What if Our Solution is the Problem?

An employee at a client’s site was injured recently when their hand was hit while sand blasting (using high pressure beads, called “sand” to remove paint or other coatings from a surface). The injury was relatively minor compared to what could have happened, he only had to have sand and dead tissue surgically removed, so the most that will likely happen is he’ll get a cool scar and nice story out of the deal.

That’s about as much as we know about the incident though, because at this point the story starts to get fuzzy. The injured employee says that he was hit by the blasting of another employee when the injured employee put his hand through a hole in the wall, while the other employee says he wasn’t even in the area at the time, so it couldn’t have been him.

The automatic response to this is so normal that no one questions it anymore – get the employee drug tested, consider retraining, consider disciplinary action for the employee who lied (depending on which one we identify in the investigation as the liar). This should allow us to get things back to normal by fixing the problem. Just another day at the office, right?

Sometimes so much learning can be gained by simply asking a stupid question. For example, why would an employee not tell the truth about what caused an accident? Because they don’t want to get into trouble, obviously. Look at the list of actions following the incident – they all involve finding problems in the person and fixing those problems.

What we spend our time on is an indication of what’s important to us, and in the case of an accident, what we spend our time on is an indication of where we think the source of the problem is. As Erik Hollnagel says – What You Look For is What You Find, which is followed closely by What You Find is What You Fix.

What’s the big deal here though? There’s clearly some level of misconduct in the case above, so someone needs to be punishe

d right? That’s where the problem comes in – so many people when they read that story automatically jump into the find and fix the person mode. This is an indication of our habitual blame response, particularly following an accident. But lets take a step back and ask another stupid question – why would we blame someone following an accident? Two reasons come to mind:

1. To prevent the accident from happening again; and,
2. To hold people accountable to the rules and procedures we have in place.

But here’s the thing - for number 1 to occur we first have to identify what happened to begin with. To put it another way – number 1 only happens if we create an environment that facilitates learning. And this creates a problem when you realize that the second reason to blame can conflict with the first reason. Put simply – our blame reaction gets in the way of our ability to learn. Why? Because when we start the investigation by looking for what went wrong with the people involved should we be surprised when their reaction becomes defensive through the hiding of information? So we’re left with a choice – we can either learn or we can blame following an accident, but it’s really hard (perhaps impossible) to do both.

And this is another example of how, in the safety profession, our reactions, our solutions to problems confound us. Examples abound:

• We spend most of our time at our desks (no where near the worksite) unilaterally coming up with policies and procedures that dictate how employees should do work that we’re only partly familiar with and then we’re surprised and frustrated when they don’t do it that way.
• We focus on preparing for the next major audit from corporate or the regulator by getting all of our paperwork in order, and then we’re shocked that others in the organization don’t appreciate our sacrifices in the name of safety.
• We develop training classes that are designed to meet regulatory requirements to the letter, but have little relevance to the actual work employees do, and then we get angry that employees look for excuses to get out of the class and those that do show up fall asleep. 

Our solutions are the problem. We’ve separated ourselves, both physically and mentally, from those we are duty bound to protect and then we are surprised when we do not understand why they do what they do. We forget that the people we work for are people. They are not dumb animals and they are not machines. They have goals (safety being one of many), they have feelings, they have creativity and ideas that may solve your problems.

But the tools safety professionals use on a daily basis blind them to these facts. We look at the world in reductionist, linear, and bimodal ways and these lenses keep us from seeing the complexity that our workers at all levels in the organization have to deal with. And when we have this separation between how we imagine our organizations are working and how they are actually working, is it any wonder that the numbers of people getting hurt and killed at work aren’t having as much benefit as they used to? The rates of people getting killed at work in most countries have become asymptotic (LINK), and asymptotes point to dying strategies. We need new strategies to deal with the new world our workers are facing.

