It was a day like any other. A maintenance crew received their work assignment at a chemical plant. They were to fix a leaking valve in a pipeline that held a corrosive chemical. These sorts of leaks were pretty common, as, like so many other plants, this plant was pretty old. However, the chemical they manufactured is a specialty material, and demand was never really that high…until recently when the chemical became a very necessary raw material in high tech products. As a result the plant did not invest much in capital improvements for most of its history. But with the demand increase, the company was asking significantly more from the degrading infrastructure, which was leading to more and more problems. In recent years the plant had a rotating door of plant managers (nearly one per year), which created an environment where long term investment seemed more and more unlikely.
But still, the maintenance crews had to make due with what they had, and they had done a pretty great job. At this plant the maintenance department had gone many years without a serious injury. So they got their needed work permits and began work with the operations department to start isolating the valve.
This was a bit of a touchy point for the maintenance folks, because a recent drive to improve efficiency at the plant led to cut backs in personnel in the form of early retirements. In one day alone, a couple years ago, 500 years of experience walked out the door. So the operations department was young and, on average, inexperienced. Furthermore, the plant did not have a good training program to train new staff on the process, so operations trainees had to learn on the job. This didn’t sit well with the maintenance crew, as they had to rely on operations to tell them where to put their locks to isolate the value. Nor did the plant have updated pipeline and instrumentation drawings that the maintenance and operations crews could reliably use to get the information they needed to do the job safely.
So the crews did the best they could. The job was completed, the valve was replaced, and everyone got to go home that day without injury.
Kind of a boring ending to an interesting story, right? Often when we tell stories like this in the safety profession it ends with explosions, mayhem, disfigured bodies, and broken lives. It makes sense that we would tell these sorts of disaster stories, because they are so interesting and because we believe they give us an opportunity to see what causes failure in our organizations. Accidents, after all, are the things we want to prevent, so if we study those accidents in depth we should be able to find ways to prevent similar accidents from happening in the future, right? So, by looking at accidents we can learn about safety.
However, in many ways the practice of looking at accidents alone to learn about safety is problematic. First, this assumes that to understand failure you only need to look at failure. To understand accidents we only have to investigate what failed. Furthermore, since we use accidents to help us know what we need to do in the safety profession so much, to understand safety, we only need to look at accidents.
This is simply wrong. How can you understand how something failed without understanding how it normally works? Now, before you answer that question, make sure you read it carefully. We aren’t saying that you need to understand how it is supposed to work. We are saying that you cannot understand failure without understanding how it actually works. This difference between how things are suppose to work (sometimes called “work as imagined”) and how things actually work (sometimes called “work as performed”) is huge and we have yet to see an organization that does not have a significant gap between the two. In almost every case though, management (including the safety professionals) are oblivious to this fact.
Second, only looking at accidents to know how to improve safety is problematic because it is so reactive! In the story above nearly every detail we mentioned (which is all true by the way) is already present and is common details we see in accident reports. This means, as Todd Conklin likes to say, that the seeds of the next accident are already sown in the organization. They can either wait until the accident happens to go out and find them, or they can go out now and find them before the accident happens.
One of the biggest gaps in the safety profession today (and in all professions involved in management) is a significant misunderstanding of everyday work. Organizations consistently misunderstand how they achieve success day in and day out, which leads to a lot of wasted resources and often a lot of blame. The Law of Fluency predicts that the adaptations of people will hide the things they are adapting to. This means people will fill the gaps in our organization, which will hide the real problems, leaving only the actions of the people in our site (so when they screw up it will be easy to see and blame them). This is where organizations tend to see a lot of drift emerge.
As safety professionals we need to change our focus, away from only focusing on what has and can go wrong, to understanding what goes right. What is actually making it so that most days your organization has no accidents? What is causing that? Shouldn’t that interest us? If we figure that out, then we can begin to find ways to shore up whatever that defense is, while also facilitating performance (thus reducing, or even eliminating the safety-production conflict).
Not sure how to do this? Here’s some ideas to get you started:
- Get out and talk to your workers. Ask them what makes getting the work done hard. Ask them what do they have to overcome to do their jobs. Do this without teaching them. Just listen and ask yourself what this says about what is making your organization successful.
- Perform success investigations. Take a job, project, design, etc., and investigate it like you would an accident. Where did the work deviate from the plan and why? Where did the workers have to adapt the work plan to get the job done and how can we help plan better in the future?
- To understand accidents, first understand how the work normally works. Don’t simply look at what went wrong in an accident investigation. Try to figure out how what normally goes right, went wrong in this case. This means you need to understand how things normally go right.