Stop start cards

IMG_2658A mechanic once burnt his hand so badly he had to seek hospital care. While at the hospital, two managers from his workplace showed up. They wanted to find out if he had completed a ‘start card’. Fortunately, he had filled one out so all was good.

As he retold me the event, it was clear that their request had upset him. The managers had been interested in the paperwork, and not the state of his hand. Or as he cynically put it: Safety isn’t about people.

Many projects I have visited use some form of ‘Start card’ (aka Task card, STARRT card, HSE card, Star card, JSEA card, Hazard Identification Tool, B-Safe card, Take 5 checklist). Before a task is carried out for the first time every day, and also if circumstances change, workers must (re)assess the situation by completing a ‘Start card’. The purpose of these cards, I’ve been told, is to provide employees with a cognitive aid to focus on the situation at hand, and to prevent people from operating on autopilot.

In a project with a few hundred employees, thousands of start cards are filled out every month. A few times I have come across entire boxes filled with used start cards. A few times I have asked managers what they do with the cards after employees have filled them out: Are they used to analyse patterns and trends? Perhaps a quality-check of work conditions?

Most of the time projects do nothing with the start cards. There’s not enough time. Occasionally they have someone who randomly goes through them to verify that people fill them out correctly. Also, some projects use the cards to measure employee performance – the annual bonus is impacted if people don’t hand in enough number of start cards. However, I have never heard anyone ascribing any organisational ‘safety function’ to them.

The mounting piles of starts cards reflect a belief that safety stems from correctly assessing hazards. Start cards perpetuate the idea that if people only processed every piece of necessary information there would be no mistakes, surprises or unwanted outcomes. Hazards are believed to be real, objective entities out there and it’s everyone’s responsibility to verify how these may undermine safety. Start cards (and more generic risk assessment procedures) suggest that risk is subject to a rational choice to undertake the task or not, or to choose to be aware of risks or not. Start cards echo a sentiment that accidents result, not from a resource/demand mismatch or unexpected combinations of conditions, but from failures to adequately assess the world.

As such, start cards rest on assumptions about the world (it’s knowable), about people (they make rational choices) and about safety (it’s about hazard management). This way, start cards limit the way people talk about and assess the hazards they interact with. This way, other conditions, constraints, resources, demands and strategies under which safety is produced, enhanced, enabled, supported, challenged, and sometimes broken remain uncharted.

The other day a safety manager told me his company had stopped using start cards. A complete waste of time, was his explanation. But instead they had put training and methods in place for people to improve their skills at having conversations about work:  What are we currently doing to optimize efficiency and productivity and how does that affect how we go about things? Have our practices changed? What do people find difficult about a certain task? How confident are they the controls are enough? What proof is there that a particular strategy is working? What are we borrowing from to make this happen? What other possibilities are there that we haven’t thought of? How can we engage people to prove the current version ineffective and make things better?

Categories such as consequence, likelihood, hazard and control, seem to be artificially purified analytic variables that come with many problematic limitations as a way to talk about situations at work. I personally would like to hear more about the stories people tell about a specific task. If we assume that people operate on auto-pilot, we can find out more about the assumptions and ‘scripts’ that drive its programming. What are the stories people tell each other about a given situation? What are the success stories? What stories are told about certain actions to avoid? What do expert operators do? These stories can then be discussed, questioned, and changed. People are normally skilled at storytelling and listening, and perhaps start cards can be used to trigger and submit stories about work.

By tweaking the questions we ask—in start cards and the like—and by asking for uncertainty, local strategies, developing practices and further questions to be flagged, we change the focus from constraining individuals, to enabling an up-and-out kind of engaging ‘informed variability’ of what currently goes on. This way, the focus goes (or should at least) from the hazard itself to reflect on the dynamics of how the organisation relate to the hazard.

