I spoke at the Oil and Gas Task Force Zero conference 2018 not long ago. Taking the motto of the conference, “Face the Facts,” to heart, I walked the audience through a bunch of recent data from a range of industries on the relationship between injuries/incidents and fatalities. As we have long known (and as has been confirmed by Macondo, Texas City and other disasters in the industry), there is of course no meaningful relationship between slips, trips and falls on the one hand and process safety disasters on the other (Hopkins, 2001; Salminen, Saari, Saarela, & Rasanen, 1992; Wright & van der Schaaf, 2004). There should be no need to point this out any longer: the so-called safety triangle is of course wrong, as it always was. That much is trivial.
What the data (those ‘facts’) from other industries did show, however, is that there isa correlation between injuries/incidents on the one hand, and fatalities on the other. But the relationship is inverted. In recent studies, construction, aviation, shipping and other fields of safety-critical work, have all produced data that shows that a largernumber of reported incidents correlates strongly with lowerfatality and mortality rates (Barnett & Wang, 2000; Saloniemi & Oksanen, 1998; Storkersen, Antonsen, & Kongsvik, 2016). Unsurpirsingly, there is even a correlation between committing to a ‘zero accident’ vision on a project and killing more people. In a thoughtful recent study, British colleagues have demonstrated that projects subject to a ‘zero safety’ policy or program actually slightly increase the likelihood of having a serious life-changing accident or fatality (Sheratt & Dainty, 2017).
A strong contending explanation is of course that this is related to honesty, openness and learning. Reducing downward pressure on honesty and reporting creates a climate in which the boss is willing to hear bad news, in which a discussion about risk is kept alive and invigorated and informed by those ‘facts’ from how work is actually done. This must be related, in part and in complex ways, to an organization’s culture and leadership. An explanation like this would be consistent with the prediction of a number of safety-scientific theories—including high-reliability theory and man-made disaster theory.
During the Q and A after my talk, one participant, scoffing at what had just been shown, asked what they were supposed to do now. The industry has committed to ‘zero’ for so long already and has had sanctionable rules in place for so long (golden rules, life-saving rules, red rules)—both of which of course put downward pressure on honesty and openess—that it must have felt to the audience as if I’d been swearing in church. What would I suggest to the CEO of an oil/gas company on the basis of these data, I was asked angrily, cynically—that they should now tell their workers that they were going to hurt some of them in the coming year? Applause and cheering followed the comment and it had to die down before I could even deliver a rejoinder.
The rejoinder was a blistering one, for sure. Would the industry rather stick with a failed approach, which demonstrably puts their workers at greater risk of dying on the job, simply because committing to zero sounds good and looks good, and because they don’t have the guts to do an about-face? Is this an industry that is so image-conscious that it shies away from safety leadership that is humble, able to acknowledge its own fallibility, and based on facts? Should it not ask in the face of life-saving rule violations, that workers help them understand how work is actually done through honest and open disclosure, rather than firing them or cancelling their site access card? If your workers feel they cannot complete the job without violating one of those rules, I suggested, tell them that you want to hear from them. Tell them that they should tell their supervisor. And if they cannot tell their supervisor, tell the person above the supervisor. And if they cannot tell the person above the supervisor, here’s a global hotline you can call (which none of them have, as yet).
The applause for my rejoinder was a lot more modest than the cheering for the earlier question. Facts didn’t seem to matter, despite the conference’s motto. It is probably no accident that the Oxford dictionary’s word-of-the-year for 2016 was ‘post-truth.’ It is a condition where facts are less influential in shaping opinion and organizational strategy than emotion, fear, righteous moral conviction and personal beliefs. To adopt post-truth thinking is to ignore Enlightenment ideas, dominant in the West since the 17thcentury. Enlightenment offers us the basis for fact-based thinking, driven by inquiry, experiment, experience, empirical data and hard research. Enlightenment asks us to embrace the centrality of fact, humility in the face of complexity, the need for study and respect for data.
