A Cautionary Safety Tale and Reflections

A couple of days ago I took a free safety culture assessment online just to see what kind of feedback I would get. I got a five-star rating. Then I went outside to water the garden, tripped over the hose and broke my wrist. 

So, I began to reflect on the connection between having a strong safety culture and reducing accidents? First, what is a strong safety culture? Some of the elements often mentioned are having a supervisor that listens and responds to your concerns and supplies you with the resources you need. Well I certainly had that in my home.

Another element often talked about is psychological safety. Is it safe for me to speak up if I feel the job is unsafe? Is it safe for me to admit that I made a mistake? And the answer was, “yes.” Other common themes are: does your boss care about you, do you trust your boss, and are you included in the development of procedures? My reply to those questions would again be “yes.”

So why did I have an accident? Obviously, I did not spot the hazard, so my awareness was low. Why was that? I was surrounded by psychological safety in my house. So maybe the problem was outside my home. I was anxious about a pending hearing for a lawsuit and it had just been postponed. My country is in the midst of a difficult presidential election.  At the same time there are several economic threats in the environment and my income has fallen quite a bit. Could those factors affect myself awareness? 

Yet, there were internal factors at play too. I live alone and the Covid-19 virus has isolated me from my friends. I have felt quite lonely at times even though I have a lot of virtual connections. I also think my age plays a factor because older people tend to fall more often than younger people.

Now, you may be thinking that the solution is mindfulness and yoga for balance. I agree, but I had been meditating twice a day and doing yoga three times a week. So, it looks like most of the elements affecting my awareness we’re not in management’s control. What goes on at home and the larger society impacts our awareness and decision-making at work. Age, physical state and mental state all play a role in accidents. Since this is part of the human condition what could management do to address these social hazards?

Sometimes Bad Things Just Happen

There is a part of me that believes that sometimes bad things just happen. However, the social conditions surrounding us at this time also show up during layoffs and mergers. They do incite distracting emotions that are usually tempered by knowing that there are people around us that care and will help us when we are in need. 

This is why I began to explore the relational aspects of safety performance. As Prof Sidney Dekker (2019) wrote, safety is a social science. That has always been true. Yet whenever I bring up that we must first put the social systems in place to support the technical systems some people respond that I am creating a false dichotomy. They are interconnected and equally important. Of course the technical systems are very important. However, unless the social needs of employees are met the resulting lack of trust and open communication can sabotage procedures, protocols and engineering efforts. It is true that the social and technical systems must be aligned and support each other. However historically, the safety engineering and compliance aspects have dominated the safety profession. We have safety engineers, not safety psychologists.

So it is difficult to shift that mindset to putting the social first. Nevertheless, the most frequent reason that the implementation of new technology fails is resistance from the users. Management tends to underestimate the length of time it takes to acclimate employees to new systems. The reason is that it took a long time for the old system to be shaped into something workable. Unless people are given enough time to understand the new system and assure themselves that they will be able use the new system with ease, there will be a lot of complaints and possibly failures.

The Moral of the Story

Since every tale has the moral to it, what can we take away from this one? I think we all agree that our level of awareness plays an important role in preventing injuries. Anything that is perceived as a threat can affect it. So, if we look at our current approaches to accident prevention is there something consistently missing? 

Once we have aligned our safety systems to mitigate risk, we need to turn our attention to the most powerful system in the room, which is the human brain. There is no doubt, based on neurological research, up that the human brain relies on belonging to a social group for survival. The Covid era has isolated people and exposed divisions that were deeper than we could have imagined. Faced with this challenge how can we make the social network more visible and concrete? This would create a greater sense of support and belonging.

One thing we can do is to begin to talk about the importance of our relationships, how we speak to each other, how we talk about others and develop the social emotional skills needed for empathy to take root. Empathy is the path to inclusion, which leads to belonging; thus ensuring that our social systems are aligned to produce psychological safety is as essential as aligning the engineering systems to mitigate physical hazards.

Navigating the social systems is the challenge facing safety professionals today. It will require knowledge in three areas: socio-tech systems thinking, mindfulness and socio-emotional intelligence. We have come to recognize the importance of trust, relationships, and conversation. Now it is time to implement the strategies that we know work. There is no silver bullet to increase trust in a relationship. Sometimes it takes trial and error as well as a great deal of persistence. This too will be required of safety professionals who work with people.

Dekker, S. (2019). Foundations of Safety Science: A Century of Understanding Accidents and Disasters. United States: CRC Press.

©2020 Rosa Antonia Carrillo



  1. Tom Osorio Reply

    Thought provoking. Isn’t there an ‘elephant in the room’ for all the old dogs? Safety culture for the organisation with psychology for the individual: necessary but not sufficient? The hose and its use matter. Physical condition and basic good practice is vital. Intellectual argument links physical unsafe conditions as a symptom of culture and psychology; which they are. But organisational culture should not distract from the immediately obvious. You don’t explain whether you were unaware of the suboptimal conditions and approach to the task (competence or degraded standards), or chose to ignore it (motivation, time pressures etc). A challenge is communication: convince the old dogs, with such simple powerful examples to act on the obvious promptly and also see the role of parallel culture and psychology challenge.

