Wednesday, November 26, 2014

“It’s Not The Rules That Make Us Safe, It’s The People” (So we should thank them…)

The part of the title that is in quotations is a direct quote from an electrical technician with 40 years experience at a small chemical plant that, essentially, manufactures acid. The facility is one with many, many serious risks (when you make acid, it sort of comes with the territory), yet at this plant they have recently celebrated over 20 years without a lost-time injury. Sure, that’s just a lagging indicator, but it’s an indicator they are pretty proud of, considering that the last major incident they had was a fatality.

Now, obviously at a site like that they have a lot of rules. There are plenty of regulations they have to follow (for those familiar with the system in the US, this site is in California, under the process safety management regulations, and in Contra Costa County), there are plenty policies and procedures from corporate that they are required to adhere to. Despite all of that, there’s a sense at the plant that all of that is just window dressing. At the end of the day it’s not the paperwork (rules, regulations, policies, and procedures) that keeps people safe. Sure those things can have a role in the process, but the employees also point to instances where employees have to find ways to create safety in spite of the paperwork.

Think about that for a second – sometimes our employees need to find ways to overcome the barriers we put into their way to get the job done, and get it done safely. Sure, it’s not always perfect and sometimes we might wince at what they do. But, at the end of the day, it’s the people that create safety.

This is a really important point, because sometimes safety professionals seem to have the air that they are providing safety for the employees. We say things like we are there to “make them safe” or to “ensure that things are safe”, like somehow the bodies would pile up if we weren’t there. After all, we’re there to protect employees from themselves, right?

Daniel Hummerdal, who manages the safetydifferently.com site, has another perspective though that we think is instructive – our chief role is to enable safety. This perspective is interesting and refreshing because it admits that deep down everyone wants to be safe, and most of the time they are really good at it. So rather than creating a management system designed more for children than adults (i.e. command and control), perhaps we need a system that facilitates and enhances the natural risk assessment and mitigation processes of our employees. Or, as Sidney Dekker says, instead of employees being a problem to control, perhaps employees are the solution to harness.

We digress though, because the point of this post is not to focus on ourselves. In the United States this week is Thanksgiving week (hence the turkey picture) and we think it’s a proper time to thank your employees for the great job they do. Thank them for working safely, in spite of imperfect conditions, confusing rules and procedures, competing goals and inadequate resources. If we’re honest, we should also thank them for making us safety professionals look good. After all, sometimes our employees are safe in spite of what we’re doing, not because of it.


And, no matter where you are, thank YOU for your devotion to the health and safety of others. Lets look forward to a great year of enabling safety next year!

Wednesday, November 19, 2014

We Need Rules for our Rules

We’ve been criticized in the past for some of our blogs (for example, here) that seem to only point out the negatives of safety rules and procedures, which leads some to believe that we are advocating the abolishment of safety rules and procedures entirely. This is not the case though. Rather, we just think rules (from now on, for the sake of space, we’re going to use the terms “rules” and “procedures” interchangeably) are mishandled and misunderstood. As an example, recently we conducted interviews of personnel at various levels within a large municipal utility organization. One of the questions we asked was about safety responsibilities, and one of the most common responses we get was some variation of “everyone is responsible to always follow the safety rules.”

That makes sense on its face, and that’s often where people stop. But think about what else has to be true for that statement to be true. First, the rule has to actually protect people in all the circumstances to which it applies. This is easier said than done. There are times when following the rules can actually make people less safe. Extreme examples can be found in emergencies, where people must violate evacuation rules due to changing circumstances. But more subtle examples are found in the explosion in permit to work systems and job hazard analysis. Often these become paperwork exercises. Why? Because employees have other pressures on them, such as production and efficiency, and these combine with normal human optimism to make what looks like a robust control on paper, nothing more than a paper tiger.

Second, the rule must be one that is capable of being followed in the real world. Often we write safety rules and they look so easy on paper, because we’re using very constrained and linear thinking. For example, we often create requirements that people must wear PPE to conduct certain tasks, which seems really easy on paper. But in the real world there are times where wearing that PPE makes doing the job difficult or impossible.

Our faith in rules in the safety profession and their ability to protect our employees is both philosophically and practically questionable. On a philosophical level, the idea that our employees can’t figure out how to do the job safely, but we have the knowledge and foresight to do so is, at best, questionable, and, at worst, offensive. On a practical level, we’ve had rules for a long, long time, but we’re still having people get hurt or killed. At some point we need to admit to ourselves that the problem is not that people aren’t following our rules. At some point we have to admit that we’re asking too much from our rules.