It seemed that despite centuries of Enlightenment and in contradiction to the motto of its conference, the oil and gas industry both reflects and exploits the post-truth tactics of sloganeering and moral posturing because it sounds so good, and it has been saying it for so long now that it hasto be true. What is more, it gets leaders off the hook when something goes wrong. It offers the comfort of blaming the worker for violating rules the industry has imposed and which it has subsequently vacated—both morally and factually. The industry might just feel right at home in our post-truth world.
A consistent finding of safety research and investigations is that more diversity of opinion typically leads to a more resilient approach to risk (Weick & Sutcliffe, 2007; Woods, 2006). I was interested to see that at the conference I spoke at, virtually all of the 400+ participants were male, white, and between 45 and 60 years of age. What is more, a spontaneous poll done by a fellow speaker revealed that fewer than 5% of them had actually had contact with frontline work or frontline workers over the past year. It is not surprising that false beliefs, contradicted by the well-considered, sophisticated facts of scientific research, become sustained in an echo chamber whose occupants do little else then breathing their own air. Their self-contained and regurgitated truths can become the Truth.
When I left the conference venue, I was stopped by a small group of youthful attendees (who had mostly been pressed into manning the help and admin desks but had attended my talk). There was more diversity in that group than in the entire conference. Their appreciation of my talk was total and genuine and unwavering. There is hope yet. For me, that brief encounter felt more like a serious conversation about the future of risk in the industry than anything that had happened inside the conference hall.
As I walked out the door, I wondered whether these young people knew how much we are now counting on them. They will have learned that their industry—data-driven, fact-heavy—has traditionally relied on facts to save it from injury and accidents. Now their industry needs those facts to protect it from itself.
Barnett, A., & Wang, A. (2000). Passenger mortality risk estimates provide perspectives about flight safety. Flight Safety Digest, 19(4), 1-12.
Hopkins, A. (2001). Lessons from Esso’s gas plant explosion at Longford. Canberra, Australia: Australian National University.
Salminen, S., Saari, J., Saarela, K. L., & Rasanen, T. (1992). Fatal and non-fatal occupational incidents: Identical versus differential causation. Safety Science, 15, 109-118.
Saloniemi, A., & Oksanen, H. (1998). Accidents and fatal accidents: Some paradoxes. Safety Science, 29, 59-66.
Sheratt, F., & Dainty, A. R. J. (2017). UK construction safety: A zero paradox. Policy and practice in health and safety, 15(2), 1-9.
Storkersen, K., Antonsen, S., & Kongsvik, T. (2016). One size fits all? Safety management regulation of ship accidents and personal injuries. Journal of Risk Research, 20(7), 1-19. doi:http://dx.doi.org/10.1080/13669877.2016.1147487
Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty(2nd ed.). San Francisco: Jossey-Bass.
Woods, D. D. (2006). Essential characteristics of resilience. In E. Hollnagel, D. D. Woods, & N. G. Leveson (Eds.), Resilience Engineering: Concepts and Precepts(pp. 21-34). Aldershot: Ashgate Publishing Co.
Wright, L., & van der Schaaf, T. (2004). Accident versus near miss causation: A critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors. J Hazard Mater, 111(1-3), 105-110.
Thanks Sidney, what a jolt. The fact that we buy with our hearts/emotions and justify with the facts isn’t a challenge which will go away anytime soon. Challenge accepted 🙂
Not too long ago I worked for an oil and gas company who embraced the belief they were in fact a High Reliability Organization. This epiphany came as a result of hearing Sir Charles Haddon Cave speak about the Nimrod air disaster. The appeal about the HRO label was that by definition they appear highly effective at managing risk and do so within particularly hazardous industries (nuclear, aviation, navy). The oil and gas company embraced one of the safety lessons from Sir Charles about listening to the quiet dissenting voice from the back of the room, and promoted this at every opportunity. This lasted for about 6 months. My point is, industry (oil and gas and any other) will embrace only the news that they agree with. This is a great example of the post truth world we live in. While your experience at the conference was telling and disappointing, spare a thought for the rest of us who share your views but don’t dare to challenge the status quo for fear of loosing our job or being labelled incompetent for going against the dominant paradigm. All the best, and don’t give up.
Well said Mark
Indeed, it can be very hard to “swim against the tide”.
