should be given to the alternative channel	Develop both channels with equal priority	Difficult to answer	Number of respondents
All survey participants	34.3%	15.0%	44.6%	6.1%	280
Senior management, heads of departments and directors of sites (middle managers)	50.0%	5.6%	41.7%	2.8%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	32.7%	20.2%	39.4%	7.7%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	31.4%	13.6%	49.3%	5.7%	140

Most of the project participants supported the development of a smartphone app that would allow shop floor employees to immediately inform higher-level managers about any safety or production risks they encountered, bypassing slower communication channels via the traditional management hierarchy. The SVP acknowledged the following: “To be honest, these days the traditional hierarchy of management does not work well when it comes to transmitting objective information about safety and technological problems to senior management… Therefore, an alternative channel for communicating this information using a dedicated smartphone app should be created. Until a culture of prompt and honest transmission of information about risks along the management hierarchy is established, a company is much better off having both traditional and alternative communication channels”.

Progress on developing the app began after the seminars and included several key features. The app can be installed on employees’ personal smartphones, but use of these is forbidden where there is a risk of explosion. Employees working in these areas will be issued with a special explosion-proof smartphone. Anyone using the app needs to be registered and sign in using their own corporate login and password. All information reported through the app will be stored on the company’s servers.

Initially, it was decided that only 5–10% of the company employees at each pilot site would be included in the scheme. It would be limited to those who (a) operated production facilities defined on site risk maps as critical, and (b) had taken part in the seminar described earlier on the problems of transmitting risk information.

Limiting the number of users was deliberate, to minimize information noise which could otherwise have obscured more important risk information. If thousands of company employees swamped the system with minor issues that senior management could not possibly address, this could raise doubts about the company’s ability to address critical issues. Struggling with all these minor issues could also negatively impact the motivation and attention of senior management to tackle critical problems at the production sites.

The employees given access to the app were first asked to assess any risk they were already aware of in terms of criticality and urgency. Critical and very serious problems were to be sent directly to senior management at headquarters. Significant and moderate problems should be reported to the appropriate site managers, and simultaneously to the special working team at headquarters. This initial grading of observed problems, and two-channel system for reporting them, helped to transmit the information as quickly as possible to the specific managers who would be responsible for addressing a given problem. Critical and very serious problems more likely to require significant additional resources were rapidly brought to the attention of senior managers.

The following scale was adopted to assist employees using the app in grading the criticality of safety and technological problems they had observed:

	Criticality of the problem
	Moderate problem (level 1): • risk of minor injuries (reversible health impacts) • threat of failure of non-primary, auxiliary equipment, which can be promptly replaced or repaired • threat of a minor environmental incident that does not extend beyond production site
	Significant problem (level 2): • threat of serious injury to employees (irreversible health impacts) • threat of equipment failure without stopping production • threat of a minor environmental incident that extends beyond production site
	Very serious problem (level 3): • threat of a fatal and/or group incident • threat of a temporary shutdown in production • threat of a serious environmental incident with a wider geographical impact
	Critical issue (level 4): • threat of mass fatalities of employees and the general population • threat of long-term or permanent closure of production site due to serious damage caused by accident • threat of a serious environmental incident with impacts at national or international level

To assist users in searching and identifying critical and serious problems, the home page of the app contains information about the most likely dangerous situations and issues that might arise in the workshop and production site where a particular employee works, arranged according to their position in the hierarchy. These lists were created by the head and chief engineer of each production site with help from the company’s production department.

Using the app, any employee can promptly inform managers about three types of observed irregularities:

I.
An ongoing safety or production problem (moderate, significant, very serious, critical);
II.
Pre-emergency situation (Level 5)
III.
An incident/accident already in progress.

Severity of observed irregularities		Message recipients	Type of message possible
I. Problem	Moderate problem (Level 1)	• Head of site, chief engineer of site • Head of workshop where the sender works • Special working team (HQ)	• Can include personal data • Can report problem anonymously
	Significant problem (Level 2)	• Head of site, chief engineer of site • Head of workshop where the sender works • Special working team (HQ)	• Can include personal data • Can report problem anonymously
	Very serious problem (Level 3)	• Senior management (production department) • Heads of company functional departments • Head of site, chief engineer of site • Head of workshop where the sender works • Special working team (HQ)	• Can include personal data • Can report problem anonymously
	Critical issue (Level 4)	• SVP of the company • Senior management (production department) • Heads of company functional departments • Head of site, chief engineer of site • Head of workshop where the sender works • Special working team (HQ)	• Report must include personal data • Anonymous report is not permitted
II. Pre-emergency situation (Level 5)		• SVP of the company • Senior management (production department) • Heads of company functional departments • Head of site, chief engineer of site • Head of workshop where the sender works • Special working team (HQ)	• Report must include personal data • Anonymous report is not permitted
III. Incident/accident already in progress		• SVP of the company • Senior management (production department) • Heads of company functional departments • Head of site, chief engineer of the site • Head of workshop where the sender works • Special working team (HQ)	• Report must include personal data • Anonymous report is not permitted

Employees granted permission to use the app have the right to take photos and video or audio clips of safety and technological problems and send them straight through to their superiors. Using the app, employees can also report accidents and incidents outside the site they work at—for example, on their way to or from work in a single-industry town where several company production sites are located. This speeds up the identification and elimination of emergencies across all company facilities.

Anonymity can be maintained for senders who may be anxious about the possible personal consequences of disclosing information about safety and technological problems. The company still retains a culture of fear among employees and managers at various levels around the disclosure of risk-related information (see tables below). This probably stems from previous experience of penalties, conflicts with colleagues, discrimination against whistleblowers, the failure of managers to address the problems identified, etc.

