By Phil La Duke
Since the advent of the Safety function, it’s been borrowing tools from other disciplines and building practices based on data gleaned from the earliest research in industrial psychology. For some, these most basic practices and methods are cherished and to suggest that any change to these is tantamount to heresy. For others, change may be possible, as long as we acknowledge that these practices are the cornerstone of the safety function and that they are necessary to some degree. While it’s true that in broad strokes we probably should retain some of our practices the philosophy that drives everything we do must change at a fundamental level.
The focus of safety for 100 years has been a centered around obsessions: obsession with eliminating injuries, changing worker behaviors, and identifying root causes of injuries. Simply put, this focus is wrong.
Obsessed With Preventing Injuries
Focusing on eliminating injuries is reactionary and treats symptoms. If we believe that our purpose as safety practitioners is to eliminate injuries we will find ourselves forever playing catch up, and what’s more, even if we achieve zero injuries most of us won’t really know whether this result is the product of hard work and sound safety practices or dumb luck.
Instead of focusing on injury reduction (an outcome) we need to focus on risk mitigation and severity reduction. In a discussion forum, someone asked the question “what is the behavior ‘safety’?” It’s a ridiculous question because safety isn’t a behavior; one does not “do” safety. Safety is an outcome and absolute safety, i.e. the absolute absence of risk of harm, is unachievable. Pursuing an unachievable goal is absolutely insane; you will merely frustrate your organization. But reducing the risk of harm to the lowest practicable level is achievable. We can, at least in many (perhaps most) workplaces lower the probability and severity of injuries below the threshold where injuries are no longer common and crippling but rare and minor. Our outcome (reduction of injuries) is the same but our strategies and tactics are focused not on the outcome but the causes (workplace risk factors).
Obsessed With Behaviors
Another object of fanatic obsession is “behaviors”; somewhere along the way, safety practitioners seized on the idea that the key to worker safety lie in modifying worker behaviors. Change the way the worker behaves, conventional thinking holds, and you can create a safe workplace. To be sure there are plenty of workers doing stupid things that get them hurt, but the obsession with behaviors assumes that worker behavior is a) a conscious and deliberate choice, b) something that can be changed through basic behavioral modification, and c) intrinsically safe or unsafe. We know that most behavior is not conscious, and is in fact subconscious habit, unintended behavioral drift, contextual, and difficult to change even when the individual desperately wants to behave differently. Additionally, far too many behavior-focused initiatives depend solely on psychology and ignore behavioral sciences that focus on behavior of populations (sociology, anthropology, et al) so focusing on individual behavior will force us to draw specious conclusions that feel right but that ultimately lead us far afield. Instead of focusing on behaviors we should be focusing on decision-making and problem solving. Instead of trying to change behaviors we should be focusing on building decision-making and problem-solving skills. If workers are able to make better decisions (which drive safer behaviors) and solve problems more accurately (instead of improvising when a problem prevents them from doing the job as designed) we are again able to reduce workplace risk and in turn reduce worker injuries.
Obsessed With Finding Root Causes
The third obsession of safety professionals is finding the root cause of injuries and near misses. This focus on finding a single “root” cause is also problematic. Few injuries are caused by a single “root” cause, and are instead caused by multiple, inter-related causes and effects that grew gradually over time. In basic problem solving methodology, the first step in solving a problem is to categorize it as either broad, specific, decision or planning. Most injuries are caused by broad problems while most quality defects are caused by specific problems. I can’t think of an injury that is caused by a planning or decision problem (that doesn’t mean they don’t exist, but I am prepared to say they are exceedingly rare.) Once a problem is categorized the next step is to identify its structure; is it gradual, sudden, start-up, recurring, or positive? In safety, we tend to see injuries as being caused by specific conditions with a sudden structure. In some cases this is true, typically in mass production environments and where the worker is engaged in standard work. But in far more cases, injuries are caused by a broad problem with a gradual structure. In these cases, the situation continues to worsen until a threshold is reached and some catalyst is present that sets off a chain reaction. People tend to look at these types of injuries as “freak accidents” that could never have been predicted and they are right to some degree, because one cannot predict or prevent these incidents when one is using the wrong tools. Traditional root cause analysis focuses on identifying the one cause of an injury and tends to minimize contributing factors. This singular approach tends to cause a problem with a recurring structure to manifest. The reason for this is simple: by removing only one of the multiple, inter-related factors that contributed to the injury one raises the threshold at which an injury will occur. The problem seems to disappear but is actually lurking just below the surface. To use a medical analogy it masks the symptoms instead of curing the disease. Sooner or later the situation will again reach the threshold and cause another, perhaps more serious injury or fatality. We see this often in today’s workplace where organizations celebrate the achievement of zero-incidents, or extremely low incident rates only to later have a fatality (or multiple fatalities) catch them completely unaware. (Incidentally, if the organization would have approached the zero-injury, or acceptably low injury rate as a problem with a positive structure, and tried to understand the factors that caused this positive outcome, it could replicate the things that work in other locations and eliminate the things that its doing in the name of safety that are costing money but having no appreciable effect on safety.) This obsession with finding the root cause, before truly analyzing the situation and context of an injury seriously impedes our ability to create a workplace that has significantly less risk.
There is no denying that safety in the workplace has come a long way over the last 100 years, but I contend that much of that has to do with the Hawthorn Effect and picking low-hanging fruit. If we are to take worker safety to the next level, we have to rethink our focus and start focusing on the things that will have the greatest impact on worker safety.