  2. Rosa A. Carrillo Reply

    Thank you Tom, encouraging to know that my message wasn’t off the deep end. You are so right that neither safety culture nor psychology helped me that day. BTW four months later I still don’t have full use of my right hand. Luckily I’m self employed so I don’t have to contend with workers comp!

    I have to ponder your question. Was I unaware or did I ignore the conditions. I think I have to go with the second. My sense of balance has been compromised due to medication and I have yet to come to terms with not doing things I used to do. I also tend to deny that the madness outside my walls can affect my judgment. I decided to write the article as a heads up that these are unusually uncertain time. So be careful and be good to yourself.

  3. Tom Osorio Reply

    Four months; as well as ‘think time’, you certainly have my sympathy. Perhaps the isolation of this accident has created a useful illustrative ‘case-study’. Despite but in part because of the ‘degraded barriers’ (balance, isolation, distraction of societal madness and pervasive health risks etc) it was important to you to do the task. The importance, increasing your tendency to ignore minor problems. Safety is easy in perfect conditions; excellent safety is effective in challenging conditions. An inherent ‘tension’ for individuals, colleagues, leadership, systems and regulators, is how to demonstrate commitment to correcting physical defects and minor acts in the workplace, which can feel petty and distracting in a way that builds not undermines the individual’s self-respect and organisation’s strong culture. Good ‘stop work’ systems, are not about what is stopped, but how it is stopped, and most importantly how it felt like to be stopped. Good procedures are not just about clarity, but how the reader responds: will you read it, feel responsible for your actions, report gaps between reality and the procedure – is it their instruction or your tool. One might speculate that you ‘ignored’ the snakey condition because of earlier admonitions in the yard. Wishing you a safe recovery, whilst you have prompted me to list ‘lock-down risks’ (DIY, exercise and health) I have taken due to the madness and desire to complete a normal activity.

  4. Rosa A. Carrillo Reply

    Thank you again Tom for helping to make my Story instructive. What you described is basically what happened and I wanted to write about something very very simple and personal that would allow me to examine why this happened. There’s a part of me that wants to say stuff happens. And the other part of me says, no I should have paid more attention to the shoes I was wearing, to where I was walking, to the stress I was feeling. Well this is all in hindsight that perhaps I can learn from it. And in sharing perhaps others can learn from it.

  5. Tom Osorio Reply

    Personal learning can be powerful. As safety professionals we do well to continue learning in this way. The same complex range of thoughts and emotions you eloquently describe will be experienced by many involved in the accident: key to remember in our questioning and investigations. I applaud your story and its delivery.

  6. Anna Illingworth Reply

    Thank you for this post and its brilliant use of an unfortunate event (hope you recover well). The importance of considering the human in the system; and our need for safety psychologists as well as safety engineers, particularly resonated.
    I have a reading query for you , and three book recommendations below.

    – I’d like to ask if you have any particular reading recommendations on the following subject: finding metrics to measure or reveal socio-technical aspects in emergency response work (my area is the ambulance service; but we need to work across other blue light services too).
    I am a paramedic trying to build a fishbone analysis showing all factors affecting risk of harm when moving or lifting patients in emergency response; trying to incorporate the socio-technical aspects that I have never seen explicitly addressed in formal training over 20 years frontline working. I then need to take the socio-technical points from the fish bone analysis and see if I can ‘scientifically translate’ these proposed aspects into measurable metrics, usable in a pilot for examining the existing range of practice and equipment, trialling new equipment options, and see what works best.
    The socio-technical factors have particular impact in three sections of the fishbone, on the Individual (staff or helper), the Load (the patient), and Team Working. I am finding that there is a spectrum of effects; each aspect can work in the positive or the negative.

    In Individual or The Patient/Load, for example: I look at neutral aspects like Stress, and describe the spectrum between ‘heroic focus’ or ‘perfect flow’ of best performance at one end vs, at the other end: the narrow focus, loss of hearing and damaged wider awareness of the ‘chimp brain’; when adrenalin and the amygdala overwhelm the frontal lobes.

    In Team Working, ‘Familiarity’ is one of the neutral values. In emergency response we range from close-knit teams who work together multiple times, and know each others strengths and weaknesses, to trained or untrained responders; ranging from other response workers (eg: ambulance, fire, police, coastguard, HEMS); and from a huge variety of willing helpers drawn from members of the public. Generally, close-knit teams who know each other well get good results, but (and although the variation can be huge), so can people coming together to help in a single purpose who’ve never met before, even under extreme stress.