Results of responses to anonymous surveys within the framework of the pilot project: Some employees appear reluctant to inform managers about problems such as equipment failure, mistakes in their work or inability to achieve their targets. Why is this happening?

Fear of blame and punishment from supervisors. Employees believe they will be held accountable for any problem they report to their supervisors.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	17.2%	48.8%	23.0%	9.2%	1.8%	326
Senior management, heads of departments and directors of sites (middle managers)	14.6%	43.9%	29.3%	12.2%	0.0%	41
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	19.4%	49.1%	19.4%	10.2%	1.9%	108
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	16.4%	49.7%	23.7%	7.9%	2.3%	177

Interpretation of responses: the company appears to have a strong tendency to blame specific managers and employees when they disclose information about problems to their superiors, instead of looking for the root causes of these problems (corporate goals, higher management decisions, inadequate provision of shop floor resources, etc.).

Results of responses to anonymous surveys in the framework of the pilot project: Alternative communication channels used to transmit risk information between shop floor employees and senior managers should keep the identity of the employee raising the issue secret—i.e. be anonymous.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	25.7%	40.4%	21.4%	8.6%	3.9%	280
Senior management, heads of departments and directors of sites (middle managers)	19.4%	33.3%	36.1%	11.1%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	16.3%	41.3%	24.0%	14.4%	3.8%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	34.3%	41.4%	15.7%	3.6%	5.0%	140

Interpretation of responses: a high percentage of agreement to this question among shop floor employees suggests that they are reluctant to give their identities when reporting risk information, perhaps because of previous negative experience.

Employees must feel confident that they will not suffer negative personal consequences if they disclose information about problems. Attitudes will change—and then only slowly—when employees see repeated evidence that the company’s priorities have changed. They need to see that there will be no penalties for reporting problems; that on the contrary, employees are praised and rewarded for being proactive, and encouraged to maintain their vigilance; that the problems they report will be addressed. The project team was focused on shifting these attitudes at the production sites and reducing fear among the workforce of the consequences of transmitting “bad news” to their superiors. Gradually, as employee confidence in senior management grows, there should be a reduction in the proportion of anonymous communications, and more employees willing to identify that they are the source of the report.

Results of responses to anonymous surveys within the framework of the pilot project: Alternative communication channels used to transmit risk information between shop floor employees and senior managers should identify the employee raising the issue—i.e. not be anonymous but include personal identification details.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	23.6%	42.5%	22.9%	5.4%	5.7%	280
Senior management, heads of departments and directors of sites (middle managers)	33.3%	47.2%	16.7%	2.8%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	25.0%	34.6%	25.0%	7.7%	7.7%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	20.0%	47.1%	22.9%	4.3%	5.7%	140

Interpretation of responses: respondents lower in the hierarchy of the company seem slightly less inclined than their bosses to support the creation of non-anonymous channels for transmitting information about the problems of the organization.

As shop floor employees mostly prefer to send anonymous risk information, it is important to make this possible when communicating problems of lower criticality, i.e. Levels 1–3 (moderate, significant, and very serious problems). The personal data of employees choosing to transmit anonymously must be guaranteed to remain permanently concealed from everyone else, including senior management; the IT and security departments of the company can credibly guarantee this. When reporting a Level 4 problem (a critical issue) and pre-emergency situation (Level 5) then it is impossible for the sender to remain anonymous, because the company may well need to get back to them directly and immediately to prevent the situation escalating into a full-scale emergency.

Without going into the fine details of how the smartphone app works, it is useful to highlight some key features regarding the processing of incoming messages.

(I)
Information about Level 3 (very serious) and Level 4 (critical) problems is not immediately sent to the SVP and senior management of the company but does go automatically to headquarters via representatives of the special working team. At the request of the heads of the pilot production sites, details of these more critical issues are double checked by the chief engineer or facility director within 4–12 h.^{Footnote 8} There had been previous instances in the company when shop floor employees informed senior management about what they believed were Level 3 and 4 problems, but these were later recognized to be only Level 2 (significant) or even Level 1 (moderate) problems. To prevent further overestimates of criticality, these reports should be first assessed by the facility managers, who must provide senior management with their assessment of the situation within 4–12 h of receiving a high criticality message. This must include both how the shop floor employee or lower-level manager who sent the initial message view the situation, and the site management’s analysis. If senior management have not received this second report from the chief engineer or facility director within 4–12 h, then the sender’s original message will automatically be forwarded to the company’s senior management, as per the agreed protocol for Level 3 and Level 4 problems.
(II)
If the chief engineer or facility director does not agree with the criticality assessment of the original message and downgrades it from a Level 4 or 3 to Level to 2 or 1, then the initial sender has an opportunity to voice their disagreement with the revised assessment by filing an appeal. The appeal is automatically transferred to the special working team at headquarters. They must arrange a prompt visit to the site by a group of company specialists, and if necessary external experts, for a final decision on the actual level of criticality of the identified problem. Neither the sender nor the site managers can dispute the final assessment of the experts. The sender’s original message will be forwarded according to the protocol to be taken into consideration for the final criticality assessment.
(III)
The production site management may decide, after assessing a message of Level 1 or 2 criticality, that the problem reported should be increased to Level 3 or 4. If so, it is taken out of the hands of the facility and automatically sent up to the company’s senior management to be dealt with in accordance to the agreed protocol. The sender of the initial message does not have the opportunity to challenge this raised criticality assessment.
(IV)
Representatives of the special working team will reply to the sender of the report on the app’s chat, to inform them about the progress in addressing the revealed problem. If need be, they can ask the sender further questions to improve their understanding of the situation. Based on their analysis, they will then message the sender with a brief outline of their planned solution. If the sender has reservations about the proposed solution, sees a delay in its application, or considers that the problem has only been partly addressed, then the sender can use the app to resend the problem message marking it “Problem not resolved”. If this happens, then a senior member of the special working team takes over the responsibility for coordinating the response. This might involve further assessment, with or without a site visit, and initiating additional remedial action. Once the problem has been resolved to the satisfaction of the senior member of the special working team, the executive can decide to close the case. The sender cannot then challenge this decision.
(V)
All messages about pre-emergency situations (Level 5) or an already developing incident/accident are immediately sent to the company’s senior managers as per the protocol above. The heads of the sites affected will of course be involved in tackling the situation, but senior management will make the preliminary assessment of these messages, because of the potential severity of the consequences and the need for urgent intervention.

