Thursday, December 17, 2015

Stop the Job – Learning from the LA School District Terror Hoax

There’s a common story told in the safety profession to illustrate a kind of measure of the culture of safety within an organization. A lone mechanic finishes a job on a piece of equipment but something doesn’t feel right to him. Unfortunately the equipment is going into a passenger aircraft and if the mechanic is right the plan could crash, killing all aboard. Of course, there’s also a chance the mechanic is wrong and there is nothing wrong with the aircraft. And if he were to go back and check his work it would mean admitting that he might have made a mistake and also halting take off, which is very upsetting and could cost the organization money and reputation.

In the story, the mechanic goes and tells his boss about the problem, halts the take-off and they go and check the piece of equipment. It turns out the mechanic is right, the equipment was not fixed correctly and it is highly likely that had the aircraft taken off it would have crashed. The mechanic is praised as a hero and usually this is shown as an example of an organization with a good culture of safety. (Note - There are different versions of this story told in different environments and industries, some true, some not true.)

That’s all well and good, but we think that if you really want to test a culture to see what it values we should see what happens when the mechanic is wrong. By that we mean, what do you think would happen in the story if the mechanic halts the take off and it turns out there was nothing wrong with the equipment, there was nothing to worry about? Wouldn’t that be a better example of how the organization responds to people bringing up concerns? After all, if they only praise someone when everything works out that’s not that interesting. If they only praise correct concerns then they are reinforcing being correct, not the bringing up of concerns.

It turns out that in the news recently in the US we had a great example of the above scenario. A terrorist threat emerged to schools in major US cities, prompting the Los Angeles Unified School District to shut down its schools. This was no small task, given that the school district is the second largest in the nation. This shutdown occurred at great cost to Los Angeles and significantly disrupted the lives of hundreds of thousands, if not millions of people.

Unfortunately, the threat was identified later as a hoax. The schools did not need to shut down and the next day kids were back at school.

Do you see the parallels with the story of the mechanic?

It will be very interesting to see the response to this situation. What will happen to those who ordered the evacuation? What about those in New York, who received the same threat but didn’t order an evacuation of New York schools? What happens to them?

Obviously all we can do is speculate at this point. But we can say a few things about what we hope happens, because, after all, there may be a few things we can learn from this incident in our organizations. When we have people bring up safety concerns and halt production as a result that is something we obviously want to have happen when there is a legitimate issue. However, we also don’t want people doing this so much that they make it impossible for the organization to do business, and we also don’t want people taking advantage of safety concerns as an excuse to stop a job for another reason. So how can we design a system that allows people to bring up concerns but doesn’t do so excessively?

First, stop rewarding outcomes. Whether the person bringing up the concern is right or wrong should not be relevant. The Mayors of LA and New York should not reward or punish those over the their respective school systems based on the fact that the threat was a hoax. In every situation there are certain aspects that are within our control and other aspects that we have no control over. This means there’s a probability aspect in all situations. You could do everything right and still end up with the wrong result. If you punish someone for bringing up a concern that will be the fastest way to stop getting concerns brought to your attention.

Keep in mind as well that doing nothing is a form of punishment. This isn’t because of anything you did, but because of the situation. Remember the mechanic? It took courage to admit a potential mistake and bring his concern to the attention of his boss. To be wrong on top of that doesn’t feel good. They feel stupid. They are being punished by the situation. So if we do not reward the bringing of concerns in some way we facilitate their punishment by allowing the situation to punish them.

Now this doesn’t mean we have to throw a big party every time someone brings up a concern or give them money or something like that. That may be appropriate sometimes, but you definitely don’t want to do it every time. Even a simple, genuine “thank you so much for bringing this up!” followed by action to investigate the concern is enough to show that you appreciate it. You could even take steps to shield them from any flack the person could get from others by acknowledging your appreciation of them to others.

Second, learn from the process. The first recommendation will get you more concerns brought to your attention, but more is not always better. This recommendation is about getting better concerns. When someone brings up a concern, if possible, take some time to walk through their thought process to identify why they thought it was a concern and what you and the organization can learn from that. The goal is to make the organization smarter and better at identifying concerns. Perhaps there are unrecognized risks out there. Perhaps your employees have concerns about a risk that you know to be minor, identifying a need for a conversation about why there is a gap in risk perception in your organization. Maybe better training or more effective two-way communication is necessary. Maybe your employees need more resources to help them deal with uncertain situations.

Note, this process should not be based on outcomes (see the first point). Whether the concern was justified or not (in your opinion) learning from the process will still be valuable. Also, this learning process should not be about blame at all. Do not turn it into an interrogation designed to find cause. What you really want is information about how to improve your organization’s and your workers’ ability to identify issues in the future. So the discussion should be future oriented. Ask questions like “what can we do to help you better identify issues in the future?” or “what would have made it so you felt comfortable handling this situation on your own or with your work crew?” Again, the idea is to learn and improve, not figure out what went wrong.

