Columns

SYSTEMS THINKING: Safety & health worst practices

August 4, 2009
/ Print / Reprints /
ShareMore
/ Text Size+


One does not learn from doing something right, but one can, although not necessarily, learn from doing something wrong, by making a mistake.
— Russell L. Ackoff, Ph.D.


For the sake of this discussion, I propose to define the term worst practice as processes, approaches, or activities that have been shown through research, evaluation or experience to be ineffective, inefficient or counterproductive, resulting in undesirable outcomes. Remember, for every best practice there is an equally opposite worst practice.

Unintended Side-effects of Safety Fixes (Adapted from Carroll 9)

Worst practices Hall of Shame

Some of the foremost reasons individuals commit worst safety and health practices include:

Beating the system: Employees who fall into this pattern of behavior believe in the axiom that “if I don’t get caught, I didn’t break the rules.” 1

Behaving unethically: Frequently, safety and health professionals find themselves in “no-win” situations. These “no-win” situations are accompanied by work pressures, peer or supervisor pressure, or offsite pressures.2 Common rationalizations described by Sims, et al. include, since it helps the organization, the organization will condone it and protect me; or it’s in our best interest; or it’s not really illegal or immoral; or, my favorite, no one will find out.3

Failing to learn: Many organizations are afflicted with “organizational learning disabilities.” They fail to learn from others’ accidents and, worse yet, fail to learn from their own accidents, even catastrophic ones.4,5 Prominent examples include NASA’s Challenger accident in 1986, followed 17 years later by the Columbia accident in 2003. In both accidents, the underlying cause was the normalization of risk (i.e., a mindset that partial malfunctions were considered normal).

Andrew Hopkins drives this point home in his comparison of BP’s Grangemouth, Scotland petrochemical plant accident in 2000 and BP’s Texas City Refinery accident in 2005.6 In both cases, investigators stressed the need to emphasize a persistent focus on the application of process safety management.

A caveat: Research in ultra-safe systems (e.g., commercial air travel) has revealed continued elimination of mistakes can paradoxically lead to a decrease in safety.7 The keys to learning from and adapting to existing and past safety and health worst practices is having an organization open to this form of scrutiny and diagnostic analytical tools to systemically assess all aspects of a worst practice.

Diagnosing a worst practice

A number of systems thinking tools can serve to diagnose a worst practice. One such tool is the modeling feature found in System Dynamics.

System dynamics is used to describe and dissolve problem behaviors in socio-economic systems through the use of feedback loops, which serve as a framework for dealing with dynamic complexity.8 Marais, Saleh and Leveson have developed safety system archetypes covering most underlying systemic patterns we face when analyzing an accident. These archetypes include:
  • Challenges of maintaining safety: Stagnant safety practices in the face of technological advances; Decreasing safety consciousness; Eroding safety goals (i.e., disappointing safety programs not living up to expectations); Complacency (i.e., operations without incidents leading to complacency).
  • Side effects and symptomatic responses: Unintended side-effects of safety fixes (i.e., unsuccessful problem resolution); Fixing symptoms rather than root causes; Improperly designed reporting schemes.
  • The vicious cycle of bureaucracy. To give you a sense of a system dynamics model, take a look at the following model that depicts the “Unintended side-effects of safety fixes” archetype.

    In this archetype, Marais, et al.’s situation involves a plant experiencing an increasing number of equipment breakdowns attributed to poor maintenance practices.10 A typical “fix” for a maintenance problem is to write more procedures (B procedure fix) and disciplining workers (B discipline fix) for non-compliance. The “B” stands for Balancing Loop, which represents moving from a current state to a desired state. These fixes often lead to reinforcing loops (R distrust) and (R complexity), which ultimately leads to making the equipment breakdowns worse. The “R” stands for Reinforcing Loop, which represents action that feeds on itself to produce growth or decline. The unintended side-effects are the workers’ reduction in trust toward management for monitoring their compliance with the procedures, the loss of workers’ motivation to problem-solve on the job and workers’ blind or malicious compliance with procedures even if they are incomplete or incorrect.

    One reminder: be sure to expand your search beyond mere proximal causes, such as technical issues or human errors, to include systemic patterns (i.e., root causes and contributing factors) in order to ensure the entire workforce will support and live by the implemented solution.


References

1 Ackoff, R.L. 1999. Re-Creating the Corporation – A Design of Organizations for the 21st Century. Oxford University Press. New York, NY.

2 Schneid, T.D. 2008. Corporate Safety Compliance: OSHA, Ethics and the Law. CRC Press. Boca Raton, FL.

3 Sims, R.R., J.G. Veres, K.A. Jackson, and C.L. Facteau. 2001. The Challenge of Front Line Management: Flattened Organizations in the New Economy. Quorum Books. Westport, CT.

4 Hopkins 66.

5 Hale, A., B. Wilpert, and M. Freitag. 1998. After the Event: From Accident to Organisational Learning. Emerald Group Publishing LTD. Bingley, UK.

6 Hopkins 66-67.

7 Amalberti, R. 2001. The paradoxes of almost totally safe transportation systems. Safety Science. 37(2&3):109-126.

8 Marais, K., J.H. Saleh and N.G. Leveson. 2006. Archetypes of organizational safety. Safety Science. 44 (7): 565-582.

9 Carroll, J.S. 1998. Organizational learning activities in high-hazard industries: the logics underlying self-analysis. Journal of Management Studies. 35 (6): 699-717.

10 Marais, et al. 576-577.

Did you enjoy this article? Click here to subscribe to ISHN.

Recent Articles by James Leemann

You must login or register in order to post a comment.

STAY CONNECTED

Facebook logo Twitter YouTubeLinkedIn Google + icon

Multimedia

Videos

Image Galleries

ASSE Safety 2014 Review

A gallery of photos from the sprawling Orange County Convention Center in Orlando, where ASSE’s annual professional development conference was held June 8-11. All photos courtesy of the American Society of Safety Engineers.

9/9/14 2:00 pm EDT

Welding: It doesn't have to be a grind. The latest in respiratory protection and PPE for welders and grinder

Attendees of this webinar will gain knowledge of hazards and appropriate PPE for welding applications, regulatory drivers that are changing the landscape of PPE within welding applications and the latest product technologies being offered in welding PPE.

ISHN Magazine

ISHN_0814cov.jpg

2014 August

Check out ISHN's August issue which features content about pain prevention, forklift operation safety and a preview of the National Safety Congress and Expo.

Table Of Contents Subscribe

THE ISHN STORE

M:\General Shared\__AEC Store Katie Z\AEC Store\Images\ISHN\safetyfourth.jpg
Safety Engineering, 4th Edition

A practical, solutions-driven reference, Safety Engineering, 4th edition, has been completely revised and updated to reflect many of today’s issues in safety.

More Products

For Distributors Only - May 2014

ISHN0514FDO_cover.jpgFor Distributors Only is ISHN's niche brand standard-sized magazine supplement aimed at an audience of 2,000 U.S. distributors that sell safety products. Circulation only goes to distributors. CHECK OUT THEMAY 2014 ISSUE OF FDO HERE

ishn infographics

2012 US workplace deathsCheck out ISHN's new Infographic page! Learn more about worker safety through these interactive images. CLICK HERE to view the page.