    When teams come together in the aftermath of a terrorist attack for instance, occasional tribal rivalries between some members of the blue light services are hopefully put aside, in favour of rapid, effective decision making and mutual support. And the contribution of citizen bystanders, with a tiny bit of direction from sparsely available emergency responders (eg coordinated lifting instructions), can be extraordinary, or as at the Manchester bombing, more effective than some parts of the emergency service response (ambulance and fire), still waiting on permissions to go forwards from those not on scene, with delays in getting enough staff into the Ticket hall and site of greatest need. So, things can also fail spectacularly in ways no-one wants to talk about afterwards, for fear of blaming those caught up in terrible events and ‘doing their best’. My argument would be that the latter might be true of the public, but an ambulance service needs to go further and should know better; – but there is very little published in any academic discussion of what ambulance services should do to put socio-technical ideas into explicit practice.

    Book recommendations, in return:

    Dr Sabrina Cohen-Hatton, a UK firefighter Commander and neuroscientist has written brilliantly about the chimp brain effects and how to apporach training to reduce them in real life; in ‘The Heat of the Moment: A Firefighters Stories of Life and Death Decisions’ and in her academic articles on the subject; she is an example of a pioneer safety psychologist.

    In ‘Compassionomics’ by Trzeciak & Mazzarelli, sceptical ITU and emergency room doctors apply academic research principles to test the validity of ‘soft’ non-clinical elements of care, and discover that compassionate care (empathy plus action) measurably reduces medical error for patients. It also reduces burnout in staff members; no matter how tired, staff benefit when applying compassionate care (vs indifference or a failure to engage on the personal level) with an individual patient.
    My take from this, is that taking a blood pressure in a patient who may be bleeding is basic clinical care; so, it turns out, is the manner with which the medic engages with the patient; this is medical ‘need to know’ not ‘nice to know’. I would be negligent as an emergency responder or ambulance service if I do not encourage the taking of two blood pressures in a patient who may be bleeding internally; but also negligent if I fail to take on board the mounting socio-technical evidence; and appreciate the effects of the human in the system. The conclusion is something we instinctively recognise; particularly when we are in the position of the patient; that effective care is only magnified when human connections are taken into account.

    – Compassionomics shows some ways to do this scientifically; do you know any others?

    And, finally, if you will forgive the hindsight bias, I have another book to recommend to you: Atomic habits by James Clear which I am using at work and in my personal life to develop my learning from incidents like yours, and set things up to make it easier for me to avoid ‘accidents’ in future (with knowledge from years of being called out to those who’ve had an ‘accident’; we call them Road Traffic Colllisons not Road Traffic Accidents now, btw). Using Clear, if we start from the premise that (as I am also reluctantly facing), as we age, bones can be more fragile, then lets develop habits that make it as easy as possible to avoid harm from slips trips falls.

    So yes, yoga for balance, stress reduction with meditation – but also a safety habits mindest that makes useful props handy (eg: slip-on, well-soled shoes with decent treads by the garden door; hiking poles for off road walks; easy access to a head torch); but also sees routine trip hazards reduced eg: items not left on the stairs, hoses coiled up after use 🙂

    Or at my work: eg: the route walk-through ambulance workers do before they carry the patient out; shutting the cat away, pushing the sofa back, and shifting the tall vase likely to topple as we try to squeeze past with the carry chair. There will be times when we are stressed and distracted yet still have to perform; habits and practice reduce the cognitive load here. Personal experience will employ hindsight from failures and near misses to build future success. If that learning is shared effectively with employers, and includes frank conversations about the socio-technical aspects often overlooked in favour of ‘easier to measure’ events (eg the broken bit of kit), the organisation can help develop shortcuts for all, with continually improving tweaks to aid safer habits. We will still fail, sometimes, but it will be easier to get things right if we have habits of safety awareness rather than just knowledge; and are open about how we use our socio technical skills.

    1. Rosa A. Carrillo Reply

      Dear Anna,

      I read your comment a while ago and it was so rich I wanted to have time for reflection.

      First, may I have your email address? I want to get you in touch with Ivan Pupulidy who is an expert in wild fires. He is a professor and will likely have some book recommendations for you. My recommend station would be chuck casto book on crisis leadership. He was at Fukushima. That says it all. The title is Station Blackout: Inside the Fukushima Nuclear Disaster and Recovery.

      I like the trend towards atomic habits or micro habits and nudging. Transformational change doesn’t happen in one big swoop unless of course it involves a huge disaster. It’s better to learn in small increments. Another book is the four stages of psychological safety by Tim Cook. He has several free webinars on LinkedIn and I have learned a lot.

      Best of luck in your endeavors and thank you for what you do.

      1. Anna Illingworth Reply

        Hi Rosa

        Sorry for delay, got sunk under Covid response; resurfacing to deal with my true passion! Thank you so much.

        Transformational change can pivot on back of a disaster if the plan is ready to go. Have ordered Tim cook – thank you again.

        Please do put me in touch with Ivan Puplidy; I have done some work in UK nuclear plants (paramedic angle for crisis events) and am a radiation protection advisor so would love to hear his take; especially since my 55Sieverts (local not whole body) during cancer treatment last year.

        My email address is: ana.illingworth@gmail.com
        (one n in ‘ana’)

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