About 20 years ago I had a profound experience that changed the way I approach my work in safety. Prior to this I very much believed that if you can’t measure it, it doesn’t exist and that 90% of accidents are due to human error.
I was working with a group of employees and supervisors to uncover the root causes of a tragic fatality. They kept telling me that the root cause was lack of trust and open communication and I would tell them those are symptoms not causes.
Suddenly, maybe because of the pain in their faces, I stopped and really listened. One person said, “We kept trying to tell them there was a problem with the layout of the equipment, but management never listened.” In the throes of my new found insight I decided right then and there that all we needed to do to get things on the right track was to tell the managers how important it is to listen and respond to safety concerns because many times the information they need to prevent a fatality is being offered to them, and all they have to do is listen, investigate and respond.
After I delivered the message to the leadership team they thanked me and never invited me back for the dialogues that I had recommended. Instead they hired a very expensive work re-design consultant firm and instituted a behavior observation program. A couple of years later they had a second accident where a man lost his arm. Could it be that the underlying mistrust and lack of communication were never addressed?
I learned safety is not only about rules, compliance, and safety management systems – it is also about feelings and emotions. The challenge for improvement is therefore complex. We can no longer rely so heavily on root cause analysis, training, and top-down driven change. We need safety management innovations that get at the core of the challenge – a company’s relationships.
DuPont did a worldwide survey in 2013 where companies revealed that their top priority was creating a safety culture where employees held each other accountable and were willing to confront an unsafe act (Lin). Every major company wants this, but our traditional approaches to safety management aren’t going to help us create a culture where people watch each other’s back and are open to giving and receiving feedback. The CEO of a mining company called me because they had had three fatalities in 18 months. After each occurrence they did an investigation and applied best safety management practices, yet they were unable to prevent the next fatality. They were looking for the missing element not provided by their audits, dashboards, standard operating procedures, near miss reporting, or behavior observations.
What’s missing? What comes to mind is the grassroots wisdom those workers offered me long ago: trust and open communication are the foundation of safety. You can have the best systems and technology, but if there is no trust there is no communication and that means eventual failure. What would it look like if management took this message to heart, and what kind of practical actions could be taken to promote this desired work environment?
The principal action is for leaders to build relationships with each other and employees so that information may be exchanged accurately, at the right time, and in an atmosphere of mutual respect. I am suggesting that investing in the improvement of relationship and conversation in your organization will fertilize the ground for your safety improvement efforts so that you can get the results you are looking for. The importance of trust and open communication may not be new, but most organizations do a fairly poor job in this area.
People attend communications workshops to learn how to give and receive feedback that may be personally helpful but do not seem to take root in the workplace. I find that follow up and supporting structures are critical to maintaining the insights gained during a workshop or from an experience such as a fatality. Teaching people how to have effective conversations, give feedback etc. go to waste without an established routine where they can be practiced, evaluated and there is some certainty of follow through. However, the structure (procedure, policy, checklist) will not make it happen. What makes a program successful is leaders ensuring that the information that is gathered is used to make corrections and involves workers in conversations about the data. The meetings, reports or checklists have meaning because they generate results that are perceived as helpful by the people participating.
These kinds of open conversations tend to naturally take place between friends and members of well-established groups/teams. Consciously recreating these kinds of relationships in work groups is a challenge but it can be done when you establish the proper environment. You can put everyone through communications training but making it part of the culture will require leaders to set the example, consistent follow up and perseverance.
- Lin, M. (2013) The Effect of Interdependence on Safety Performance and Operating Dexterity. DuPont Internal Technical Report.
• Quality / Safety Shortfalls/ Failures
An inescapable fact is that quality/ safety shortfalls/ failures are the result of not meeting requirements and/or the requirements being inadequate to forestall the shortfall.
Good morning Bill. Nice to communicate with you beyond of the nuclear safety forum. First let me say that I am not suggesting that we don’t need procedures, training or engineering to have a safe workplace. We do. My work in relationships attempts to reveal the underlying causes that impact the effectiveness of those measures. Much like disease could not be contained until someone “saw” the invisible germs. We will not progress in our mission to greatly reduce fatalities or the kind of thinking that led Tepco to not implement the engineering recommendations to build a higher wall to protect the Fukushima nuclear plant from tsunamis unless we are willing to look for the deeper underlying forces that keep the present dynamics in place. The nature of relationships is one of those forces.
