Executive Summary: both South African and American history show that if we want to do better at ensuring worker safety we have to think differently. Continuous use of the existing way of thinking and explaining accidents and incidents will get us the results we are getting. Peoples ability to adjust and become expert at their jobs, and the local demand to reconcile (sometimes) irreconcilable variables leads to a “drift into failure”. For safety to be good business this drift into failure has to be managed.
Good safety is Good Business
“Lean (Construction Institute) advocates minimizing waste and continuously improving. Incidents that disrupt the flow of work or lead to injury are waste, so the relationship between lean and safety is clear.” (Howell et all, “Working Near the Edge”)
In South Africa the relationship between lean (workflow) and safety is blurred. For example, lost time due to injury. Only the lost time is of concern to the production driven company, since the cost surrounding the injury is covered by Workman’s Compensation, administered by Department of Labour. The cost of property damages are more visible as direct drains on profits. But, if the attitude is that incidents are an “embarrassment” and has to be hidden, then the relationship between lean and safety is deliberately obscured.
One quick way to do a rethink on the profitability of safety is in asking how to apply the returns received annually from Workman’s Compensation. A number of companies known to the authors use those returns as a stop gap to fill a financial hole somewhere. Its significance as “profit” due to good safety performance is more often than not, totally missed.
New Questions:
At the forefront of asking questions about how to improve the current safety statistics are researchers like Jens Rasmussen (“Cognitive Systems Engineering”), Greg Howell (Lean Production Institute), Sidney Dekker (Lund University, Sweden) and others. Their concern is that the way “human error” is described and used as “the” explanation when investigating accidents are not leading to better solutions.
Sidney Dekker, for example, uses the following formula to explain the current (old) approach to accident investigation. Accidents=f(1-mechanical error) where 1=human error. Whatever is not mechanical error must be human error. This dualistic (one or the other) view has two major flaws: firstly, it takes the context out of the equation. This means paying attention to the situational demands and what happened for an accident/incident to take place at that time. Also, asking questions what were some initial soft signs, or corporate acceptance of practice that could have lead to the accident happening when it did. Context this includes the physical and organizational environment of the situation.
Secondly, the “local rationality” is not given due attention. For example, the accident (verify time and date) of the Cessna in the Swartruggens mountains were explained as “the pilot flew to low”. What lead to the pilot to make this fatal error? His decision during the difficult circumstances of mist etc. cannot be explained merely by “pilot error” or “decision error”. The label and static description “human error” only tell a part of the story. The “how” and the “why” during the ongoing incident is missing and will be needed for the whole story. The whole story is needed to understand, and not merely explain and label the “error causing” the accident.
People do not come to work and with the intention to fail or have accidents. The “bad apple” view of human beings can be called an “attribution error”. This describes the tendency to attribute motives and thinking patterns to people in negative circumstances which might be invalid. In the context of investigating accidents this means that the view of workers willfully and stupidly transgressing the rules of perfectly designed systems therefore causing accidents, might be attributing motives and thinking patterns to people involved in accidents which are an error in itself and needs closer examination.
Banality-of-accidents
Opposed to this is the “banality-of-accidents” theory. Dekker defines this as “accidents, and the drift that precedes them, are associated with normal people doing normal work in normal organizations-not with miscreants engaging in immoral deviance”. (“10 Questions”, p.24) this approach opens up questions like “why would an experienced electrician bypass the lock-out procedure?” “why would a team of operators drive their equipment as fast as they can get away with rather than consistently and knowingly keep to the speed limit?” “how does an experienced driver think that lead him to drive his hauler over the berm during a dark misty night on a coal dumb?”.
The range of “why” questions would include how management could be contributing with their emphasis on speed and production-measures at the cost of safety. For example, unsafe behavior is an embarrassment to avoid, and anyway, “it is the area of responsibility of the safety department”, whereas line management “generates the income.” The core message is “do your job faster and better” and don’t get caught doing it in an unsafe manner.” The result is that “a department” is responsible for safety as opposed to everybody having a stake in and responsibility for safety.
It is also true that accidents are not fully understood by allocating a single error to a known outcome. In the context of safe behavior experience has good news and bad news. The good news is that experience leads to unconscious competence, the basis for fast, efficient and expert level work. The bad news is that it could lead to an inattentiveness to changing environmental information, or a confidence that any change will be handled “when necessary.”
Confidence in ones ability to deal with events can invalidate (make less important) the rules of safety. “Since I know the job, have done this many times, knowing how to do it quickly, is OK under these circumstances.” Every time the person “gets away with it” they are re-establishing a new standard for how to apply their expertise. This is the source of “drifting into failure.” (Dekker, “10 Questions”, p.18) But, drifting into failure is not reserved for the experts, it also happens when the criteria for doing a job invalidates safety. For example, doing it faster and better…One company we have visited has a logo on everybody’s safety hat: faster, better safe. These three words are in a triangle, the base line being “safe”.
Managing “drift into failure” as good business
If firing the individual for making the error leading to an accident/incident, or the reprimand they “deserve”, or the retraining and effort to increase their motivation was effective, the accident statistics in South Africa would have looked better. It is known, people will always be responsible for 70 of the causation of errors producing accident/incidents. This means that if we had to add preventative thinking to dealing with the occurrence of accidents, then it starts with managing the issues conducive to how people drift into failure.
If safety were given the same attention as any other business driver, then the “expense” of safety would not be frowned upon. It would mean making “safe” an integral part of designing “faster and better” as opposed to tag safety on once the financial decision of a viable business project has been made. Changes in work-context and –conditions would immediately lead to a discussion about changes in working faster, better, safe. People would be reminded frequently how to act safely, since they are protecting an asset, namely themselves. PPE would be designed for the job, and not bought at bulk because the low price is more important than the fit for the job. There would be no “safety meetings” only operational meetings, because good business is good safety.