Every time the system helps to prompt identification of a very serious or critical issue, allowing swift and effective intervention to prevent a serious incident, senior management should use the app to spread the success story. They can message the pilot project participants or a targeted subgroup—for instance, the workforce at that site, or all senior and middle managers in the company—by push notifications.

One of the objectives in creating the smartphone app was to facilitate the prompt transmission of photo and video material from the scene of any incident to senior management. It is very important that employees only send this sensitive—and probably volatile—information using the app and are not tempted to post it on social networks or pass it on to the media. The company makes it clear that unauthorized sharing of such audio, video, and photo information on social networks or to the media is completely unacceptable and will result in an investigation, and possibly the dismissal of the employees concerned. At the same time, prompt transmission of serious safety and production issues up the hierarchy will allow the company’s emergency services to urgently address the situation, minimizing serious incidents and reducing the scale of emergencies. Employees who send these messages can potentially save the lives of their co-workers. The aim is to encourage employees to see themselves as active, responsible, and caring employees rather than bloggers.

XII.
CREATION OF ADDITIONAL OPERATING FUNDS AT THE PRODUCTION SITES

To address severe Level 3 and 4 problems identified through the app, all the operational resources available to the company’s senior management may be required. The precise solution and resources will depend on the nature and extent of each individual problem, and this will be determined primarily by the company’s SVP and the special working team leaders on a case-by-case basis.

In order to effectively resolve moderate (Level 1) and significant (Level 2) problems identified through the app, the company allocated significant additional funds to each pilot project production site. The site directors were given full authority to make purchases as they saw necessary to speed up the response to Level 1 and 2 issues. This allowed them to bypass the bureaucracy of the standard company procurement system. The size of each fund was determined by the SVP according to individual site requirements and the size of the facility. This process has the additional benefit of demonstrating that the SVP trusts the site managers in their ability to solve most of the moderate and significant problems disclosed through the app at their own facility. These budgets are revised every year and increased where necessary. Any unused budget can be carried over from one year to the next without reduction.

Establishing these additional operating funds:

encourages site directors to identify and address moderate and significant problems at their facility;
speeds up the resolution of many minor site problems to the benefit of all shop floor employees;
saves both managers’ and employees’ time by simplifying financial processes and avoiding the bureaucracy that was involved in working through the standard company procurement system;
reduces the number of requests from production sites to senior managers for permission/assistance to solve their onsite issues, as they can now tackle most of these without input from headquarters.

XIII.
NO PENALTY FOR DISCLOSURE OF INFORMATION ABOUT RISKS. PENALTY FOR CONCEALMENT OF RISK INFORMATION

As part of an in-depth interview, a senior manager said: “The first time a leader yells at his subordinates is the last time he will hear the truth from them”. The entire philosophy of the project is focused not on penalizing employees and managers who make mistakes, but on helping them so that they do not repeat the same mistake in the future, and will openly admit any errors they do make and report them to management.

Results of responses to anonymous surveys within the framework of the pilot project: How do you view the adequacy of penalties at your enterprise for various misconduct offenses?

	Excessively hard	Hard	Adequate/Fair	Soft	Excessively soft	Number of respondents
All survey participants	2.5%	22.5%	70.4%	3.9%	0.7%	280
Senior management, heads of departments and directors of sites (middle managers)	0.0%	13.9%	72.2%	13.9%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	3.8%	21.2%	72.1%	1.9%	1.0%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	2.1%	25.7%	68.6%	2.9%	0.7%	140

Interpretation of responses: the lower the respondents are in the company hierarchy, the more inclined they are to rate the existing penalty system as harsh.

Results of responses to anonymous surveys within the framework of the pilot project: Managers should not penalize employees for their mistakes, but look for systemic flaws in the work of an organization that may have created an unsafe situation for employees.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	31.4%	44.6%	19.3%	2.5%	2.1%	280
Senior management, heads of departments and directors of sites (middle managers)	36.1%	47.2%	16.7%	0.0%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	26.9%	51.9%	15.4%	4.8%	1.0%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	35.7%	42.1%	16.4%	0.7%	5.0%	140

Results of responses to anonymous surveys within the framework of the pilot project: It is only justified to penalize employees when they have deliberately violated safety rules or neglected their duties.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	62.9%	31.8%	3.6%	0.4%	1.4%	280
Senior management, heads of departments and directors of sites (middle managers)	75.0%	25.0%	0.0%	0.0%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	64.4%	29.8%	2.9%	1.0%	1.9%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	58.6%	35.0%	5.0%	0.0%	1.4%	140