100% Sidney. I think that ultimately, it comes down to how Boards, CEO’s & regulators think about health & safety risk management. The ‘what interests my boss, fascinates me’ rule impacts the thinking of every layer below, both operational and functional. The bigger the organisation, the further away the corporate office is away from the front line, making the challenge of changing mindsets & philosophies exponentially harder. The light at the end of the tunnel is still only a little pin-prick but I’ve seen enough to want to be involved.
Frustrating for you obviously. Good account of an interesting and relevant problem. My short guide to oil and gas safety: stop the pipes leaking.
Thanks for a great post Sidney. It is so frustrating that real safety initiatives are not conducted and real safety outcomes achieved and I believe it is because of the reasons in some of the comments mentioned above, for example I have quite often agreed with many intelligent and strong people on safety issues that challenge the status quo but have been afraid to comment or like for fear of being ostracised by the wider Safety Community because of my agreement of those views. I also get frustrated that there has been a high reliance on a Safety Advisor’s (SA) having diplomas or degrees and these SA spending their whole time behind their computers and not engaging with workers on the ground in a positive, truthful and relevant manner. Great with excel spreadsheets but no knowledge on how to apply all these great things practically. I have found these SA quite often make safety decisions from the desk with out any knowledge on how to practically implement the safety initiatives they have come up with while standing around and talking with other admin staff around the coffee machine.
None of these safety initiatives are working, we were killing workers a decade ago and are still killing them today, nothing has changed. We don’t give the worker any respect or acknowledgement that they know what they are doing and can make the right decisions, we just police them which means not giving them the respect they deserve and thinking they are not capable of making the right decision, the safe decision.
Because we have these rules it is also driving safety underground, we keep adding layer upon layer (like an onion) of new procedures and actions to be completed by the worker before they complete their task that even still these layers get stripped off and it all ends in tears, then another layer is added instead of addressing the real issue that caused the incident.
So frustrating…. the whole lot needs to be thrown in the bin and start from scratch, using the knowledge, skill and experience from the workers it affects most.
Hi Sid, thanks again for bravely crossing swords with modern forms of obscurantism. Your score on the clapometer seems to have been lower but at least the argument was heard at the right time, and at the right place. Yes, perhaps some were frantically typing on their smartphone “which intensive BBS course do I need to take to save my soul after a Dekker presentation?” and didn’t clap. But others who didn’t clap were maybe just unsure, or downright skeptical, about what comes next after the frontline workers are listened to. How many in that room knew exactly what’s going on at both the sharp and the blunt ends (because fundamentally it didn’t change in years), couldn’t do much about it (because there’s no resource from above and/or no usable ‘intelligence’ on the next steps to do things differently), and retreated behind their desk far away from the frontline (also because the paper monster needs to be fed anyway)? That’s learned helplessness.
I’m sure you read the article by Oswald et al. in Safety Science 107 about the problems with safety reporting systems. Yes, unlocking operational learning is key. And then what? Let’s keep building the case with more and more positive examples from the frontlines, so that boards’, CEOs’ and regulators’ legitimate skepticism morphs into genuine interest. This website looks like a nice place to share all those positive stories.
Sidney, you message is clear, strong and courageous. Please don’t stop. If history teaches us anything, the more scoffing you hear, the closer to the truth you are getting. We keep talking about the importance of creating a workplace where people feel safe to speak up to point out an error or potential problem, but it isn’t going to happen until those in authority build up the courage to say “I’ve been wrong” or “i’m sorry.” This kind of vulnerability isn’t acceptable for these men. We are up against centuries of culture, so we will have to keep working with the young people like the ones striving to change the gun laws in the USA. We also need to search for those leaders who are already open to spread the message. That is the future.
I work for the US Forest Service and we too have a challenging world (fighting wildfires) and have suffered from many tragedies/loss of life. About 10 years ago our management turned our safety world around by adopting a lessons learned safety culture versus a zero accident policy. No longer are employees afraid to report incidents or close calls in fear of being reprimanded. It took time but now, as you mentioned, we have many more safety incidents reported and actually less major injuries/fatalities. This new safety culture has empowered employees (new and old) to be the ones to make a difference, to report, to ensure Lessons Learned/Rapid Learning Assessments created from this reporting is shared agency wide. Multiple websites share these close calls/incidents. We will never know how many tragedies have been averted by this new safety culture, but it is certain that when fear of reprimand, fear of being that one accident that blows up your zero tolerance, is removed – the attention to safety by the employee for themselves and for their fellow employees is greatly increased.