I agree that in hindsight almost all accidents could have been prevented if only we had taken “right” action. The problem is that without the benefit of hindsight the consequences of our actions aren’t certain. People violate procedure all the time without negative results. Once in a while they get caught, but it is not frequently enough to control behavior. The solution could be to install more police, or try to invent more technology that removes human choice. (The new driverless cars are moving in that direction.) We can also design a process or procedure to forestall similar shortfalls after each failure.
We are faced with the reality that we can install all the requirements we want, but that will not ensure that those requirements are followed. Nor can we guarantee that those requirements will meet the unexpected. People are our best resource to meet the unexpected. People do not operate autonomously, they operate within a network of relationships. If those relationships are dysfunctional, you get dysfunctional decisions. Fear, mistrust, lack of respect, focus on your own bonuses at the expense of the plant’s performance–these are all precursors to disaster because they keep information from surfacing or being accepted that could have forestalled the shortfall. A single human cannot hope to process the billions of bit of information that rains on him or her each moment, but the human network does expand our capabilities to detect the meaningful data and act on it. It could be argued that interdependent relationships with trust, mutual respect, and good communication skills create the strongest layer of defense against safety.
Ms. Carrillo’s article is on point but two key terms merit further definition/discussion: trust and open communication.
To my mind, “trust” means the boss/coworker won’t use the information/suggestions you provide against you, i.e., to screw you. It also means he will look out for your interests (in addition to his own). And it means he won’t betray you to curry favor with his own bosses.
But the wicket gets sticky if you tell the boss something that evidences a breach of law or corporate rules. It may provide some insight into improved safety but what do you expect him to do? What should he do?
“Open communication” can also be problematic, viz., open to unforeseen consequences. WHAT someone is saying may be factually correct but WHY is that someone telling me? To be helpful? Intimidating? To insinuate himself? Lots of training is needed to condition people to give/accept open communication with an open mind and heart.
Couldn’t agree with you more Lewis. Lot’s of training required. Even more importantly a leader with high emotional intelligence, good people skills and a willingness to mix it up is required.
Rosa: I couldn’t agree with you more that relationships matter. A lot of our prevailing safety practices are historically based on scientific management and systems thinking where the whole is equal to the sum of its parts. BPR, RCA, SMS, et al have trained us to be reductionists; we break down the parts, analyze each separately, fix, and put them all back together. Works great when you’re working with Lego parts. Not so great if there is a human component. When people are involved, I think of mayonnaise as the whole and the futility of separating out the salt, vinegar, egg, etc.
Much of the real world is not linear but non-linear – a complex adaptive system (CAS). Glenda Eoyang defines a CAS as “a collection of individual agents who have the freedom to act in unpredictable ways, and whose actions are interconnected such that one agent’s actions changes the context for other agents.” Smart safety professionals understand the whole is greater than the sum of the parts. It’s greater because of emergence, one phenomenon that systems thinking cannot deal with or chooses to ignore. The emergence of new behaviours and states arises from the relationships and iteractions amongst the parts. That’s why relationships matter and we must pay attention to them.
Hi Rosa, this approach is how things got done 100 years ago…..when things were built to last. All great enterprises seem to have as cornerstones trust and communication. It is what we are missing in our fast-paced commercial environments now. It also ties in perfectly with the recent article about “People are the solution”. The answers are before us, if we know where to look and who to ask.
Paul, I have had the same thought that we need to return to some of the ways we used to get things done. I remember when I first began to study organizational development I learned that in trying to improve efficiency the coal mines in England broke up the teams that shared tasks to make “specialists” in 1949. It completely destroyed morale and productivity. Now you’ve probably noticed how much effort has gone into restoring “high performance teams.”
Yes, the creation and development of teams within the work place adds so much more. The shared sense of purpose, willingness to go the extra mile and “looking out” for your mates actually do have a measured affect on budget, timetables, quality and of course safety outcomes.
