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POSITIVE SAFETY CULTURES: Being mindful of safety

June 1, 2007
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Repetitious or assembly line jobs can lower alertness levels.

As important as it is to be well trained, to have good equipment to work with and safe conditions to work in, it is also essential that workers be alert and conscious of their surroundings as they go about doing what they know how to do. The critical attentional variables are sometimes summarized in the research and practice in behavior-based/people-based safety as “mindfulness.” It is critical that people who are working safely stay mindful of what they are doing, and of the conditions in which they are working, and act consistently with that mindset.

Mental shutdown
But here’s the problem: The more practiced and experienced we become with a task, even an incredibly complex one like playing a musical instrument or operating an automobile, the less mindful we are of what we are doing and how we are doing it. It is truly like being on autopilot.

Researchers have coined the term “highway hypnosis” to describe that familiar state in which an experienced driver may cover several blocks or many miles without “paying attention” and without storing anything that happened in the last x minutes (Did I stop at that stop sign a few intersections back?).

I have done lots of management and leadership training over the years. One of the conceptual models of adult learning that we use says that the highest level of learning has been achieved when skills are at the level of “unconscious competence.” By that term we mean, we do something well (give corrective feedback, show good active listening, do a developmental delegation to the team) without having to stop and think about it — we automatically, reflexively “do the right thing.”

The learning model is widespread. But it doesn’t fit so well in situations where there are safety risks. Paradoxically, one of our biggest enemies can be the complacency that comes from being thoroughly familiar with and routinizing work around potential hazards. Indeed truly effective safety training must include strategies that take our performance off autopilot and re-engage the mind. We have to check back in with “conscious,” mindful competence.

When you least expect it…
Some years ago I was part of a consulting team that was asked to develop an effective lockout/tagout training program for an industry-wide oversight group. The industry had suffered a spike in lockout-related incidents, including several fatalities over a 12-month period. Before building a “here’s how you put a lock on a power switch” training program, we asked for the opportunity to come in and study the issue a bit.

While there were many scenarios in the accident reports we read, and many possible causes identified by the focus groups of operators and maintenance folks we interviewed, one surprising common pattern did emerge. The most common incident scenario involved a skilled, experienced, high seniority maintenance technician on a routine maintenance job, or a familiar repair job, doing something he had done time and again. Throw in something a little out of the ordinary — a fuse that won’t come out, a missing tool, a helper who is late for his shift, preoccupying problems at home — and the situation becomes even riskier.

In fairness, there were some “new on the job… never seen this before… didn’t know what to do” type incidents, but they were the exception, not the rule. More often it was the guy you would least expect to be involved in an accident – the Class A electrician, best in the shop – doing something he knew full well how to do.

Familiarity breeds…
I recently went on a safety audit, in which a couple of hourly workers, a supervisor and I watched a three-person welding team doing some heavy repair work. They were experienced, highly competent professionals, working in a coordinated way, simultaneously, on different parts of a very large piece of equipment. It was just amazing what they were able to do with a welding torch!

When we had the chance to talk with them, I asked a “how do you know where the other guys are and what they are doing while you are working over here?” kind of question. Their response was, “We have worked together for a long time… we know what the other guys are going to do.” As true as that may be, they were describing the very conditions that make it critical to stay mindful.

The real challenge
So often the trick to safe work is not so much teaching workers what to do, how to do it, and what to watch out for (important as all that is). It is teaching workers, especially the most experienced, how to stay mindful of their work, when they have “done it a thousand times.”

Workers should always have an explicit game plan, even for a fairly routine job, such that everyone knows his part, and how we will work together to achieve the goal.

It is essential that they communicate — before, during and after a job. The before-communication includes going over the game plan, identifying any hazards, and making sure that all are on the same page going in. The during-communication part aims at creating accurate shared situational awareness, as they say in Crew

Resource Management (CRM) programs. Communicate to make sure everyone involved has the same big picture —– knows what we’ve got and how we are dealing with it. Also borrowing from CRM, use so-called “repeat backs.” That is, when Jack says to Ben, “Put a clamp on the v-line,” Ben says “clamp is on the v-line” instead of “uh-huh” or saying nothing. That way we all know that the request/direction was received as sent, and is being acted upon correctly.

For the after-communication, there should be a de-brief — how did we do as a team, did anything unexpected happen, what could we have done better, how will we improve next time, etc.

When something seems “off”
It is also especially important that workers identify and react to any off-normal situation. Recognize that a common denominator of many accident scenarios is “a little something out of whack.” Whenever such a circumstance occurs, stop action, step back, communicate and remain especially mindful and on the alert. Off-normal conditions should make all the sensors come out.

As much as habit is “the great flywheel of society” as the philosopher and pioneer psychologist William James said over a century ago, it also can be the enemy of safe work. Mindfulness must be a central concept that safety professionals teach and live.

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