Safety is Bunk

I am continually surprised at how firmly people cling to Behavior Based Safety (BBS) as a way to improve workplace safety, despite increasing criticism and a growing body of evidence that BBS just doesn’t work (at least for long.)  I don’t have a vested interest in BBS, and I have (I think) made it very clear that I am a “process safety” proponent.  Even by process safety standards I am something of an outsider.

Perhaps it’s because I came from outside the field of safety.  My background before diving into worker safety was in organizational development and training. The position  I held meant that I was expected to fix organizational problems and process defects and to essentially ignore blaming people.  That sounds like sacrilege to many. I mean, how dare this guy (who isn’t a CSP, an MBA, or CHSP, or DDT, or ETC, by the way) come in to our organizations and tell us the emperor is naked?!? Simple: blame just doesn’t matter that much.

It Doesn’t Matter Who Did It

One of the first things they teach you in problem solving is to ask “How did this happen?”  This a subtle but important shift from the traditional “What happened?”  Knowing “what happened” is really about recording an event.  It creates the sense that somehow by knowing what happened we have accomplished an important measure.  By keeping a record, we think we are making progress.  Henry Ford reputedly said “History is bunk.”  Having grown up with a love of history, a stone’s throw from Greenfield Village and the Henry Ford Museum (for those of you who aren’t familiar with these terrific organizations they were founded and supported by Henry Ford,) I was always puzzled by the seeming contradiction.  But as I spent more time in problem solving and investigating worker safety, I realized that not only was there no paradox in what Henry Ford said and what he did, but:

History IS Bunk

If we view history as this static record of “what happened” and we list all the pertinent whos, whats, wheres, whens, how muches, and how manys, but we ignore the whys and the deeper hows, then we gain no insight. Without insight there can be no learning, and without learning our knowledge never rises above trivia, meaning there will never be any true wisdom or understanding. Those who record events without interpretation are merely bearing witness to history, and the adage that  “those who don’t remember the past are condemned to repeat it” not only becomes true but it doubly damns the observer, because not only does the observer lack any true understanding (i.e. can do nothing to avert a disaster from repeating,) but also runs the serious risk of misunderstanding the very nature of what he or she has seen.  The record itself is useless because the tale has been tainted in the telling.  This is true of many things, but when it comes to safety I think it, no pun intended, painfully true.

The Short Happy Life of Just Culture

So what are we left with?  It’s all well and good to talk about the Utopian “no-blame” culture, but what about situations where the outcome was catastrophic? Do we forgive a Chernobyl? A Love Canal? Can we get past Texas City with an “oops?” The self righteous indignation rises up in us and makes our blood boil.  When people act so stupidly, so recklessly, and so inexplicably we MUST get retribution.  While satisfying, that attitude is wrong-headed and stupid.  Just culture grew out of research that showed that: a) mistakes are inevitable, the brain functions in such a way that (and research here gets a bit fuzzy on the exact number) a person makes an average of 5 mistakes an hour.  That’s 40 mistakes a work day; 20o mistakes in a work week, and 10,400 mistakes in a work year.  Sometimes the mistakes are small and of little consequence, like ordering a cranberry muffin instead of a raspberry muffin.  Other errors are big mistakes with life altering consequences like marrying my ex-wife or forgetting to lock out and losing a hand. And still others get people killed.  The point is this:  no matter how much we try to stop it or how much money we spend, people will still make mistakes.  So there are many, many mistakes made (see my resume for a fairly detailed and recent list of mine) and yet only 2% or 3% are ever rep0rted.  Dangers lurk, and people know about them, but say nothing for fear of punishment.  The culture of blame created an environment where reporting an error would be akin to seeing a policeman and telling him that you blew three stop lights and were speeding most of the day. Honest yes; smart no. Reporting your mistakes invites punishment.

A fatal flaw of Just Culture as it was first conceived is that it didn’t satisfy people’s sense of justice.  People have tweaked Just Culture and it is seeing a resurgence in popularity (largely, in my opinion, based at least in part by the work of Dr. Patrick Hudson—now at Delft University of Technology  in the Netherlands) especially in the U.S. in health-care.  There is more right with Just Culture than could ever be wrong with it, but getting people to report near misses is only half the equation (if that.)  Just Culture without a robust process for investigating injuries is tantamount to bearing witness to history, recording the “what” without the “why.” It’s not useful, at least, not useful for preventing those injuries from recurring.  So while Just Culture is a leap forward (especially when one considers the work of Dr. Hudson et al) it needs to be combined with situation analysis to make it a viable tool in culture change.

And Then Along Comes Engagement

“Engagement” is one of those words that make me want to scream.  It gets bandied about by whoever is the latest and slickest pundit in a lexicon of jargon designed to make him/her seem smarter (and more valuable/useful) than he/she is in reality. Our eyes glaze over and he/she cashes checks.  But true engagement—call it embracing safety, hard-wiring excellence, or what have you,—is essential to sustaining a corporate culture where not only safety is of paramount importance, but so too are quality, delivery, customer service, cost control, and any other business element that organizations think are important.

The most important work on the subject of worker safety in the 21st century may well already have been written; and it’s not a book about worker safety (an admittedly sad commentary on my work, but I think once you’ve read it you will agree.)  Carrots and Sticks Don’t Work: Build a Culture of Employee Engagement With the Principles of RESPECT™ (by Dr. Paul L. Marciano) should be required reading for anyone working in worker safety in any capacity. In fact, it should be required reading for anyone working or interacting with people.  Maybe I’m over selling it, but seriously, if you are considering a BBS system or a safety rewards system, stop what you’re doing and read this book.  And get a copy for your head of HR and your CEO too. And no, I don’t have any stake in the sales. Marciano, like Hudson, has a gift for taking a fairly complex concept and breaking it down in simple, layman’s terms and practical tactics for building a cultural base wherein mutual trust and respect can make a blame-free, Just Culture not only viable, but workable and practicable.

Tying It All Together

I guess being deprived of this unfettered and unfiltered forum has made me a bit long winded, but please indulge me one last paragraph to tie this all together.  There are a lot of good ideas floating around that are too academic, too incomplete, or too impractical to ever reach fruition.  For some of us, that means a professional life fraught with frustration.  For others, it means trying to sell an incomplete solution and apologizing when it doesn’t work. And for everyone else,  it means chasing our own tails as we run from one expert to the next.  Meanwhile, Operations execs get more and more impatient with us are more likely to buy into junk theories and safety snake oil.  I think combining the theories of Marciano, Hudson, and a handful of other thought leaders is an essential next step.  I don’t have all the answers; no one does.  But if we can divorce ourselves from dependence on a single, “quick-fix,” methodology long enough to consider how these approaches might just fit in our organizations; and if we can get something that is simple, practical, and most importantly, fast; we might just finally get the results that the organization demands and the respect so many of us crave.

There is more, but this is enough,

Phil

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