After having observed the fact that on two sites with different clients, the frequency of small incidents increases after a critical or fatal accident, we started researching this phenomenon. The question asked by the researchers was: why would the frequency of minor incidents increase? In a way it is counter-intuitive, because wouldn’t most people now be more cautious? What follows is a description of how to understand and deal with this event.
At the time of writing this article we have information of 7 companies confirming this. These companies are from the mobile equipment, electronics, manufacturing and transport industries.
The first observation happened after a fatality on a site which had close to 3 million LTI free hours. The incidents in other businesses were different but for some weeks after the incident a number of minor incidents occurred. These incidents were unusual for the site and included minor accidents between loaders reversing into each other, scrapes on equipment and slight property damage due to inappropriate tight cornering, people tripping over debris and cutting hands and fingers.
A second consequence of a critical incident is natural but seems to support the climate for minor incidents happening, namely the informal stories about the event, the activity around the investigation, and management’s response to the event in the form of meetings, new procedures, threats etc.
We had to deal with a few truths about safety to understand this occurrence.
- Safety is not random, but happens by design. The way people work at successful sites is that their behavioral practice is happening at an unconsciously competent level. This unconscious competence includes the necessary safety “rituals”.
- The unconscious competence characterizing safe work habits includes an effective awareness of contingencies, or the “unusual,” which requires new thinking and new behaviors.
- The “design” of safety seems to be the results of constantly adhering to building blocks which, as a gestalt, produces safety. Safety is not merely a recipe, it is more like a fruit salad of components which as a whole is safety producing.
- Safe work practice is worded as “the way we do things around here.”
- Co-workers hold each other accountable for safe work methods, and if dealing with it at a peer level is not effective, it would escalate to the next or supervisor level.
With the attention given to a critical incident this natural rhythm of unconscious competence gets disturbed, and people start to pay selective attention. Unconscious competence in safety includes a way for workers to adapt to the complexity of the challenges made, like the trade offs required between safe and productive. When this rhythm gets disturbed it is as if they slide back on the learning curve and for a period become “slow” by paying attention to what to avoid as opposed to the whole recipe for being safe. This is typical when people work at a consciously competent level in the learning curve when they do the task piecemeal or according to a slow deliberate sequence.
The anchoring of the incident through the attention it is getting by management, the investigations etc. contribute to people paying attention to the one, or one big thing, at the risk of getting back into their habitual safe thinking and doing mode.
Post Incident actions:
- Remind people of the basics and the existing safe ways of doing the work.
- Whatever new systems or procedures has to be introduced, emphasize it’s “add-on-value”.
- Only if it replaces old practices, then talk of replacement, or the “new” way.
- Introduce the changes slowly after people have been reminded of the old working-thinking-doing methods. Be careful to not get a “throw the baby out with the bathwater” message across, since it implies a relearning, and going back on the learning curve to absorb what is new.
- Train people to recognise the cues and conditions for the extra caution, or new behavior or application of new rules. This “contextualisation” helps people to be ready for the “when” of the new with the confidence to still rely on what worked.
- Retraining to include recognise same, recognise difference, and clear descriptions of the operational behavior required.
- The people who have drifted into an unsafe margin when doing their work will either learn and move into more effective safe behavior, or they will justify their unsafe practices. This justification may be made in a way to convince the others, so keep finger on the pulse for unsafe messages in the grape vine.