Luck: The Most Effective Tool In the Safety Pracitioner’s Toolbox

By Phil La Duke

First let me apologize for the late post. I wasn’t lollygagging on Holiday,  I am in the middle of two computer crashes and another that is coughing up blood.  I’m not sure this week’s post is worth the wait but here goes.

On Saturday there was one explosion particularly loud. Despite being the Fourth of July weekend this particular explosion wasn’t a firecracker or skyrocket, rather a natural gas explosion at a DTE (the company founded when Michigan Consolidated Gas and Detroit Edison merged to form DTE Energy) training center. For me it underscores what I have been preaching for the last three weeks: SAFETY ON PURPOSE.

I think most of us would feel pretty safe in a training center of a company of one of the safest companies around, but it underscores the point that things happen and I am not prepared to trace it back to the behavior that may have caused this explosion. My point is a major catastrophe happened (fortunately on a Saturday when the building was vacant) and there is no one to blame, not the workers, not leadership, not even the admiral’s cat, and certainly not the culture. It leaves me wondering what would have been the death toll (the building was a total loss) had this happened during a big training event. The only difference between this being a local inconvenience and a national headline is luck.  No one was harmed (as far as any news report can tell me) and nobody did a damned thing to prevent these injuries.

Zero injuries should be a wakeup call for company that has them, heck, LOW injury rates should alert us that we are doing something either very right or very wrong. On one hand we may truly have done something that has caused us to create a safe work environment, but without knowing what that is we can only sporadically repeat it, on the other hand we may have just been lucky and the results we are achieving are just are workers beating the odds or the works are so full of fear that they don’t report injuries

It’s Not the Crime; It’s the Cover Up

When we think of what I am calling “Safety On Purpose” I’m referring to an active approach to drive safety. Certainly, the idea that companies need to “drive safety” isn’t new, and it certainly isn’t original.  But I wonder how much we really drive safety instead passively waiting for safety (or injuries) to happen.  .  Invariably this kind of talk leads to a discussion of “culture”. I keep hearing people bellyaching about the culture, and the need to create a “safety culture”.  (The worst thing the great James Reason did, is coin the term Safety Culture, one of his steps toward what he described as a “Just Culture”.  Reason believed the key to successful ethical governance was through the creation of a culture of justice where people were only disciplined for truly reckless and criminal acts.  But before one can create a “Just Culture” organizations must create a “safety culture”, in other words, a culture where people feel safe admitting mistakes, can be forth coming with the details of the their mistakes. Reason once said, “Errors plus blame equals criminality”[1]  What Reason was saying, is that by creating a climate of fear—we all make mistakes, in fact one study suggests that the average person makes five mistakes a day[2]—people will not admit mistakes and will actively conceal them. In industries like the healthcare, aviation, or the nuclear energy concealing mistakes can be catastrophic and devastating, but in all other industries unless we create a culture where it is safe to tell the truth without fear or repercussion we will never get perfect—or even good—information on injuries.  So let us not forget that we all participate in the corporate culture and we all have to work to actively create a culture worth having.

One of the characteristics of a culture of fear is the blood in the pocket syndrome. This phenomenon is where workers will conceal their injuries from their employers either out of fear of discipline, or more likely out of the fear of the loss of some incentive, not just for themselves, but for their coworkers as well.  I have never visited a workplace where a culture of fear openly existed where the safety practitioners didn’t deny any possibility of under-reporting.

Creating the Desired Culture Takes Work

Some reading this will immediately point their fingers at leadership, and moan that if the leaders don’t support them then they can never change the culture. Leaders, for their part, wring their hands and scratch their heads and wonder why they can’t seem to change the culture no matter what they do. Workers for their parts wait patiently for the great change to come…but it never does. Culture exists whether we manage it or not; it’s that simple. The only question remains is “is this a culture we want?”

A Bit About Cultures

Cultures are (for those of us who have spent a fair amount time studying them) the shared values, norms, and belief about what is acceptable behaviors (I see this as different than norms, because something can be a norm but people can still see it as unacceptable behavior). Think of cultures of corporate habits.  All organizations of seven people or more have a culture, and those organizations place a relative importance on safety.  Think of a family with two parents and five kids; this family will have a largely unspoken code of behavior. In this family there are shared values (and just like in a larger organization these values lie somewhere on a continuum, with some things being more or less important to one member than to another) but there is a fixed line where all family members agree that should a member cross it, negative consequences must be imposed. Norms make behaviors predictable and predictable behaviors keeps populations from devolving into violence.  Norms are the basis for laws and the policies with which we govern our workplaces.  Unfortunately most norms are unspoken.

Superstitions develop when we have a norm but we no longer understand the “why?” that drives the norm. As cultures evolve the reasons for the rules become murkier and devolve into superstition. Do you know why in many cultures it is considered bad luck to put shoes on a table? Because an unskilled worker’s most valuable possession was his workbooks his friends would typically take the deceased worker’s shoes back to the widow and place them on the table while he gave her the bad news.  Several generations later shoes on a table developed into the superstition of impending death. Eventually the superstition is dismissed altogether and shoes on the table no longer carry with it any stigma.

Taboos are those activities that actively violate our expectations of acceptable behaviors, but we don’t know why; they’re just wrong. Everyone knows their wrong, but no one can exactly say why.

All this is a lot of background that I’m not sure you need, but I give it to you so that when you ask a worker “why did you do this?” and you get the answer “I don’t know” you may be getting more information than you think. Does the worker truly not know or is the worker afraid to tell you why he or she did what he or she did?

I write all of this about culture because so many reading this don’t have a clue what the word means as applied in the context of safety. Stop worrying about culture and start gathering data on why you don’t have more injuries than one could reasonably expect.  Until you do you are just sitting in a training room betting that it won’t explode.

[1] I attribute this to James Reason irresponsibly.  I have seen the quote and searched for the author and people have told me it was said by Reason, but if anyone has a better, and definitive source I would appreciate it.

[2] Another statistic that I picked up in a lecture at a medical safety conference but the author and the study were lost in a flood of my basement, if you know the source, please let me know. I trust its veracity but I don’t expect others to without science behind it.