Here are some ideas that can get you started:

• Take a hard look at all the things you do every day and ask what that says about your priorities. Sometimes our conscious priorities and our unconscious ones don’t line up. How can you bridge any gaps you find?
• If you want to up your “worker engagement” then get out from behind your desk and start engaging your workers. It starts with walking around, observing normal work, and having real conversations with people. And we mean real conversations, not teaching moments. Your workers have things they can teach you about the job and about themselves. Go out there and learn.
• Seriously consider removing blame from your investigation process. What if it was impossible to blame individuals after an accident – what would the result of your investigation be?
• We need to start conversations within the safety profession about the development of new tools that allow practitioners to identify drift within their organizations. We have tools for hazard and risk assessment but at the organizational and decision-level we leave it to the workers, until after the accident, when we blame them for not knowing better. Right now the only ones we’re aware of are either pretty complicated, or they are proprietary (which means that the only evidence we have that they work are marketing materials). This isn’t good enough. We’ve got a lot of smart people in our profession, but we need to start the conversation.

Why “My Door is Always Open” Isn’t Good Enough

It’s sort of a one question IQ test – if your employee has a concern, particularly a safety concern, do you want to know about their concern? Of course you do. In fact, if we pressed you further you would likely say that it’s very important to get that information from your employee. You would probably admit that information from your employees about what’s really happening on the ground floor is vital. In fact it’s pretty rare to find a manager or supervisor (or, much less, a safety manager) that says that information from employees is not very valuable.

But here’s the thing, when we ask most managers and supervisors (and yes, including safety managers) what they are doing to get this valuable information from employees we get a pretty consistent response – “the employees know that my door is always open.”

On the surface this seems like a good idea. After all, you’re a pretty approachable person, right? And it can’t really be that hard for someone to just walk into your office, sit down, and bring up a concern, can it?

Here’s the thing though – in nearly every case where the only way that employees can bring up safety concerns is through an “open door” policy, when we talk to the line employees there’s a perception that management doesn’t know what’s really happening in the organization and that management doesn’t really care.

How can this be? After all, we’re pretty sure that most of the managers and supervisors we’ve talked to who said that their “door is always open” meant it. They really, genuinely wanted to know what employee concerns were. Why weren’t employees taking advantage of the open door policy?

The only natural conclusion is that it must be something wrong with the employees, right? …right?

Maybe it’s not that simple. To understand the problem a little better lets simplify it a little bit. So a manager wants to get something out of employees, in this case it’s information, but let’s keep it general for now and just say that the manager wants anything out of an employee. The manager has two options to get the employee to do what they want – the passive approach and the active approach. In the passive approach, the manager waits for the employees to give the manager what he/she wants. In the active approach, the manager goes out and gets what they want.

Just on its face, it should be pretty clear that (a) open door policies are closer to the passive approach, and (b) the passive approach will be less effective in the long run. But let’s examine this more closely.

Let’s consider the fact that there are some things that the manager takes an active approach on. For example, there are plenty of production issues where the manager doesn’t wait for employees, they go out and get what they want. So what really determines what the manager takes the passive and active approaches on? Usually it’s a matter of priorities. Those things that the manager just can’t leave to chance require an active approach because they are too important. Of course, the manager has a finite amount of time, and therefore they can’t take the active approach on everything, so those things that are important, but not the highest priority get the passive approach.

If this is true, that means that the typical approach most organizations take toward employee feedback and concerns shows that employee feedback and concerns are not a high priority. The cause of this belief could be because of one or both of the following:

1. The manager may not feel that learning is a high priority for an organization.
2. The manager does not feel that employee feedback and concerns are a good source of learning in the organization.

In the safety space, both of these ideas are caustic and hopefully we don’t have to explain why (we can if you’d like though). But we have to come to grips with the fact that no matter what we think, when we take passive approaches to employee interaction we send a message that the information that employees have is not very important to us. And then we wonder why there’s a trust deficit in our organizations.

Now, open door policies are fine, but they won’t really work unless they are coupled with active approaches. If organizational learning through identifying what’s really happening on the ground floor is really valuable to your company (it should be) then you need to get out from behind your desk and start talking to people. You may not like what you hear, but that’s sort of the point – if you don’t like what you hear that means that there are things happening in your organization that you also would not like. But ignoring it doesn’t make it go away. If you are a manager, supervisor, or safety professional you aren’t paid to dig your head into the sand. Your job is to make the organization work, which involves finding and fixing problems. You can’t do that from behind a desk. You won’t get this information from a spreadsheet.

