Wednesday, April 23, 2014

Success Investigations: Safety’s (Under Utilized) Secret Weapon

A worker puts the finishing touches on a project that she has been working on for the better part of two days. It was a bit of a challenge, some of the design drawings that engineering gave to her weren’t accurate, but she was able to figure it out and improvise a solution. Before leaving for the day she sees the site safety manager near the break room. The safety manager sees that the worker is done and immediately rushes to action. He furiously pulls out his phone and begins to coordinate getting a team together, while also yelling at the site supervisor to preserve the scene. A thorough investigation is done to identify the causal factors that led to the success and a report is issued to facilitate lessons learned.

Ok…the above almost never happens, right? Safety professionals don’t investigate success. Our job is to look at failures. Success usually isn’t even on our radar screen. We’re too busy as is. If we had to investigate every time a job went off without a problem we’d never see the light of day again. Besides, isn’t there enough data from looking at failures to make looking at successes a waste of time?

Hold that thought for a minute and consider the following quote from “Risk”, by John Adams:

"Road engineers with their accident statistics frequently dismiss condescendingly the fears of people living alongside busy roads with good accident records, heedless of the likelihood that the good accident records reflect the careful behavior of people who believe their roads to be dangerous."

Wow, what a quote! Consider the implication here – things are working out in a version of success, but not because of those whose job it is to create a safe system. The system could be safe simply because of the people overcoming an unsafe system.

The idea is pretty straightforward – if we have low accident/incident statistics there are a few potential reasons:
  1. You could have a safe system and the statistics reflect that.
  2. You could have an unsafe system and the statistics reflect the ability of your workers to overcome that unsafe system.
  3. You could have an unsafe system, but you’re just really lucky that you’re not having a lot of incidents.

So in two out of the three cases your system is unsafe, you just don’t know it yet. Of course you could argue that you would figure this out if an incident happened and you conduct a thorough investigation of that incident. But that means you have to wait for something bad to happen before you can learn the truth and that just doesn’t seem right.

What if, instead, you occasionally got out from behind that desk and went out to investigate why the majority of the time things are going right. Sidney Dekker advocates at least a two-hour blackout period for managers and supervisors, including safety managers, where all electronic devices must be powered off and the manager/supervisor just observes how work is being done. You should even have conversations with employees to get their perspectives on why things are working out. Many times we’ll find a story similar to the fictional story at the beginning of this post – our employees overcoming obstacles to create safety on a day-to-day basis using a combination of improvisation, creativity, and intelligence. Perhaps if those road engineers from the quote above got out from behind their desk they would see something similar.

How you do this can vary from informal processes, like those discussed above, to formal reviews, such as where you have a debriefing after key projects to identify lessons learned. A lot of really great things can happen when we start to investigate successes in addition to failures.
  • First, you can identify failures before they happen, as opposed to just after.
  • Second, you get a much clearer picture of the environment that your employees operate in, which builds understanding and trust between you and your employees. It also helps you recommend better interventions that will work with the workflow, rather than inhibit it.
  • Finally, it allows you to identify the reasons for success and make recommendations to increase the likelihood of success, in line with the concepts of Safety II.


So the next time you see your employees clocking out for the day safe and sound, don’t just pat yourself on the back for a job well done. Ask yourself what allowed that to happen. Once you understand that you may be able to make it happen again tomorrow.

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