I’ve been reading some of the stuff that you guys are doing Ranger Jim, it’s inspiring stuff. I’ve also listened to Ivan Pupulidy a couple of times. Well done, keep on learning & improving!
RangerJim – Thank you for this message.
I have read the older US Forest Service Accident Investigation Manual, which begins by stating that human error is responsible for almost every problem that ever occurs (on page one of the manual, by the way) — and then, the Facilitated Learning Analysis documents built around Dekker’s Field Guide to Human Error, which takes a much more systems-based, practical and useful look at incidents aimed at prevention rather than blaming. I am glad to see that some divisions of the federal government are following progressive and research-based practices which I appreciate and respect.
Good article Sidney…. It may just be that the top-half of organizations simply like the idea of keeping the focus on the bottom-half. Such an approach insulates top leadership from day to day events. However, if the underlying causes are actually systemic rather than isolated, one time occurrences (as consequences are often treated) cannot be “fixed” by focusing on front line workers. Yet “Goal Zero” always implies its the action of the welder or a machinist that needs to change, but clearly if the problem is systemic and linked to the overall culture of the organization, then as they didn’t create this the answers must lie elsewhere. Furthermore, rather than over-obsessing around worksite actions, there often seems little attention paid to the idea of exercising Stop Work Authority (SWA) for someone at a senior manager level determining budget cuts on safety critical equipment for example. As always, the key here is metrics and data points. Change the metrics and you’ll begin to change the focus and perhaps create a very different picture of performance. And then maybe, just maybe we can finally have some truthful conversations….
An excellent article.
As an older member of the health and safety fraternity (I mean that kindly). I struggle with the UK’s concept of safety. We still have “towards zero” and similar wonderful sounding war cries.
I hate the computer and I hate statistics, but I have to use both to get principle contractors to understand that workers don’t go to work to be hurt. Cutting corners is often the only way to achieve work given tight time schedules and limited resources.
We have to work with ” 5 points of safety” because; obviously the workers are unable to think for themselves. I’ve recently had to explain why furniture installers can’t work with grub screws whilst wearing Cat 5 gloves. They might just as well be wearing boxing gloves and as for the poor electrician trying to make connections…!
Too many times I have been told that the worker is the problem, go and sort them out and been accused of heresy when I have shown top management that the managers are the cause of issues. Often through lack of contact with the front line and being slaves to statistics.
We must do safety differently….
Agreed. ‘Zero’ can be the aim but not all managers can explain how they are going to reach there. Improving the safety mechanisms and culture is the way forward.
Two words to think about; epistemology, and agnotology. The first asks “How do you know what you know?”, and the second is “culturally-induced ignorance”. Both need close scrutiny in the world of “safety”……
Thank God, someone else share my view on safety. I feel a lot less alone.
I am intensily studying machine learning in the belief that this could be an effective tool to deploy in safety. Hoping to mix my domain knowledge as HSE manager, with insight I gained in this field.
The starting point, to tackle safety issues from this perspective, is to collect data.
Where can I collect all those incident datas you were mentioning in the pamphlet?
Glad to hear you spoke at a recent energy conference. Your messages on false models and misuse of goals and statistics ring true. And am disappointed to hear that a participant responded with scorn. I am not surprised however. It may be worth noting that the man didn’t argue your primary point – the industry is barking up the wrong management tree — rather he asked “What do I tell my CEO?!” He was cynical, but the emotion is a good sign in my view.
In my reading of your recent book, “Safety Anarchist”, (you can read my review of it here: https://www.jmj.com/blog/sidney-dekker-autonomy-mastery-purpose/ I praise the arguments you have made, and am encouraged by your suggestions and stories, including the Woolworth’s “safe to fail” experiment.