And you know what? Your employees know all of this. They know that you don’t know everything that’s really happening in your organization. But when you don’t ever engage them and ask them it says to them that you don’t really care. They start to think that other things are more important to you than their perspective. They expect you to be a leader and leaders lead by action, and when you take an active approach to things like production and take a passive approach to their concerns, can we fault them for thinking that you don’t really care? So why would they go out of their way, put their neck on the line, to tell you about the issues? They will just go on making the best of a tough situation, like they always have and you will be none the wiser…that is, until the accident happens.

The bottom line is that if you really care about what your employees think and you really want to hear their feedback and concerns, prove it.

Benchmarking, Best Practices, and Hot Dogs

We do a lot of assessments for a variety of organizations in a variety of industries. These assessments range from your typical, run of the mill compliance audits to high-end management system and culture assessments. In many of these assessments a topic that comes up often is benchmarking and best practices – essentially people want to know where they are relative to others. Now, technically benchmarking and best practices are two different things. Benchmarking is more directly measuring just what others do, without much judgment, whereas best practices are actively looking for the best things that others are doing. However, people often use the two terms interchangeably, so, for the sake of this post, we’ll do the same.

But the need to “benchmark” is innate. Humans are social creatures. We just don’t like to be on our own because being on your own increases the likelihood of being exposed to a threat. After all, if everyone is doing it then you can point to the group as the reason you did what you did instead of being personally liable. But if you’re on your own your ability to shift the blame is diminished. There’s safety in numbers. So we constantly wonder where we’re at relative to others because if we get too far away from the pack we are treading on risky ground.

Now, when people want to benchmark or identify best practices most people are coming from the perspective that if they are too far behind they know they need to catch up (and in the case of specific best practices, they know what they should do to catch up). The intention is a good one but the problem we run into is that people often don’t think of the downside. What could be the downside of catching up to the pack, you ask?

Think of it this way – if all we do is attempt to catch up the pack, how can we expect to get ahead of the pack? Benchmarking and best practices is almost the exact opposite of being innovative. At best, you’re trying to identify the innovations of others. That alone is not bad, but what if it’s constraining you from improving?

Don’t think that’s possible? Consider the example of competitive hot dog eating (if you didn't know such a think exists, click here). In 2001 the world record for number of hot dogs consumed was 25.5. However, that same year Takeru Kobayashi downed 50 hot dogs. How did he do that? He did that by being innovative. He did not bother with benchmarking , but instead, he experimented with new methods. He focused on identifying the best way to do things, not just on what others were doing. The results? He won the world championship six years in a row. Now, simply by challenging what people thought was possible, the average number of hot dogs consumed is more than 50.

Sure, that’s a silly example. But it illustrates an important point – benchmarking and best practices may not get us what we want. As another example from our business, safety, if all we do is ask what others are doing you may miss the important features of your organization that are gradually moving you closer to disaster. This is partly what happened in the case of both BP disasters, the BP Texas City Refinery explosion in 2005 and the Deepwater Horizon explosion in 2011. In both cases, from a benchmarking perspective, both sites had exemplary safety programs. Both had extremely low incident rates and had programs in place that most safety professionals would say were parts of a highly functioning system (e.g. behavior safety programs, risk assessments, etc.). Yet both experienced significant disasters, with almost 30 people killed between the two incidents. In the specific case of the BP Texas City, you could argue that benchmarking and best practices may have contributed to the disaster, as benchmarking on maintenance spending showed that the refinery was spending more money compared to peer organizations, even though the plant was experiencing numerous incidents resulting from inadequate maintenance.

The bottom line is that benchmarking and best practices have two downsides:

1. The question affects the answer. Simply by asking what others are doing you may be constraining your organization from achieving amazing results. After all, what if everyone else is doing it wrong?
2. They are insensitive to context. Because of concepts such as drift we find that accidents, particularly large accidents, are often sneaky – they are a product of normal work. That means they are very context dependent. Major accidents often are specific the conditions that were present in the organization before the accident. That means that benchmarking and best practices may not be useful in identifying and fixing the real issues.