Still, rules have a place within a safety management system. Rosa Antonia Carrillo had a great way of characterizing a primary purpose of rules – they capture what we know so far. They aren’t perfect, because the world is complex, so no rule can deal with that complexity. As Sidney Dekker says, rules and procedures are resources for action. They are a tool that we can use to determine the best course of action in a given situation. But they should never be considered the only resource for action.

The title of this blog comes from David Borys, who, with Andrew Hale, completed a review of the relevant research on safety rule following (you can read the whole report they published here). One of the key recommendations from this work is that we need rules for our rules – i.e. we need a system to manage our rules and procedures. Without this we may create a situation where we are the emperor without any clothes on – we feel comfortable, but we look pretty silly.



The above figure, taken from the Borys and Hale report, presents a recommended rule management system, both for existing rules and new rules. The process they outline is at least interesting, because, unlike most management systems, it does not view rules as immutable. Rules should be monitored, just like any other recommended safety defense, to ensure that they actually work.

As a quick overview of the process (for a more in depth review, we recommend you look at the above report), for existing rules you start with monitoring individual and group adherence to the rules (1). From there you evaluate whether the rule is actually protecting employees and is able to be followed (2). For those rules that are effective, you ensure that employees are trained on how and why to follow the rule, including when rules must be adapted (9), and then all employees are held accountable based on the rule (3), with the understanding that there will be exceptions that must be dealt with (4). Old and ineffective rules are scrapped or redesigned (5).

For new rules, the first step is to identify whether a rule is needed to achieve the goal of employee safety and resilience (6) sometimes rules are unnecessary or not the best way to achieve the goal. Then needed rules are written (7), tested to identify effectiveness (8), and employees are trained accordingly (9). And then the system cycle continues, very similarly to the PDCA cycle of continuous improvement.


Is the above-mentioned system perfect? Probably not. But we think it’s time in the safety profession that we take safety rules off the pedestal that they have been on for too long and that we begin to the discussion on proper rule management.

Wednesday, November 12, 2014

Some Resources for the Safety Professional

Last night some of our folks attended a presentation where the speaker made the valid point that most safety professionals lack a solid foundation of fundamental knowledge that safety professionals should have and seem to believe many ideas that safety professionals just should not believe. We couldn’t agree more – our profession is broken and needs to be fixed.

But how?

That question is the key question that we must answer. Most safety professionals we’ve spoken to agree that the profession is in need of repair, but when we start talking about solutions everyone has their own preferences and sore points that get in the way of consensus. We just can’t seem to agree on who we are as a profession. Is it about certifications? What about education? Surely, a safety professional needs experience, right?

Part of the problem, from our perspective at least, is that “who we are” mostly comes from “what we do”. Another way of saying this is that a profession has an agreed upon body of knowledge that informs our actions, which then defines what qualifications we need. Surely safety has been around long enough to have an agreed on body of knowledge right?

Once again though, our profession falls short. The American Society of Safety Engineers (ASSE) has their own Body of Knowledge, but this is not really a professional body of knowledge in our opinion, because anyone can post anything. There’s no real peer review process, so how do we know that the information on there is true? And this is consistent with the bulk of the information we’ve found in the safety profession – the only evidence most use to “prove” that what they are doing or will do is effective is either anecdotes (“this worked for me, so it will work for you”) or marketing materials (“this worked for all these other customers, so it will work for you”). Neither of these make us into a knowledgeable profession, and, for a profession that claims to be having a hand in the saving of people’s lives, for us to base our interventions on spurious evidence is borderline unethical.

So where’s a safety professional to go to get good information? Here’s some resources for your consideration.

Looking for a pretty good safety body of knowledge? The Safety Institute of Australia developed this one (and updates it periodically). The information about regulations is obviously specific to that country, but the general information about safety is overall good and all chapters are peer reviewed, giving the information more credibility.


Did you know that there are actual academic, peer-reviewed journals where people and publish safety related research papers? If you’re like most, the answer to that question is “no”. But there are lots. Looking to implement a safety incentive program? Why not see what the actual peer reviewed research has to say about it? Here are a few of our favorite journals (but there are many more):


Having trouble engaging with your workforce or looking to implement a cultural intervention? Why just look in safety related journals? There are plenty of great journals out there. Here’s some databases you can use to search for a journal to help you solve any organizational problem you may have:


Finally, nothing can replace the synergy of individuals getting together to share ideas. Here are two conferences outside of the normal safety conferences (e.g. ASSE, NSC) that we recommend you look at:


Note that we have no vested interest in any of the above journals or conferences. We just believe that safety professionals need good resources to get the information they need. Without that information how can we expect to move forward?