Because your examples – and those of others — are encouraging and even inspiring, when we hear objections to calls for change, I think it is time to respond with examples that not only challenge current ways of managing, but open new ways of thinking, working and even measuring.
You have repeatedly made the case against the current approaches – let’s close the book on that chapter and start the next book on new ways of working and leading.
I see managers to be as victimized by the current management “paradigm” as safety professionals and supervisors – thus the scorn. They are yoked to triangles, incident rates and behaviorism with no way out. They are chained to their PC’s, force-feeding a hunger for data that appears to be insatiable. That one of them lashes out in anger is understandable and maybe even a good place to start.
A brief story: Recently I visited a work site and then the home office of a large operation. The site was poorly run, with sloppy housekeeping, obvious hazards in multiple areas and a lack of adequate supervision and more. Further review revealed that the site suffers from lack of adequate funding, shortage of trained managers and a vacancy in the HSE manager position.
The HSE senior manager in the home office met with me and shared my concerns. He then showed me a draft report – in response to the situation, he had already drafted next month’s incident report! Given recent incidents, he wanted his management to know that they were about to cross the red line into results that were above the corporate target!
Basically, his response to a bad situation needing immediate help in the field was to stay in his office and produce more data – only earlier this time. Wow.
Without condemning him I found a way to point out that his concern and effort is laudable, but mis-directed. Within a very short period of time he was out from behind his HQ desk, filling in for the missing site lead and taking steps to improve safety (and productivity) on site. On my next visit I will make sure to reinforce his shift in focus and see what he can do so that others suspend their rear-mirror analysis and improve the work unfolding in front of them.
In polarizing times, perhaps even post-truthful ones, people are looking to be inspired, to have fresh thinking and get guidance on causing a positive disruption to their sagging approaches. Let’s help them Lead Safety differently. – Mike Goddu, JMJ
The faith-based ideologies of Safety are all evident in this story. Faith is not a rationalist construct therefore, doesn’t ‘think’ in a rationalist way. No amount of evidence or positivist endeavour can shift the mind of faith. Indeed, the notion of truth and post-truth is not a faith-based language.
Sad to see again some sort of blaming the sloganeering and zero harm logic on the cause why things don’t get reported. Can you imagine having a slogan of Trust and Openness…and that this new slogan was to be driven hard to cure mans shortcomings to do act in ways to prevent harm…I think Sidney has failed greatly to see/acknowledge that the very reason we have such a thing as SAFETY is because we simple have those at the top who cannot nor dare not practice safety to any level of practicality…no o have been on this stuff for years but the gurus here don’t want to know that the cost of such a trusting and accountable workplace would kill the profit and harm more than they dare to know…
Excellent comments here… and so very true.
Very late – two responses. One of first companies I had close involvement with that adopted “Vision Zero” was Linfox – “Zero fatalities; Zero injuries; Zero motor vehicle incidents; Zero net environmental emissions; and Zero Tolerance of Unsafe Behaviours and practices.” I knew one driver who was very proud of the fact he was a safe worker – he worked in another state away from head office. After adoption of the new policy the first time he went to submit a safety incident report he was shocked – his manager argued it wasn’t a safety matter and refused to accept the safety incident report! And that remained the manager’s position! He was then asked to drive with an open topped container to get a load of gypsum – he was issued with a special tarpaulin to put over the top once it was loaded. When he got to the worksite it was an open quarry style area. The container was loaded using a large loader. He then has to throw the tarpaulin over one end of the container, climb up and sit on the edge of the container at about 4.4 metres height, and than work his way along the edge and attach the tarpaulin. He then had to transfer to the other side and repeat the procedure. Finally he had to attach the end while standing on the truck tray. There was no working at height safety equipment. So he decided to report that! Once again not accepted as a safety issue – they had no record of a driver having fallen off! But they did take action. The next time he went there he was instructed to get into the loader bucked and whil standing there to attach the tarpaulin! And that did no follow safety practices and there was no working at height equipment! But of course no safety incidents reported!
Secondly in the heavy transport industry it is well shown by research that 65% of fatal or serious injury crashes involving trucks are caused by other roadusers! So how can a road transport company have a goal of ” Zero motor vehicle incidents!”