This isn’t to say that benchmarking and best practices do not serve a purpose. Identifying the innovative ideas of others can be very beneficial. However, here’s some tips that may assist your efforts in benchmarking and best practice reviews:

• Know what best practices are NOT useful for (see above). Find other ways to identify deal with aspects such as drift.
• If the question affects the answer, then change the question. Instead of merely asking what other people are doing, ask how you can improve and make more context-specific the things that others are doing.
• Include a research/literature review with a benchmarking/best practices review. Sometimes, and this is especially the case in safety, there is a disconnect between research and practice. In that case a benchmarking and best practices analysis may be flawed. Couple it with a review of research on the topic you’re interested in. Don’t just use magazines or marketing materials but go to the peer-reviewed journals. In the safety world, that includes Safety Science, Journal of Safety Research, Professional Safety, as well as many, many others.

The Dogmas of the Quiet Past – A Time for Change in (Safety) Management

On October 15 and 16, the American Society of Safety Engineers is hosting a Virtual Symposium entitled Organizational Behavior: Safety ThroughHuman Performance, Leadership, Learning, and Resilience. Two members of our team are speaking at the symposium, Paul Gantt on the need to define a safety profession (which you can get a preview of here), and Ron Gantt on new models for safety practice. This week’s blog provides a sneak preview of Ron’s presentation. We hope you can make it to the symposium!

The title of this post comes from a speech provided by Abraham Lincoln in an address to Congress on December 1, 1862. The speech (you can read the concluding remarks from which the quote is taken here) comes on the eve of the adoption of the Emancipation Proclamation, one of the Rubicon moments in the ending of slavery in the United States. Lincoln’s words point to the need for change, but he does so in a way that does not condemn. Instead, Lincoln points to the need for improvement through collaboration (“we can succeed only by concert”). His words point to, what he called in a different speech, “the better angels of our nature.” There is no blame, there is only the pragmatic need to strive for better than the normal at a pivotal point in US history.

I think management in general, and safety management specifically, is also at a pivotal point (although, admittedly, less pivotal than the abolishment of slavery). The safety industry is at a crossroads. We’ve achieved much in the way of reductions of injuries and fatalities, but for the last 20 years we’ve seen significant reductions in the return we get for our investment. According to data from the National Safety Council, the CDC, and the US Bureau of Labor Statistics, between 1913 and 1933, the estimate rate of fatal occupational injuries in the United States fell by 39%. From 1933 to 1970, the rate fell 51%. From 1970 to 1991, the rate fell about 50%. From 1992 to 2013 the rate fell by 38%.

Consider for a minute that we had the same percentage reduction between 1913-1933 as we did in 1992-2013, and what the difference between safety practice was in the US in the early 20^th century compared to what it is today. With all our efforts, all our programs, all our slogans, all our training, all of the things we’ve learned, we aren’t getting the results we used to get. People are still dying and what we’re doing to stop that from happening is having diminishing returns – we are getting less results for our increased efforts.

The dogmas of the quite past are inadequate to the stormy present. These words imply an intense conflict between belief and reality. What we believe to be working and, indeed, may have worked in the past may not work anymore. Why? Because the world has changed. This is especially true in the case of organizational management. Whether or not you believe that the ideas of, say, Scientific Management applied back in the early and middle 20^th century when they were created, the world we live in today and the organizations we work at are dramatically different. Our ideas about command and control management styles don’t work in a world that is complex and unpredictable. Furthermore, in a world that cherishes innovation, prescriptive management styles that look to limit human performance variability will inevitably kill the very creativity that so many organizations need to survive.

As our case is new, so we must think anew, and act anew. Our world has grown dramatically more interconnected and complex. New technologies, new ways of connecting aspects of work that were not possible before. Some argue that the world may have changed, but the work hasn’t – construction is still construction, mining is still mining, etc. But this misses the fact that the people doing these jobs live in that world that we all admit has changed and therefore experience the change with the world. How can we then expect that our jobs will not change?

We must disenthrall ourselves… One of my favorite pictures of Lincoln is the one above – the unkempt young man. It reminds me that even this great man didn’t know all the answers and he often made mistakes. But he understood that the key to change is to separate our beliefs about should happen from what is happening. In the same way, in a perfect world we would be rewarded for our efforts, but in the real world, effort expended in the wrong place is often not rewarded at all. Instead of trying harder, expending more effort and resources on the things that aren’t working as well anymore, why not try something new?