Research on human cognition teaches us that most of us go through life on autopilot most of the time. We don’t have the mental resources necessary to actively think through every action and decision, so we use do most things without thinking. This works most of the time because we’ve built up a lifetime of rules and mental short-cuts that allow us to operate that way safely. For example, think about driving – you don’t have to ask or think about which side the accelerator pedal will be on. It’s always on the right side, and the brake pedal is just to the left of it. The next time you get into a car to drive you’re likely not going to check where the pedals are.
Think about that for a minute – why not? How do you know that the pedals will be where you believe they are? Because that’s where the pedals have always been. You’re basing your future actions on past knowledge. And that works a large majority of the time because things like that often don’t change. So you go through life with the assumption that the pedals in your car won’t change and you’ll be safe in that assumption most of the time.
Until you’re wrong.
Obviously it’s unlikely the pedals on your car will change any time soon. However, it’s amazing when you think about how much of the time you operate based on the assumption that things are the same today as they were yesterday. And that’s where the trouble starts. When those assumptions no longer hold true we are at risk to make mistakes, and sometimes those mistakes come with extreme risk.
Take for example a project that we’re currently working on for a client. It’s a maintenance shutdown (a “turnaround”) at a chemical plant. We’ve worked with this client for years and we’ve had over a decade of annual turnarounds without a lost-time injury. A record like that is certainly something to be proud of, but like we’ve talked about in other blogs (here and here), safety is more than what doesn’t happen, so we are always trying to get the client to look at their current risks, rather than just focusing on past success. And by doing that we found some interesting things:
- This maintenance shutdown had to be made shorter in terms of time, but the number of jobs scheduled has not been proportionately reduced, meaning that the number of jobs scheduled per day is not significantly reduced, and increased in some cases.
- The engineers planning the process are very young and inexperienced, with an average tenure at the plant of about 2 years.
- The majority of the contractors brought in to do the project are either new contractors or contractors who have been at the plant before, but the work crews they are bringing in have never been at the plant before.
- The plant’s corporate safety group recently rolled out a new permitting system for all jobs, including confined space and lockout/tagout, that plant employees are still getting used to.
Individually any one of these issues is a small increase to risk. Together they lead to a cascade of assumptions that are no longer valid. A normal shutdown is successful when you have experienced crews working with experienced planners, engineers, and project managers, using safety systems they are familiar with. However, none of those conditions are valid this time.
This situation shows the value of a robust management of change process. Each of the above conditions exists as a result of changes that are relatively commonplace. When you’re dealing with commonplace the assumption is that everything is fine (because common things are usually not that risky). But the management of change processes at the plant, mixed with a healthy preoccupation with failure, identified these conditions and we are working with the plant to build in systems to show employees that their normal assumptions are invalid and to help them reduce the risks.
A key learning point in developing an effective management of change process is to manage assumptions. Here’s some best practices in managing assumptions in a management of change process:
- Identify what assumptions in the process, workflow, or systems are safety critical. For everything to work out as you’d like it to, what assumptions are you relying on (tools, people, environmental conditions, training, management processes, engineering processes, economic conditions, etc.) and what are the consequences if those assumptions are invalid?
- Once you identify those assumptions that are safety critical, identify what aspects of the assumptions you have control over and what you don’t. For example, we may not have total control over the work crews that contractors send us (although sometimes we do), we do have control over the training programs for engineers and project managers.
- For those areas we have control over, make sure you develop systems to ensure that what needs to happen does happen. For example, a learning from this shutdown is to build in better training systems for engineers and project managers. This program will include measurements of competency, so that those with less experience are identified and receive more training.
- For those areas we do not have control over, we need to build in resilience and ensure that we’re not pushing safety boundaries. For example, for this shutdown more site-specific training/orientation and supervision has been provided to contractor employees, and engineers and project-managers are looking for ways to take additional pressures off of contractors, such as scheduling pressures.
How you do it depends on the job. But when making safety and risk management decisions, ask yourself, what assumptions are you making and what if you’re wrong?