Results of responses to anonymous surveys in the framework of the pilot project: Managers should create a workplace climate where the voluntary admission of an error by an employee does not then result in them being penalized.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	42.1%	49.6%	5.7%	0.7%	1.8%	280
Senior management, heads of departments and directors of sites (middle managers)	50.0%	47.2%	2.8%	0.0%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	45.2%	51.0%	1.9%	1.0%	1.0%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	37.9%	49.3%	9.3%	0.7%	2.9%	140

During the seminar training for management, and in all the supporting documents for the pilot project, it is essential to emphasize that employees who voluntary disclose safety and technological problems must always get positive feedback from higher managers. This can be in the form of thanks, rewards and public praise. No employee who voluntarily reports an issue should in any way be held personally responsible, reprimanded, or have their bonuses docked—however serious the problem that has arisen or the outcome of the disclosure. It must also be considered unacceptable for senior management to express dissatisfaction with the director of a production site where problems have been reported voluntarily. Most unresolved risks at industrial facilities are the result of previous long-term underinvestment in the modernization of infrastructure, previous over-ambitions corporate goals, and so on. In most cases, production site directors have for many years had limited resources to address safety and production risks.

Senior management should immediately and repeatedly reassure facility heads that:

no one is looking to find employees or managers to blame for reported problems;
senior management and site managers are allies and must work together to manage the risks at their facilities and prevent emergencies;
senior management are ready to devote their time and attention to gathering details of all critical risks, and securing the resources required to address the underlying issues.

This reassurance will stop site managers from seeing the pilot project as a threat to their career and position, with information about risks and problems reaching senior management independent of the traditional management hierarchy. They will then be less likely to try and prevent their subordinates from reporting critical problems to senior management via the smartphone app. Rather than showing displeasure with their most proactive and conscientious workers, site managers should praise them for giving honest feedback about problems and thank them for information that could prevent disasters.

Results of responses to anonymous surveys in the framework of the pilot project: In a company where a voluntary risk disclosure to superiors is never penalized, employees or managers who deliberately hide information about risks in their area of responsibility should face dismissal.

	Strongly agree	Rather agree	Rather disagree	Strongly disagree	Difficult to answer	Number of respondents
All survey participants	28.6%	47.9%	16.1%	2.5%	5.0%	280
Senior management, heads of departments and directors of sites (middle managers)	50.0%	38.9%	8.3%	2.8%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	24.0%	50.0%	19.2%	1.9%	4.8%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	26.4%	48.6%	15.7%	2.9%	6.4%	140

Interpretation of responses: the lower the respondents are in the company hierarchy, the less inclined they are to fully agree that it is necessary to dismiss employees or managers who deliberately conceal information about risks in their area of responsibility.

The company’s official supporting documents for the pilot project stipulate that any employee—regardless of corporate level—found concealing information about safety and technological problems or incidents will face disciplinary measures, which might include dismissal. It must be crystal clear to every employee that deliberately withholding information about risks can have very serious personal consequences.

Some managers were worried that if they did not discipline their subordinates for safety violations reported voluntarily, they could be perceived as weak, leading some to think they could act with impunity. The company’s senior management explained: “We do not agree that, if an employee comes to us and admits a problem or mistake in his area of responsibility, then he must always be completely forgiven. This could provoke the following problem. A second employee might think: ‘I also made a mistake, but nothing bad happened. So I’ll go confess now, and I won’t be punished’. And then a third one will think: ‘I’ll go and say, sorry, dear boss, I made a mistake. I won’t do it again’. For the first time, the manager may be happy to let things ride, but this becomes difficult if similar mistakes continue to be repeated by the same employees. Surely it is necessary to understand why the employee made that mistake. Look at what really happened—was it an organizational problem, faulty machinery, poor instructions, or maybe simple human error, etc. Only from an objective analysis will it become clear where the responsibility and fault really lies. Only then can the truth be uncovered and employees fairly reprimanded. The word ‘justice’ is key here. Management should only penalize subordinates according to their degree of true responsibility, so that the whole workforce can see that the system is treating everyone fairly”.

Based on the responses of senior leaders, the following provisions were adopted:

Every critical and very serious problem disclosed should be investigated in detail to understand the systemic root causes that led to the problem, and to accurately determine the relative responsibilities of each manager and employee involved.
When systemic causes and specific failures in responsibility are identified, employees are informed of their degree of responsibility for the situation, but still no one is penalized if the risk was disclosed voluntarily. Everyone is encouraged to learn from their mistakes, so as to not repeat them.
Fair and proportionate punishment is applied only when employees and managers repeat mistakes they have already been warned about and were not previously punished for.

XIV.
ANALYSIS OF ROOT CAUSES OF CRITICAL AND VERY SERIOUS PROBLEMS

The special working team of executives meet regularly to analyze the causes behind criticality Level 3 and 4 problems. Analysis of level 1 and 2 problems is carried out at the discretion of the site directors.

When conducting an analysis of a particular issue, managers should try to answer the following questions:

How did the corporate management system allow the problem to occur?
What top-level decisions contributed to the problem?
Why could managers and employees in the field not promptly and effectively manage the problem?
What responsibility do the individual managers and employees involved bear for the issue becoming critical?
How can company procedures be improved to prevent a similar problem from occurring again?

The results of this analysis are documented as a free-form report and sent to the managers and employees involved, both at headquarters and at the site(s) where the problem was identified.