If when we have workers bring up concerns and stop work we focus on outcomes and blame the next time we hear about concerns will be during our next investigation of an accident where we will ask the question “why didn’t the worker stop the job?” Instead, if we proactively avoid discussion of outcomes and we learn from the process workers used to decide what was a concern and what merited stopping the job (or shutting down a school district), we will find not only an increase in concerns brought up, but also an increase in risk competence, engagement and trust in our organizations. Interestingly, this not only will help make it easier to create safety in organizations, it will likely improve productivity as well. Not a bad deal – change how you react to workers stopping jobs and you can increase safety and productivity.

PS. Happy holidays from all of us at SCM!

Thursday, December 3, 2015

Why Investigate Accidents?

An employee gets injured at your jobsite. You make sure the employee gets the appropriate medical treatment, you fill out the forms required by the appropriate regulators and your insurance and then you have an accident investigation.

This is a pretty standard response. The only real question is “how”, as in, how are we going to get all this done? Some common questions asked:

How are we going to investigate the accident?

What methods do we use?

Who do we get involved?

How long should it take?

What do we do with the information we find in the investigation?

There are plenty of resources out there designed to help us answer these questions. There are books, blogs, seminars, training courses and websites devoted to how to investigate an accident. We argue about the best methodologies that will give us the results we want and who should lead the investigation. We discuss what types of events should be investigated – is it just accidents or also other events (e.g., close-calls, near-misses)?

One of the puzzling things to us though is that with all of this discussion about how to investigate accidents there is very little discussion about why we investigate accidents. After all, accident investigations cost resources. Someone (or a group of people) have to take time out of their normal work schedule, stop producing whatever it is they normally produce, and conduct a proper investigation. Then the organization has to devote resources to fix whatever problems the investigators find. So investigations come with a cost. Are they worth it? Why do an investigation?

Now this probably seems like a trivial question to a few of you and we totally understand why – everyone knows that the reason to investigate accidents is to figure out what went wrong so you can prevent it from happening again.

Let’s look at this a bit closer. There’s a key assumption underlying this reason – accidents are caused by negatives that must be found and removed from the system (or prevented from having their effect). Something broke, someone failed in some way, etc. Therefore, the job of an accident investigation is to find the thing that broke (i.e., the root cause) and fix it (or replace it). Once fixed, the system is safe and the accident can’t happen again.

There are some problems with this line of thinking though. The idea that bad things are caused by something failing or breaking is something that works great for machines. If you’re trying to figure out why your clock stopped working you look for the part or parts that failed and fix/replace them. But, if we’re dealing with people and organizations, it doesn’t work that way. People do things that help them achieve success (or avoid failure). Therefore if someone does something that we say leads to an accident, to call that a failure or an error is often a very narrow and limited view.

To illustrate, lets use an example – someone worked on a piece of machinery without properly de-energizing it (i.e., locking it out). From the perspective of a safety professional that is a failure, because they failed to follow a rule. But the person didn’t do what they did because they wanted to fail. They acted in a way that they believed would help them achieve success in the environment they were in. Therefore, from another perspective, there was no failure.

Now, this doesn’t excuse the behavior, but look at how the reason we investigate (the why) leads us to specific conclusions. If we take the perspective of finding the broken part we would often stop here. The employee broke a rule, that’s the broken part. We might decide to go a little further, look at the supervisors, the managers, etc. But our inquiry is about why the person didn’t care enough or didn’t know enough to do what was necessary to stop the accident. Therefore we always end up in the same place – blame. Someone, somewhere failed. People are the enemy of safety. Corrective action – name, blame, shame and retrain.

What happens if we take a different perspective – the reason we investigate accidents is to learn about how our system is working and improve it? This is based on the idea discussed above, that people do things that help them achieve success, but sometimes these things also cause accidents. Success and failure (accidents) have the same causes. Therefore, looking for what broke and trying to fix it doesn’t work. Instead, figure out how things normally work, i.e., why things are normally successful, to understand why it didn’t work this time.

Notice right away that by changing why we investigate accidents it changes how we investigate accidents. For example, if we accept the idea that success and failure have the same cause then methods designed to identify the faults or failures that led to the accident won’t be very effective. We need methods that help us understand success, not things that only model failure.

Looking at our example above, if our goal is to learn and improve it leads us down multiple paths. We can start asking questions about equipment, working conditions, incentives, communication, culture and how all of these elements worked together to lead to the behavior in question. In the process we are free to ask questions unrelated to the accident. We aren’t constrained by only looking for “cause” anymore. We look at the instance as a special case of normal work, so if we find something we don’t like, we fix it, just like we would during non-accident conditions.

So if you want to get more out of your accident investigations, perhaps rather than asking how to do accident investigations better, start with the question that seems so obvious no one is asking it – why?

Tuesday, November 24, 2015

The Stepford Safety Program

Safety is about setting the standard and then holding people accountable for deviating from that standard.

Do you agree?

Many do, and even those who don’t necessarily agree with the above statement (especially those who say “it’s so much more than that”), agree with their actions. Look how much of safety is spent doing things to make people comply with the standards we set. We write rules and procedures, we train them, we develop complex job planning systems, we develop incentive programs (with both punishment and rewards), we conduct behavior observations to make sure they are doing what we want them to do.