However, insights, mess and the existence of less than rational assessments may frighten some organisations. It potentially exposes organisations to a liability from knowing about existing possibilities, changes, messiness, ideas, nuances, complexities, etc. It could potentially be opening Pandora’s box. This would require an organisational mechanism to capture, structure and address the wealth of available information. It will be a more difficult approach for management and require organisational attention and effort to support work and assess information and channel ideas, rather than specifying the one best way. But this way, starts cards can go from being the end point of making people responsible for safety, to becoming the starting points for people and organisations to continuously learn, develop and improve. It’s potentially difficult, but not impossible.


  1. Rodney Currey Reply

    Yes do agree. However I think stard cards or another type of hazard assessment should not be used by the workers but by the supervisors before task assignment. The other point on why these companies insist on start cards etc. is what I call safe safety.They are playing it safe by using a safe tool to manage safety based on it is widly excepted tool, so we automatically use it.

  2. Mark Schenk Reply

    Nice piece Daniel. Much of the current thinking is based on the assumption that safety can be controlled, managed. But, when things are complex (many variables, cause and effect only known in hindsight, lots of opinions about what’s right and great difficulty finding a single correct answer) control is an illusion. I like the idea of start cards being the start point for a conversation. But, my experience is that in the work environment, most people don’t have the necessary story telling or listening skills and that focussing on building those capabilities might yield pretty reasonable dividends.

  3. Tanya Hewitt Reply

    Wonderful post, Daniel – and I echo Mark’s comment that conversations may be difficult to organically grow and consequently help front line workers with “mindful awarenessness”. This reminds me of Erik Hollnagel’s premise of performance variability – that safety efforts (possibly these start cards) are based on the premise of constraining performance, but this is not what we should be aiming for. After all, the exceptional performance that surely we all societally appreciate is likewise unconstrained – just that the outcome is positive instead of negative. Hollnagel has argued that workers’ ability to measure (or even recognize) this performance variability is weak, but is trainable. In this way, the workers could become more “situationally aware” as a matter of due course, and recognize if their individual or their collective performance might be on an undesirable course, and allow them to engage in realigning the performance to achieve the task – safely.

  4. Rodney Currey Reply

    Further, on organisations focus on hazards, it has been my experience that organisations become paralisysed or unable to deal with a hazard when confronted with it. This I believe is deep in the company’s psyche of the fear they have for safety in general. They fear that safety stifles or interfears with production. Then on the other hand they fear the risk of a fatality.
    On the view that organisations are frightened of having knowledge of hazards etc. but not being able to subdue or conter them is an old view anti safety managers pursued. This was highlighted with the mentality that if you don,t acknowledge the hazard you are not responsible for it. This is a misguided opinion that is driven by ingnorance. Organisations have much more capability than they know. The new knowledge era that is upon us is the way to head. We all rely on things like start cards, JHA,s etc. but actually they are work imagined not work done. We all need to get real with strategies and objectives that we know works, not just hoping they do!

  5. David Dunham Reply

    When I was a carpenter I used to write down a detailed sequence of operations before beginning a complex task. The goal wasn’t safety related, but rather the avoidance of mistakes that would cost me time and resources. With fewer mistakes I felt like I was less under the gun and I was therefore able to perform the work more thoughtfully.

    If you have the opportunity to work for someone who is exceptional at what they do you will likely find that they all do something to mentally prepare for a task. They might talk it out with others, write out a plan, or ruminate on it for some time. It seems to me that this form of assessment could be much more valuable than a standardised card or checklist. We should train workers to take time to carefully consider their work in its entirety; teaching them to ask, how can I perform my work as efficiently as possible? What are common challenges associated with this task? How can I prepare for my task so that I am not having to improvise or feel as though I am lagging behind?

    I’m not against the start card entirely. I just think that the intent of the tool has been lost to the fear of liability, diluted by the normative pressures, and ignored due to the allure of standardization.

Leave a Reply

Your email address will not be published. Required fields are marked *