If the analysis reveals shortcomings in the work of specific managers or employees at the site, no disciplinary measures are taken. Instead, the information is shared directly with them, and changes that both the company and the employee can make to avoid a recurrence are discussed.

If the analysis establishes that either the managers or the employees have repeated previously identified errors, then they are issued with a warning. If the same errors are revealed to have caused the same problem for a third time, then disciplinary measures are taken, up to and including dismissal.

XV.
EMPLOYEE REWARDS FOR DISCLOSURE OF INFORMATION ABOUT RISKS

Results of responses to anonymous surveys within the framework of the pilot project: Choose what you believe to be the most appropriate methods of reward for disclosing information about safety and technological problems (choose only one answer).

	Material rewards only	Non-material rewards only	Combination of material and non-material rewards	No rewards needed — disclosure is the professional duty of employees	Difficult to answer	Number of respondents
All survey participants	7.9%	4.3%	57.5%	25.7%	4.6%	280
Senior management, heads of departments and directors of sites (middle managers)	0.0%	2.8%	80.6%	16.7%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	4.8%	5.8%	58.7%	28.8%	1.9%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	12.1%	3.6%	50.7%	25.7%	7.9%	140

Results of responses to anonymous surveys within the framework of the pilot project: If the company decides that it needs to combine material and non-material rewards for disclosing information about safety and technological problems, what should be prioritized?

	Combination of mostly material and some non-material rewards	Combination of mostly non-material and some material rewards	Equal priority to material and non-material rewards	Difficult to answer	Number of respondents
All survey participants	31.4%	27.9%	30.4%	10.4%	280
Senior management, heads of departments and directors of sites (middle managers)	13.9%	50.0%	33.3%	2.8%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	27.9%	32.7%	29.8%	9.6%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	38.6%	18.6%	30.0%	12.9%	140

Interpretation of responses: the lower the respondents are in the company hierarchy, the more highly they regard material rewards. The higher the position of the respondents, the more important they regard non-material rewards. The most likely explanation of this variation is that managers have built a career in a critical infrastructure organization, so they value non-material rewards such as praise from a senior manager as they believe this will assist their career progression. On the other hand, shop floor employees are more concerned with securing an adequate income, so they set greater value on material rewards, especially financial.

One of the most controversial issues in the pilot project was how to reward employees and lower managers for their proactive and timely action in voluntarily disclosing information about safety and technological problems, about pre-emergency situations to avoid escalation, or promptly reporting an ongoing emergency.

It was decided that the company would never offer employees personal financial and material rewards (i.e. hard cash or personal presents like smartphones, TVs, cars, flats, etc.) for disclosing information about safety and technological problems. Such payments have several negative aspects as discussed in Chap. 3, Recommendation No. 10: “Reward employees for disclosure of safety and technological risks”. These were confirmed by the group work during the site seminars.

Advantages of personal material rewards for specific employees (from results of seminar group work):

High motivation to become involved—many employees will immediately join the search for risks and problems at their sites.
Fast transmission of risk information and a high volume of risks reported.
Training of employees to communicate risk information and remove psychological barriers to voluntary, objective disclosure.

Disadvantages of personal material rewards for specific employees (from results of seminar group work):

Information noise: employees will try to find as many problems as possible. There is a threat of information overload with many insignificant problems that still have to addressed.
Senders will demand rewards for trivial messages. A high rejection rate will lead to loss of confidence in the project.
Deliberately bringing equipment to a critical state: some employees will be tempted to allow/ encourage machinery to reach a pre-critical state in order to receive a reward for reporting it. Smaller monetary rewards may not be enough to incentivize employees to disclose risks, whereas a large reward may motivate some employees to go as far as deliberately damaging equipment.
Envy from colleagues.
Employees will spend too much time “risk hunting” and this could reduce productivity.

After discussion with senior management and with all seminar participants, a mixed reward model including material and non-material rewards was agreed. This was designed to maximize incentives, and convince employees that reporting safety and technological problems was worth their while and would be generously rewarded by the company.

A key factor with financial rewards paid to employees for disclosing information is that they can only be spent within the company’s operations (i.e. tokens or “virtual money”). This means employees who have uncovered issues spend their rewards on professional equipment, tools, and extras to make their immediate workplace and that of their colleagues safer, more comfortable, and more productive.