Perhaps the best way to illustrate how much this paradigm affects our practice in safety is to do a little exercise with us. Take out a piece of paper and write out all of the things you do in your job as a safety professional that do not involve trying to get people to conform to a standard that you (or management) set for them. Be specific! How many can you list? If you’re like most safety professionals you probably can’t list that many.

Another example – what’s the biggest threat to your safety program? Did you say something like:
  • Complacency?
  • Shortcuts?
  • People not paying attention?
  • Human error?
  • People violating rules and procedures?

In 1972, Ira Levin released The Stepford Wives. The book, which was adapted into a movie twice, is a satire about feminism and conformity. Husbands allegedly replace their professionally successful and free-thinking wives with robots who are more docile and submissive. The term “Stepford Wife” has achieved a bit of pop culture icon status in being a way to describe the stereotypical passive, obedient wife that lives to serve her husband and kids.

Sometimes it seems like what the safety profession really wants is Stepford Workers. We want workers who don’t think for themselves, but just listen for instructions and do exactly as they are told. Deviations from standards are stupid. Why? Because these are safety rules and standards after all! Any deviation from a safety rule must be the result of someone who is either morally or mentally deficient, right?

So we set up our Stepford Safety Programs accordingly. We set the standard and look for ways to get people to comply with our standard. We don’t have the luxury of turning our workers into robots, like the husbands in Stepford did. But we do the next best thing – we take all the thinking out of the job. We don’t trust workers to think for themselves, so we design the work with as little thinking as possible, which makes workers bored when they work, so their minds wander, which can lead to more instances of deviations and error, which reinforces our lack of trust in them.

What if we’re wrong though? Let’s go back to the statement at the top and analyze it a bit to see if it passes the sniff test.

Safety is about setting the standard and then holding people accountable for deviating from that standard.

If this true, then consider the following:
  • This means that the standards we create have to perfectly or near-perfectly match the work environment. How often do rules and procedures perfectly or near-perfectly match the work environment?    
  • This means those who write the standards need to have special knowledge and/or abilities that those who must comply don’t have. How much training do managers typically get on safety management? How much knowledge do managers and safety professionals typically have of how work actually gets done?    
  • This means that deviations must result only from the individuals making decisions to deviate. Are there ever any organizational, social and/or environmental influences on why people would deviate from a standard?    
  • This means that when someone deviates, the best (and perhaps only) way to deal with that deviation is to punish that person. Are there ways to eliminate violations that don’t involve punishing the worker?    
The reality is that:
  • Rules, procedures and plans are always imperfect They are poorly written and can never account for every work environment. This creates situations where workers have to choose between violating the rule to get the job done or to not do their job. What do you think most of them will choose?
  • Managers rarely are trained on even the basics of managing safety and most managers and safety professionals have very little clue about how work is actually getting done in their organizations (although they think they know exactly what’s happening).
  • There are almost always outside influences in the organization, in the social environment or in the physical environment that exert pressure on workers. These act like magnets, pulling workers in various directions. Often these pressures contradict, so that to meet one goal (e.g., production), the worker must fail at another goal (e.g., follow the safety rules). 
  • The easiest way to eliminate violations is almost never punishment.  Take a very simple example of ladder violations – eliminate the ladder (i.e., find another way to do the job that doesn’t include a ladder) and you eliminate the violation. It’s a simplistic example, but it shows how taking a bigger picture view opens up possibilities outside of the individual for dealing with individual problems. 
Now we’re not saying that deviations are necessarily good. We aren’t saying that standards, rules, procedures and plans are unnecessary.

What we are saying is that the safety profession’s obsession with behavior and treating people like they are a problem to control is misguided. The best part of our workers is their ability to think, to be creative, to problem solve. If we have Stepford Workers we miss out on this.

Standards and accountability play a role in a safety management system, but only a part. We must have a system that utilizes the strengths of standards and accountability, yet is also aware of their weaknesses and limitations. So when we set standards, we have systems in place to identify when the standard is inappropriate or ineffective and we can adjust accordingly.

What does this look like? Here are some tips to get you started:
  1. Never put in a rule, standard or procedure without having some way to know if the rule is actually effective These things are supposed to help people do their job, so perhaps an easy way to measure effectiveness is to see whether the new rule, standard or procedure makes the job easier or harder to do. 
  2. Practice humble inquiry Your workers have unique perspectives on the jobs they do. Tap into that resource. Before you implement a standard, rule, or procedure get your workers involved and ask them how they’d fix the problem. 
  3. Get out and talk to your workers. This is not a behavior observation. Ask them questions like “what is making your job difficult these days?” You’ll find safety issues that you would never find any other way. 
  4. Whenever you have violations, find out why the violation makes sense to the employee (and don’t just say because he/she is stupid or a jerk). They did what they did because they thought it would help them get their job done safely (although not necessarily in compliance with the rules). Why? What in their environment made them think it was ok?    

Doing these things will get us well on our way to dismantling our Stepford Safety Programs and setting up Safety Programs based on engagement, teamwork and continual improvement.