Communication has become a catch cry for both the safety profession and regulators, yet it seems that significant barriers exist from multiple stakeholders to prevent or discourage real communication. Professor Sidney Dekker challenged us with his writings on “Just Culture”, to build organisational practices that encourage and foster open communication both for success and failure, that foster broad and honest information exchanges.
The computer industry has been a leader in building active participation in information sharing, most prominently exhibited in the open source software community. Don Tapscott recently gave a presentation at TED where he identified four principles for an open world: Collaboration; Transparency; Sharing and Empowerment. I would posture that the same four principles would revolutionise our current state of safety thinking to one that engages with complexity, and powers innovation.
In the safety profession today, the benefits of incident reporting are espoused, whilst concurrently incentives are imposed to eliminate incidents. The resulting practice is one of active misinformation that diverts the discovery of incident events.
At a lunch late last year, I listened to a speech by Minister Bill Shorten. In this speech he challenged employers to promote open communication with their employees about safety, and avoid the blame behaviours that were displayed in the ESSO Longford incident. This on the face of it is a reasonable and obvious expectation, however, the current regulatory practice is an active deterrent to this objective.
In 2002 the New South Wales government amended the Civil Liability Act to exclude apologies as admissible evidence in civil litigation. The intention of this change was to allow medical clinicians to openly communicate errors that occurred in patient treatment, where an apology could be offered, and this transaction not be admissible in any future proceedings. This change has begun a change of culture, where both the clinical outcomes are improving, and patients are less traumatised by these error events.
The Civil Liability Act has a number of exceptions to this provision, one being for injury related to workers compensation. Such a provision continues to discourage organisations communication around failure events and sponsors the culture of protection of legal privilege for internal investigation processes. Whilst prosecution only proceeds in a very small number of incident events, the communication lock down routinely occurs as a risk management strategy.
The regulators would achieve a step change for safety benefit to the community if it allowed companies to openly engage in investigation, and communicate error without fear of prosecution based on the derived findings. By pursuing such a strategy, successful prosecution for significant injury will not be diminished, as the facts of the injury themselves are sufficient to demonstrate that there was a not a safe place of work or a safe system of work, however, the need to prosecute would diminish.
Kirby Ferguson gave a great presentation on intellectual property at TED: Embrace the Remix. Kirby challenged our notions of Intellectual Property through copyright and patent practices. He showed the importance of “Remixed” ideas as a continuum of knowledge development.
Safety has developed a culture of intellectual property practices through our systems, programs and protection of learning’s as competitive advantages. As a profession we need to challenge these practices amongst ourselves and with our employers. If we are going to continue the evolution of our safety science within increasingly complex operational environments, we have to embrace oneness and relinquish the attraction of locked door knowledge storage.
I was recently challenged by an eminent colleague to publish every incident investigation and lessons learned to the public domain. I was not sufficiently “brave” to do so, knowing the risk this would pose to my organisation from a regulatory perspective. I am sure that such openness would not be rewarded. This does not illustrate that the concept is flawed or naive, rather that we need to shift in the state of practice and regulation.
What needs to change if we are to truly engage in a communication culture for success and failure events?
- Remove performance incentives for incident and injury rates.
- Retire the reductionist thinking that we are constrained by with Root Cause Analysis.
- Disband the language of Zero Harm, to release us from its destructive effect on communication.
- Build a leadership practice for open communication, for both success and failure.
- Reform the legislation to remove the admissibility for an apology relating to a workplace injury.
- Openly communicate our success and failures to the public domain.
- Manage safety for success rather than avoidance and fear.
I agree with the drive to open sharing between persons engaged in safety roles.
I decided a long time ago that if my work could help save even one injury (even if I didn’t get to hear about it) then I had achieved something important for Australian industry.
I’m also strongly aware that I have developed almost nothing ‘from scratch’. I have found an immense amount of informaiton and documentation available on the Web and have usually ‘borrowed and adapted’ those documents for my purposes.
I now actively share my own policy and procedure documentation with a range of persons who I am linked to through a Safety Forum of Not For Profit organisations. All I ask is that those people a: remove all references to my current employer and b: they do not forward ‘my work’ to others without my permission. My primary aim in asking this is that I want to minimise the potential for others to profit from my ‘gift’ referred to as intellectual property and usually coverd by copyright if applied.
I also agree with sharing safety information. But as Kelvin points out we are often restricted when it comes to sharing information on incidents. None the less, as you point out, this shouldn’t stop us from sharing our initiatives and successes.
The beauty of being solutions focused is that while we may look around and see what other people are doing we will always need to tailor the solution for the people that we are supporting. If someone wants to cut and paste your work then in the long run they are not doing anyone any favours, least so for the people that they are trying to help.
Two years ago I wrote a small grant to study content in incident investigations. I simply wanted to analyze the type of failure (active or latent) identified and the solutions offered (hierarchy of controls). In the grant writing phase many organizations were excited to participate, and I received numerous letters of support for my application. I was fortunate enough to be awarded the grant. However, when I approached my partners for their de-identified data reminding them that their company name would never be known to anyone other than me and my grad student, it was disheartening that their response was that now they could not participate due to confidentiality concerns. The grant objectives were recently completed but took much longer than anticipated. I like Kelvin’s list. His thinking would actually make the grant irrelevant, and that’s the point. I’ll be sharing some of the data from the grant activities in March. We have a long way to go and a lot of work to do. I think about the very inspiring Compliance Paralysis article written on this blog not too long ago; some of my findings are unfortunately similar.