Type of message		Employee motivation for disclosure of risk	Reward model
I. Problem	Moderate problem (Level 1)	Senders can help mitigate risks and problems in their area of responsibility by obtaining resources from the additional operating fund This helps to secure the incomes and job security of themselves and their colleagues	Various non-material rewards Sender of the best message received in a month (judged in competition) is given a virtual check for US $1000. This can be spent (with site director’s approval) on the purchase of equipment and extras for the sender’s workplace to make it safer, more comfortable, and more productive
	Significant problem (Level 2)	Senders can help mitigate risks and problems in their area of responsibility by obtaining resources from the additional operating fund This helps to secure the incomes and job security of themselves and their colleagues	Various non-material rewards Sender of the best message received in a month (judged in competition) is given a virtual check for US $2000. This can be spent (with site director’s approval) on the purchase of equipment and extras for the sender’s workplace to make it safer, more comfortable, and more productive
	Very serious problem (Level 3)	Senders can save themselves and their colleagues from serious injury and even death, as well as protect their jobs and income	Public expression of gratitude to the sender from the site director Various non-material rewards Sender is given a virtual check for US $10,000 for the purchase (with site director’s approval and support of three colleagues) of equipment and extras for the sender’s workplace to make it safer, more comfortable, and more productive
	Critical problem (Level 4)	Senders can save themselves and their colleagues from serious injury and death, as well as protecting all employees’ jobs and income by maintaining the long-term resilience of the company’s critical sites They are also protecting the safety and livelihoods of more than 100,000 people living near the company’s industrial facilities	Public praise and gratitude is given by the SVP — the highest award the project can bestow Various non-material rewards Sender is given a virtual check for US $20,000 (up to a max US $60,000 in exceptional cases) for the purchase of equipment, vehicles and extras for the sender’s workplace to make it safer, more comfortable, and more productive. Sender needs to obtain spending approval from five colleagues as well as the site director
II. Pre-emergency situation (Level 5)		By informing senior management about pre-emergency situation, senders could save themselves and their colleagues from serious injury and death, as well as protecting all employees’ jobs and income by maintaining the long-term resilience of the company’s critical sites They are also protecting the safety and livelihoods of more than 100,000 people living near the company’s industrial facilities	Public praise and gratitude is given by the senior manager of the company’s production department Various non-material rewards
III. Incident/accident already in progress		By promptly informing the entire management hierarchy about an incident/accident, senders have initiated an urgent emergency response, saving the lives of employees and public and reducing the overall severity of the incident and the amount of environmental damage caused	Personal public gratitude from one of the heads of the company’s internal emergency services Sender is presented with the corporate “Rescuer” award and a formal letter of thanks from the company’s leaders

The amount of remuneration is determined according to the severity of the identified problem assessed and confirmed by the special working team.

It is important that the sender cannot independently decide what equipment to purchase. This must be done in agreement with other members of the workforce and the site director. This ensures that the sender does not become an outcast. Colleagues of the sender can feel they are involved in the process and can see that there is no benefit in deliberately ignoring risks. It also discourages employees from bringing production facilities to a pre-critical state in the hope of receiving a significant reward that they can spend on themselves: the sender’s colleagues could prevent this at the outset, well before the equipment has been driven to a pre-critical state.

Payments are made from the site director’s additional operating fund to make the process as simple as possible and minimize bureaucracy and delays. The site director has access to significant financial resources and rewarding employees for reporting major safety concerns is a legitimate use of these.

If messages about problems are sent anonymously, then the sender cannot receive any reward or recognition for their actions. However, the sender of the message can choose to reveal their name at any time, and then receive their deserved reward.

The company’s risk information transmission system is focused on motivating employees and managers to preemptively disclose information about problems in their area of responsibility to prevent serious incidents and emergencies. The level of remuneration for reporting the problem decreases the closer the problem comes to causing an emergency situation. This encourages employees and managers operating critical infrastructure to focus on preventative control of existing problems, and to report any risks they encounter to their superiors before the situation reaches a dangerous point.

A line graph of the level of remuneration versus time. The sooner production site employees inform management about potentially critical problems, the higher the remuneration they will receive, and it decreases as the problem gets closer to causing a serious incident at the production facility.

Three out of four of the pilot production site directors agreed with the following scheme of virtual money, which could be spent on equipment and extras for the sender’s workplace to make it safer, more comfortable, and more productive. Nevertheless, the fourth plant director stated firmly that he is worried about giving senders any kind of financial and material reward: he thinks that even with virtual money, there is a real threat of equipment being deliberately pushed towards, or negligently allowed to reach, a pre-critical state in order to report a more serious situation and get the reward. He insisted that he will reward his staff only by non-material means. Finally, the senior management came to a compromise that all the reward schemes mentioned should be tested within the pilot production sites over the next 6–12 months, according to the respective preferences of the plant directors. This will give the project team more information about the most effective ways to motivate staff at the plants to disclose risks. Based on this experience, the best reward menu will be selected and implemented as the project is extended to the other production sites.

Along with these material rewards, various non-material incentives and acknowledgments were developed to recognize the valuable contribution of employees or work teams who report safety and technological problems. Below is a list of the ones selected for use by the seminar participants. The three most popular responses at each level of management are highlighted in green.

Results of responses to anonymous surveys within the framework of the pilot project: Choose what you consider to be the most appropriate and effective non-material rewards for employees disclosing information about technological risks (multiple answers can be selected).

	All survey participants	Senior management, heads of departments and directors of sites (middle managers)	Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	Engineers, foremen, and shop floor employees who operate critical infrastructure at sites
Public commendation from senior management to an employee or work team	58.6%	81.0%	87.0%	53.0%
Professional internships at other company enterprises or additional professional training (including abroad)	37.9%	50.0%	58.0%	33.0%
Diploma personally signed by senior management	36.1%	47.0%	61.0%	27.0%
Special honorary order (corporate medal)	35.0%	53.0%	61.0%	25.0%
Inclusion in the list of best employees at the site	34.3%	50.0%	57.0%	26.0%
Tickets for all family members to attend major sporting events or concerts	32.9%	56.0%	56.0%	24.0%
Letter of gratitude sent from senior management to a employee’s family acknowledging his/her contribution to the safety of the site	32.5%	33.0%	47.0%	30.0%
Additional days off	30.7%	28.0%	31.0%	39.0%
Weekends at the corporate recreation center for all family members	29.6%	44.0%	42.0%	28.0%
Article in the corporate the employee/team who prevented a serious emergency	24.3%	44.0%	42.0%	17.0%
Opportunity to become a mentor, passing on their successful experience to other employees within the company	20.0%	42.0%	34.0%	15.0%
Joint photo with senior management	16.8%	25.0%	26.0%	14.0%
Videos featuring outstanding contribution to company safety by employee/team. Broadcasting these videos to other employees across all the company sites	9.6%	31.0%	16.0%	7.0%
Lavish dinner for distinguished employee/team with senior management	8.6%	11.0%	15.0%	6.0%
One-year allocation of personal parking spot alongside top company executives	8.6%	11.0%	13.0%	7.0%
Total respondents	280	36	104	140