I had the misfortune of hiring a contractor that had split its operation into areas of specialization. It was a disaster. In order to get his company to deliver I had to provide project management and system integration as a customer.
My take: Specialization causes stupidity.
Bill, how interesting that the client had to provide the integration. I wonder how they could stay in business.
This is a good example of the ongoing pendulum swing between generalists and specialists. We bundle and then we unbundle. We outsource and now we’re seeing re-insourcing.
Just for fun, let me throw this thought out. Designers of org structures are blinded by a vertical governance “the buck stops here” mindset. The view deems silos and cliques as evils of efficiency. They fail to understand these are informal horizontal mechanisms and how resilient people through trust relationships devise “the buck flows there” workarounds to get the job done. So let’s put more value on silos and cliques as opposed to dispensing with them.
While this idea may sound bizarre, it’s actually a complexity science phenomenon called self-organization and what agents in times of confusion do to build stability.
This is a good point, Gary. I have often said that people work naturally in a matrix organization, right up until the point when we try to put it on paper with dotted and solid lines and confuse them. We will never get rid of silos – they are a structural necessity – so lets align them with the best interests of the business and use them
Great article. I learned as a new safety hand several years ago that I had to establish relationships in order to gain credibility. Only then could I help divergent groups find common ground and I could influence their safety and operations solutions.
Jane, that was a valuable insight. I wish more people would understand that relationship building isn’t about being friends with everyone because some supervisors and professionals feel that distance is necessary to maintain order. It is actually the opposite as you point out.
I always find it interesting to remove the word ‘safety’ from discussions such as this and see how well it applies to everything we want to do better in the workplace. The improved trust and communication cannot be developed in isolation as a ‘safety culture’. The overall organizational culture must be addressed first and businesses that miss this point will never make improvements that are sustainable in the long term. Trust is either there, or it isn’t. It can’t be turned on and off dependent on the topic of conversation
I agree with you Craig that trust in safety is not separate from the rest of the organization. Do you think that safety might provide a definable opportunity to rebuild or increase trust? People often need a concrete place to start and safety has always seemed like an area that both labor and management can agree on as crucial.
Absolutely, Rosa. I always point it out as a very good place to start, as it can have more impact more quickly when people believe that you genuinely care about their welfare. The Shingo model for operational excellence, for example, has a safe environment as one of its foundational principles.
The only thing to be wary of – especially if your culture has historically been poor – is the cynicism that can accompany it. The key to this, I believe, is to go to the workforce and get their feedback first, rather than suddenly change your stance.
Dupont had their STOP program which did not concentrate on feelings nor emotions but heavily looked at the behaviour of managers and the interconnected behaviour of the workforce. According to STOP, you can expect the highest safety performance of “followers” came up to the lowest safety performance of ‘leaders” (supervisors). In this sense, the relationship affects behaviour. If we are to move safety to the compliant positive side of the compliance continuum, its all about the behaviour of companies, leaders and followers.
Alan, that is an excellent point about another form of relationship–the relationship between supervisor and direct report performance. A former DuPont plant manager–richard knowles wrote a book about his experience and there were plenty of emotions and feelings involved. The company just doesn’t talk about it in those terms very much because it is considered less professional. Do you or did you work for DuPont?
During the 90’s, I was working for South Pacific Tyres (tires) in Melbourne, Australia. The Dupont Stop safety program was implemented in the plant. It had immediate results as management were required to walk the floor specifically looking at the behaviours of supervisors and their staff. It was amazing to see some people change their (unsafe) behaviour once they became aware of the presence of managers.
Companies have a fundamental choice to make in relation to safety costs. The first and preferable choice is to invest in safety to make it at least equal to other elements of running a business. Alternately, companies can hire the best legal teams to attempt to protect them following accidents.
The best safety culture is when the entire workforce are encouraged and actually do report near misses to ensure the next accident is identified and avoided.
I agree Alan that the whole workforce must be involved. Looking back do you feel the STOP program worked just because supervisors were observing or did other things happen to the relationships between supervisor and workers?
FYI, A 2012 book by Todd Conklin called “Pre-investigating accidents” has a similar theme – listen to the boots on the ground because only they know how the system is actually working. Worth a read by any safety practitioner.