What other quality resources are out there for safety professionals?


Tuesday, November 4, 2014

After an Accident, You Can Either Learn or You Can Blame – You Can’t Do Both


NASA had another mishap, this time without any human casualties, but they did an estimated $200 million in damage after the Antares rocket, whose mission was to carry supplies to the international space station, exploded on take off. Obviously the investigation is ongoing. As Neil deGrasse Tyson, of Cosmos fame, noted on his Twitter feed on the day of the incident:


However, we were a bit dismayed when we noticed this headline from the Huffington Post UK about the incident:



The title of our blog post comes from a presentation by Todd Conklin, who makes the case that our dual needs following an accident to blame and to learn are conflicting. The more you do of one the less you do of the other. He joins a chorus of other safety researchers and practitioners who make similar assertions, such as Sidney Dekker, Erik Hollnagel, David Woods, Nancy Leveson, David Borys, Michael Behm, Daniel Hummerdal, Richard Cook, and many, many others.

We’ve also talked about it many times in the past, both in our training and consulting activities, as well as in previous blogs (here, here, here, here, and here). However, many people still feel that it is possible, and some even feel it is necessary, to both learn and blame during an accident investigation. Since this idea is so prevalent in our culture, and, we believe, this idea is so caustic to safety we though it would be appropriate to directly explain why we believe that learning and blame are negatively correlated.

First off, we must be clear, our argument does not consider any legal or philosophical issues (although, we feel that our argument could stand up to scrutiny in both of these areas). All we are saying right now is that from a purely pragmatic perspective, if we want to improve safety, and if we want to improve safety then we must improve our ability to learn, which means we must also remove blame from our investigation processes.

Here’s why:
  1. As we mentioned in our last blog post, Erik Hollnagel has two (rather unfortunate) acronyms – WYLFIWYF and WYFIWYF, or What You Look For Is What You Find and What You Find Is What You Fix. Essentially, what he’s saying is that our current understanding of the world has a significant influence over what we look for and what we see in an accident investigation. So if we are looking for blame we will find it, and if we find blame that’s what we fix – blame the individual and fix them by either getting rid of them or discipline. But if our current understanding heavily influences what we are seeing, doesn’t that mean we are inherently biased? We expect to find blame, therefore we find it, and when we find it our minds are motivated to stop there because we’ve found what we’re looking for. We don’t need to look further because we found what we were looking for. So a focus on blame inherently puts blinders on and limits the results of an investigation to identifying and fixing problems in individuals.
  2. Of course, one could argue that just because blame tends to limit investigations doesn’t mean that people can’t move beyond those biases and still achieve learning. However, the assumptions that underlie our tendency to blame inherently conflict with a systems viewpoint of safety. To use a very basic definition, a system is a set of interrelated components. We tend to focus on the components but the most important part of any system is the relationships between components. To give an example, if you want to change a football team the least effective way is to change any one player on the team. You might change the team a little bit, but a more effective way to change the team is to change the rules of the game, which changes how the team members relate to one another. A focus on blame inherently focuses on components (the person who messed up) without consideration of relationships that influenced their behavior. With a blame focus, we are setting ourselves up to have the least effect on the behavior of the system, and therefore the least effect on system safety.
  3. Blame inhibits the investigation process. When we go into an investigation with the goal of finding fault (blame) the people we are investigating inherently know this. Therefore, what do they do? They withhold information that they feel might be used against them. This means that investigators can never get the full story of what happened. They can piece together hypotheses of what happened through reviews of evidence and other witness statements, but the only information they have will be inferred and they will never know the full perspective of the people involved. So, with a blame focus our investigations will always be incomplete and therefore our ability to learn from the event will be crippled.
  4. Finally, blame inhibits future learning. People learn that if something goes wrong they can be held liable. Therefore, if something goes wrong and they think they can get away with not reporting it they won’t report it. The gap between how we imagine things are going in our organizations and how our organizations actually are operating will widen. When we blame following an accident we are actively separating ourselves from the messy details of the normal operations within our organizations…that is, until the next major accident happens. 

Don’t get us wrong – there are potentially reasonable reasons to blame following an incident. If someone violated a rule it makes sense to punish them to send a message to others. However, we have to weigh the need to be consistent in our disciplinary policies against the need to build a learning culture. In our opinion, we agree with Neil deGrasse Tyson – learning must take precedence. As Ivan Pupulidy says – before an accident the normal accountability structures that exist within the organization apply. After an accident the organization is accountable to learn.