XVI.
HOLDING AN INAUGURAL EVENT TO PRESENT THE SOLUTIONS CREATED DURING IMPLEMENTATION OF THE PILOT PROJECT

When the pilot project begins, it is agreed that once all the above elements have been established (the app, the reward schemes, the additional operating funds, etc.) it would be beneficial to mark the occasion with an inaugural event for the project participants. The event is guided by the project leader, and attended by the SVP and key senior managers of the company’s production and HSE departments. It is held in the largest venue in the city, which has the capacity to accommodate 250–400 project participants.

The central task for the SVP and the senior managers at this event is to convince the project participants that the top officials of the company really do want to receive prompt and accurate information from their subordinates about critical and serious safety and technological problems. This is because getting such information in time can prevent these problems from escalating into emergencies, thus saving people’s lives and the integrity of production facilities.

It is also important that senior managers take the opportunity to personally re-emphasize the key aspects of the pilot project to all the assembled participants.

Senior management and site directors will quickly address any critical or very serious problem brought to their attention. To demonstrate how this has already been successfully achieved, videos are shown of how the seven critical problems revealed by participants in the pilot project were successfully dealt with.
The company has had successes (and difficulties) in addressing 104 other less critical problems disclosed by the pilot project seminar participants.
Senior management have sufficient resources allocated by the owners and main shareholders to address the most critical and serious issues that are identified.
The site directors have additional resources available to them for addressing significant and moderate issues at their facility.
The causes of critical and very serious problems will always be fully investigated to identify the underlying organizational flaws that created the issues and to prevent the repetition of the same errors in the future. Senior management will explain how this analysis is carried out, as well as the penalties employees can expect to receive if they repeat the same mistakes and fail to learn from past negative experiences.
The company guarantees that it will never penalize employees for mistakes if these were voluntarily and promptly disclosed to their superiors. However, severe penalties will be applied to anyone deliberately concealing information about risks.
A scheme has been agreed to reward employees for the disclosure of information about risks. This will be explained in detail.

In the presence of hundreds of project participants, the SVP and senior management of the company then personally reward those employees who have already uncovered critical and very serious problems, thus preventing several accidents and incidents. All project participants are urged to follow the example of these valued and proactive employees.

As part of preparing for this event, the IT department pre-installs the application on the smartphones of all project participants. At the end of the event, the senior management urge all project participants that when they return to their everyday job, they should start using the app to quickly transmit information about any problems and risks that they observe.

For those employees who cannot attend this inaugural event, the company’s PR department will provide a short video covering all the main points discussed. This is posted on a dedicated web page on the company’s intranet. This web page also includes details of all the principles and solutions developed within the framework of the project so far. All project participants receive a link to this page in three ways—an SMS, a push notification in the project smartphone app, and on corporate email. (Not all project participants, especially shop floor workers, have a personal corporate email.)

Results of responses to anonymous surveys within the framework of the pilot project: As part of the pilot project, it is planned to present the solutions developed by around 500 employees and managers who attended the seminars. What is the most convenient format for you to participate in this presentation?

	Personally participate in a special event where senior management will talk about decisions within the project; opportunity for attendees to ask questions directly	Receive a link to a video on your smartphone, which explains the solutions that were developed within the project; online chat with answers to questions	Watch a specially prepared video with colleagues at the facility; ask questions to a representative of the HSE service	Difficult to answer	Number of respondents
All survey participants	45.0%	36.2%	11.8%	7.0%	280
Senior management, heads of departments and directors of sites (middle managers)	60.0%	35.0%	5.0%	0.0%	36
Lower managers: deputy directors of sites, chief engineers of sites, heads of workshops, heads and representatives of HSE services at sites	52.9%	25.9%	9.4%	11.8%	104
Engineers, foremen, and shop floor employees who operate critical infrastructure at sites	37.1%	43.5%	14.5%	4.8%	140

Interpretation of responses: managers are often trying to build a career in the company, therefore more likely to be interested in building good relationships with higher managers by personally attending a special event. Shop floor employees are more focused on earning a regular income than on a career in the company, therefore show less interest in attending events where senior management are in attendance.

XVII.
TRAINING OF INTERNAL TRAINERS

Within the 15 seminars, a special seminar was held for 33 managers working at various levels within the company’s HSE department. In addition to familiarizing these managers with the ideology and details of the pilot project, the task was to find potential internal trainers among the seminar participants. As a result, eight people expressed a desire to undergo further special training under the guidance of the project leader, so that they could conduct similar seminars in the future, when scaling up this project at other production sites.

XVIII.
HOLDING NEW SEMINARS AT THE COMPANY’S OTHER INDUSTRIAL SITES

The project team agreed that the scaling up of the project will begin when the procedures and solutions mentioned above have been successfully tested at the four pilot production sites. When scaling up the project, 5–10% of employees will be selected from the workforce of each new site. These employees should be responsible for the operation of critical site infrastructure and have extensive experience in their role. The project leader will conduct training seminars for site managers, workshop supervisors, and other lower-level managers, as well as for representatives of the HSE department at each new site. Specially trained internal instructors will conduct training seminars for the selected engineers, foremen, and shop floor employees who operate critical infrastructure.

