September 23, 2015
"Scholars and experts have said for decades that virtually all incidents are not caused by errors and human behavior, yet most managers still believe it and most organizations still operate that way. Investigations proceed that way. Even enlightened investigations invite managers to go beyond worker behavior as the cause and look for other 'causes' such as supervisor accountability. This is just shifting the blame one level up."
Note: This is Part XII in a series of posts entitled "Evolving Beyond Behaviourism." To read Part XI, please click here.
Not too long ago, a colleague and I led a session on Leading Safety Differently for the management team of a large refinery. On the wall of the conference room was this poster:
With the poster hanging literally over our heads, imagine us introducing these new ways of leading safety:
- People are not the problem;
- behavior is not a root cause;
- blame stops learning;
- safety is over-managed and under-led;
- procedures and rules do not keep you safe, people and leadership do.
We had to reconcile our statements with the poster dealing with “loss.” The poster oozes suspicion and blame. The need and cause for change in safety leadership—even in this poster—was striking.
Today, too many organizations and projects respond exactly as the poster instructs: “Always start with personal factors.”
What does that say, really? Look for blame, first and foremost.
This obsession with blame is both prevalent and toxic. A common assumption underlying this belief: “After all, our plant is safe, well-organized, -managed and -run. For there to be an incident, there must be some aberration like a bad behavior, a bad employee or a procedure that somehow got out of date. Likely, even that is the result of an error by a misguided employee or his bad decision. Let’s get to the bottom of whose fault that is, while we are at it.”
Scholars and experts have said for decades that virtually all incidents are not caused by errors and human behavior, yet most managers still believe it and most organizations still operate that way. Investigations proceed that way. Even enlightened investigations invite managers to go beyond worker behavior as the cause and look for other “causes” such as supervisor accountability. This is just shifting the blame one level up.
In fact, one can view “leadership accountability” as yet another veiled attempt to make even managers conform to the safety system. This thoughtless, obsessive drive for conformity—and, by extension, blame when there is not conformity—is what still underlies most safety systems and management thinking. (And we wonder why safety stats aren’t improving.)
Attempts to drive Safety Leadership in organizations also fall into the conformity trap. One of the global oil “majors” holds managers accountable for visible engagement in the field or on the floor. The manager has to enter one engagement per month into the global system to show she is leading safety well.
There are SO many things wrong with this kind of practice it is hard to count! As if one engagement per month will make a difference! When do you think most of the visits and entries are done? (Yes, in the last few days before the report is due).
Management meetings include reminders and everyone just rolls their eyes. The stats are compiled, then individuals and their manager are “named and shamed.” This is grade school-level safety management. As someone who works in safety, project and operations management every day, I am deeply disheartened with people rolling their eyes at misguided efforts to improve safety.
Meanwhile, the above mentioned world-class organization has not reduced the number of fatal and project execution incidents. The incidents have, in fact, increased. Along with this, that organization has significant operating issues as well. Despite “accountable” leadership, their project, start-up and ops performance on the whole have not improved, and in some cases have deteriorated.
Can we please stop looking to personal factors as the primary cause of organizational failures? Especially safety failures? People are not the problem, they are the solution.
Interestingly, there is a recent movement in safety management to get away from people and focus strictly on equipment and system fixes. There is some merit to this approach as it opts out of the blame game. But looking strictly at the physical world falls short of what is needed as well.
JMJ suggested that perhaps there was a bigger opportunity here. Rather than just reinforcing the rules, what might provide a better overall outcome?
A quick story:
Earlier this year, one of the largest construction projects in Australia suffered a troubling run of serious incidents, mostly work-at-heights related, suffering dozens of incidents in a matter of weeks. Management told everyone to focus, pay attention, be disciplined and, when incidents persisted, shut the sight down temporarily. This behavior and discipline-based approach, with a focus on worker and supervisor compliance (the good old-fashioned personal factors) did not help. Incidents continued.
An outside investigation was called and, to its credit, insisted that the project add real-world fixes to the units under construction and hook-up: nets, toe boards, tool lanyards, etc. Sure enough, the incidents dropped to almost zero overnight as the physical kit was deployed.
This project is global in scope; the operator and constructor are world-class. Surely, they were aware of the benefits of physical barriers. Why had there been resistance to doing what works? The answer in safety terms: “Goal conflict." In plain language: barriers cost time and money on a job that had run out of both, so no nets.
How many times have we seen that? Does it takes dozens of dropped objects and serious incidents to see the need for nets, or get shocked out of willful blindness?
A focus on physical barriers and defenses will fall short without clear, committed leadership, willingness to own up to biases, and the courage to address goal conflicts. Managers need to stop reading their safety management bible. They need to go find out from the workers and engineers who do the real work as to what is really occurring and what an organization needs to learn in order to operate safely and productively.
And you know, regardless of the remaining budget, if you don’t want to kill someone, sometimes you’d better spend some more dough. While a focus on physical fixes won’t necessarily cause necessary change, courageous safety leadership will—the kind of leadership that recognizes when it’s time to prioritize safety over cost savings. This is safety leadership that calls for hard answers, not just hard barriers.
The hallmark of a well-led organization is how well it responds to incidents and “failures”
A positive anecdote…
My company, JMJ, has been supporting and working in partnership with another oil “major” in its safety journey. This company is making great advancements in incident investigation and, more importantly, in learning.
Following a serious incident, this company undertakes two distinct efforts: One focuses on defenses—where did the layers of defense come up short? Is there a fix that needs to be made or an improvement needed? The second approach does not look for shortcomings, rather it seeks the driver for the incident. Why did people do what they did? What were the causal factors? What did they think they were doing “right?”
This is a radical notion, but very pragmatic. Instead of assuming someone did something WRONG and should have done something differently, the inquiry looks for why the people and system worked in perfect harmony. The outcome was the result of many people doing what they knew to do based on the information and context they had in the moment of the decision. This inquiry works to understand what drove those decisions. The language of error and blame is not present.
This approach goes well beyond the one diagrammed in the above poster. It also goes well beyond forcing compliance within an existing system or adding more barriers. This approach especially emphasizes learning. There is no blame, no error-guided basis for the discussion, no assumption of guilt: it’s about dispassionate inquiry, not inquisition. It’s refreshing, and even more importantly, rewarding.
We need to lead safety differently. Some of us are making progress. Others among us are struggling to break the reins of plodding organizations. All of us are to be applauded for individual commitment and staying the course. Stay on the journey. Join the conversation.
We can and do make a difference.