My son was a bit provocative as we watched the Super Bowl…
Toward the end of the Super Bowl he remarked, “This game is taking more than 5 hours!” Indeed, extra commercial breaks and halftime boogie concert didn’t help. But the reason for the exceptional delay was a power failure to the Superdome that rendered the stadium lights dark.
They stopped play for 34 minutes for safety reasons. My son remarked…”don’t they play football in all sorts of weather, snow & rain. Why can’t they play in the lower light?”
The answer undoubtedly had to do with safety. In such a dangerous, fast-paced game, limited visibility could also limit players’ ability to be aware of oncoming hazards and the risks of certain actions.
The “Super Bowl Blackout” ironically, got me to remember a recent discussion I had with a new friend while we were having dinner with his fellow corporate HSE directors overseas. He was telling me about a supervisor who had a close call with a high-pressure hose that nearly took off his head. Two years later, this same individual was teaching a new worker to do the very same procedure. This time physics was not so forgiving and the worker lost an eye.
The question to me during dinner was, from a behavioral safety perspective, how can you account for people like this supervisor who intentionally took short-cuts during a procedure that put him at risk? And, to make it worse, teaching others to do so?
My new friend was clearly personally upset with this supervisor. He labeled the supervisor with such words like “stupid”, “reckless”, and “word-that-shouldn’t-be-uttered-in-mixed-company”. I’d be upset too. This is a person whose intentional actions hurt others.
I could see that the oh-too-human drive to blame the culprit had turned out the lights on the real game at play. And once the lights are out, the true causes of incidents like these cannot be illuminated.
Consider the label “stupid”. If that’s your conclusion for an incident investigation what are you left with? You can’t fix stupid. Your left with no solutions. Worse, if we get in the habit of labeling blame we tend to use it as an easy excuse not to do the harder work of a behavioral assessment of the incident.
We go no further… we solve nothing … the incident will likely happen again, and this time take out an eye.
Instead, approach the incident with a clear understanding of the cause and effect relationships between the behaviors that were related to the risk and the reasons why that person, knowingly or unknowingly, was put in the position to take that risk.
Understand the cause of behavior and you’ll begin to see a pathway for solutions.
A) Ask critical questions around training, tool availability, equipment flaws, perceived time pressure, missed reporting, supervision, and work flow.
B) Ask yourself about the person’s experience doing the task in the past. Was the safe way to do the task cumbersome or ineffective? Did they adopt the risk in an effort to save time or trouble? What can be changed in the task to alleviate the “costs” of the safe alternatives.
C) Then take a close look at your Safety Culture. Was this person told how to do the risky short-cut by others? Alternatively, would a peer be likely to stop and coach the person if they saw the risky behavior occurring?
As my friend and I started drilling down into the supervisor’s behavior we started getting an audience of his fellow HSE leaders. The lights had been turned on.
We discussed equipment and tool changes that could help make the risk avoidable. We discussed how the older generation had grew up in a safety culture where supervisors taught short cuts and encouraged them. They now saw a need for targeting supervisor refresher training and safety selection methods of promoting new supervisors.
Then we got to what I considered a root cause. Evidently, when the supervisor had done the shortcut in the past and barely avoided personal injury himself, a Close Call report was completed on the incident. In fact, this close call was flagged as “High Potential” for serious injury or fatality.
The Close Call report concluded “Human Error” as the cause of the high potential incident.
Then, of course, nothing happened. The “Close Call” was filed, the supervisor was talked to, and the work went on, only to have the risk repeated ... how many times by how many people? You don’t know – no lights.
When we shined the lights on the Close Call reporting system we concluded that it needed to be fixed. It was too easy to blame the worker and not uncover truly actionable changes to the work and the work system that could have stopped the risk from happening, not only with this one individual but throughout the workforce. The Close Call system had to be actionable, it wasn’t and the incident was forgotten…until two years later.
If you have “Human Error”, “Human Factor”, or “Stupid” as an option in your incident investigation forms it is all too easy to just stop there, turn out the lights, and keep on promoting the environment that caused the risk in the first place.
“If you accept a life of labels, you can go through it moving not among things but among words.” ―William Golding