Four to six months after these new seminars, the company’s SVP, together with other senior managers, will hold an inaugural event (as described above) to reward employees who have uncovered new critical risks at their sites and helped prevent disasters. The company’s management will also use this opportunity to encourage all employees to always be alert in identifying risks and problems in their area of responsibility, and immediately informing their superiors about these issues using the dedicated smartphone app.

According to the authors of the handbook, it will take this large industrial company approximately three years to roll this project out across all sites, and significantly improve the quality and speed of reporting accurate risk information at each site.

PRELIMINARY RESULTS OF THE PILOT PROJECT

The authors would like to cite a letter of recommendation provided by the company’s senior vice president (referenced earlier as SVP), who is responsible for the production at the main industrial complex of the company. This was based upon the results achieved over the first 10 months of the pilot project.

A letter of recommendation. Some of it reads. The project has paid for itself many times over as risks revealed during the seminars were swiftly brought under control, allowing the company to avoid a number of emergencies. I believe that the solutions proposed by Doctor Dmitry Chernov are unique.

TESTING IDEAS AND SOLUTIONS IN OTHER CRITICAL INFRASTRUCTURE COMPANIES

The authors are open to cooperation with other critical infrastructure companies worldwide to test ideas and solutions for improving the quality and speed of critical risk information transmission and for preventing accidents. They are ready to provide critical infrastructure companies with the results of their many years of research and their extensive experience in managing similar projects in other companies. They are also willing to spend lengthy periods at the location of a company’s industrial sites to lead and supervise the implementation of new scientific and practical projects.

The authors are confident that a radical improvement in the quality and speed of communicating information about safety and technological problems is possible in companies operating critical infrastructure. This can be achieved by the open exchange of experience between industrial companies around the world, by the systematization of project design and implementation, and by the publication and distribution of best practices. This will help to establish tested mechanisms for proper and timely intra-organizational risk communication for a global community of risk management specialists. The goal of all of this is clear: to prevent industrial accidents and disasters from occurring in the first place, to save people’s lives, reduce environmental damage, and increase the resilience of critical infrastructure facilities.

The authors believe that an international corporate standard for building a risk information transmission system within critical infrastructure companies could be established within approximately 10–15 years. To this end, the first author plans to devote his future scientific and consulting career in the field of risk management to developing such an international corporate standard, through the experience of implementing further scientific and practical projects in various critical infrastructure companies around the world.

Additional information: dmitrychernov@riskcommunication.info and dmitrychernov@mail.ch or dmitrychernov@ethz.ch.

Notes

1.
Dmitry Chernov, Didier Sornette, Man-made Catastrophes and Risk Information Concealment: Case Studies of Major Disasters and Human Fallibility, Springer, 2016, https://www.springer.com/gp/book/9783319242996.
2.
Dmitry Chernov, Didier Sornette, Critical Risks of Different Economic Sectors (Based on the Analysis of More Than 500 Incidents, Accidents and Disasters), Springer, 2020, https://springerlink.fh-diploma.de/book/10.1007/978-3-030-25034-8.
3.
Dmitry Chernov, Didier Sornette, Giovanni Sansavini, Ali Ayoub, Don’t Tell the Boss! How poor communication on risks within organizations causes major catastrophes, Springer, 2022, https://springerlink.fh-diploma.de/book/10.1007/978-3-031-05206-4.
4.
SVP: Senior Vice President in charge of production at the key industrial site of the company.
5.
Dmitry Chernov, Didier Sornette, Giovanni Sansavini, Ali Ayoub, Don’t Tell the Boss! How poor communication on risks within organizations causes major catastrophes, Springer, 2022, https://springerlink.fh-diploma.de/book/10.1007/978-3-031-05206-4.
6.
Dmitry Chernov, Didier Sornette, Giovanni Sansavini, Ali Ayoub, Don’t Tell the Boss! How poor communication on risks within organizations causes major catastrophes, Springer, 2022, https://springerlink.fh-diploma.de/book/10.1007/978-3-031-05206-4.
7.
Dmitry Chernov, Didier Sornette, Giovanni Sansavini, Ali Ayoub, Don’t Tell the Boss! How poor communication on risks within organizations causes major catastrophes, Springer, 2022, https://springerlink.fh-diploma.de/book/10.1007/978-3-031-05206-4.
8.
This message validation model is a trial version within the pilot project. It has both supporters and critics among the senior management of the company. To decide on the effectiveness of the model, it should be tested within 3–6 months of the launch of the smartphone application.

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Authors and Affiliations

Reliability and Risk Engineering, ETH Zürich, Zürich, Switzerland
Dmitry Chernov
Department of Nuclear Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
Ali Ayoub
Chair of Reliability and Risk Engineering, ETH Zürich, Zürich, Switzerland
Giovanni Sansavini
Southern University of Science and Technology, Shenzhen, Guangdong, China
Didier Sornette

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Dmitry Chernov
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Ali Ayoub
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Correspondence to Dmitry Chernov .

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Chernov, D., Ayoub, A., Sansavini, G., Sornette, D. (2023). A Pilot Project—Introducing a System for Transmitting Information on Safety and Technological Problems Within a Critical Infrastructure Company. In: Averting Disaster Before It Strikes. Springer, Cham. https://doi.org/10.1007/978-3-031-30772-0_4

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DOI: https://doi.org/10.1007/978-3-031-30772-0_4
Published: 28 June 2023
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A Pilot Project—Introducing a System for Transmitting Information on Safety and Technological Problems Within a Critical Infrastructure Company

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