It’s time for a New View of safety
Focus more on positive outcomes & systems, less on bureaucracy and human failure.
Do we need to do safety differently?
It’s long overdue, according to Dr. Sidney Dekker, who in 2014 wrote an essay on “The ‘Failed State’ of Safety.” Yes, says Corrie Pitzer, who is giving a talk, “Safety at a Dead End” at the American Society of Safety Professionals’ annual conference this June.
ISHN asked more than 20 safety professionals, consultants, academics and authors for their opinions about six tenets of the so-called “new view” of safety. It’s also referred to as “Safety Differently,” “Safety-II,” and includes human and organizational performance (HOP) practices.
By any name, the “new view” is more a philosophy and mindset than any single program. New safety tactics and strategies are flowing out of this new mental model. It is anything but another “flavor of the month” program or slogan -- something here today, gone tomorrow.
The “new view” or doing safety differently has been written about in books, discussed at workshops, and even made into YouTube documentaries. But U.S. safety and health pros – and companies – are just beginning to get wide exposure to the differences between traditional safety and safety v2.0.
So what do our survey respondents have to say about six of the pillars of this new way of thinking about safety?
Safety is at a dead-end and is a “failed state.”
Proponents of doing safety differently make several arguments here. Safety and health performance in the U.S. is stagnating. Both in terms of metrics and fresh ideas. Even companies with excellent EHS performance are frustrated by their inability to reduce the most serious injuries and workplace fatalities.
In millions of U.S. workplaces, especially smaller businesses, the focus remains as it has for decades: rulebooks; compliance; policing; PPE as the first line of defense; and command and control, top-down, “do-as-I-say” safety bureaucracies. These practices, the argument goes, continue to leave too many safety and health departments isolated and detached from mainstream business imperatives.
Not surprisingly, some pros see marketing-driven shock value in proclaiming safety a failed state and at a dead end. “I absolutely and unequivocally disagree with this,” says Ryan Gilmore, human resources and safety director for B&B Fabricators, Arlington, WA. “Just because safety is not easy we don’t give up. We work together and do everything to steer our safety programs in a positive direction.
“The safety profession is replete with its share of pessimists,” says Mark Hansen, director of risk management, Contek Solutions LLC. “Safety success is a marathon, not a sprint.”
“Quite the opposite; I believe emerging technology will result in even greater reduction in injuries over the next several years and decades,” says Aaron Rowland, an EHS supervisor.
Safety is more than identifying and managing things that go wrong. The focus should be on the 99.9% of the times things go right, and learn from these successes.
“New view” advocates are distressed by the profession’s decades-old embrace of recordable incidents as the measure of performance – in many companies the only measure that counts. This over-emphasis on the numbers leads to unethical management, suppression of incidents and injuries, and over-specified and over-prescribed rules, they claim. Plus, traditional recordkeeping numbers give safety a negative image. Top management think of safety in terms of accidents, risks, hazards, OSHA violations, human error and unsafe acts, because that’s the language many safety pros speak.
A key principle of doing safety differently is that this focus on negative outcomes results in most of organization life going unexamined. Safety and health departments need to identify and learn from things that go well. What makes for successful confined space entries, lockout-tagout procedures, and safe work at heights? What makes most work come off without a hitch? Study and learn from how normal work processes get the job done – almost always without incident. Communicate these positive learnings up the chain of command to show top managers the value and advantages of safe work.
Many professionals are coming around to a proactive, positive attitude toward their work. They “get it.” Safety needs to pivot away from fishing for faults and the goal of finding and mitigating errors. “Safety is much more than identifying and managing the things that go wrong,” says Gilmore. “Focus on successes and positives.”
“To increase teammate ownership, focus on the actions people take to protect themselves and others,” says Rowland. “Show off their successes, give them positivity, and they will keep working on the goal of incident prevention.”
Safety too often views humans as a weak link, a liability or a hazard.
Blaming the injured victim is the path of least resistance in many investigations. Concluding that human error or unsafe acts are the culprits, the primary cause of failure, saves time, wraps up incident analyses quickly, and gives management the easiest of answers. Just discipline, retrain, or terminate.
Again, more safety and health pros are seeing the fallacy in this approach. “We are ‘human beings,’ not ‘human doings’,” says Deborah Grubbe, owner and president of Operations and Safety Solutions. “We get it right much of the time.”
“It’s easy to blame the worker. It’s harder and ultimately more beneficial to analyze an incident to find multiple systemic breakdowns,” says Abby Ferri, CSP, president of The Ferri Group LLC.
Systems thinking in safety is nothing new. Same with complexity theory, human factors, high reliability organization theory and resilience engineering. But safety v2.0 emphasizes that today these approaches are more relevant than ever. Technology, robotics, artificial intelligence, the Internet of Things and smart factories make operating systems and process more complex and shape-shifting than ever.
Posters, safety slogans and songs, compliance controls, a rush to do observations at the end of the month are not going to uncover how conditions, systems, upstream decisions and complexities influence behavior, say new view proponents. They stress looking for sources of variability – frustrations; constraints; unrealistic time pressures, schedules, goals; too many rules; poor communication; lack of resources; inadequate defenses; design shortcomings; degraded, poorly maintained processes – and enable workers to respond to system variabilities positively and safely. Developing and sustaining situational awareness is a key.
Rather than focusing on individual workers and conditions, pros should expand their view and identify drivers, complexities and the entire context of the system as causes of incidents and failures.
People inevitably make mistakes. Human error is normal, Obtaining and sustaining zero incidents is impossible.
The new view of safety is not particularly vested in the goal of zero incidents. Zero incidents is oriented around numbers, cases and recordables. Doing safety differently means pivoting away from these lagging indicators of performance – getting away from an obsession with numbers.
Zero incidents is akin to the idea of “safety first.” Workers know the truth. Profits come first. And achieving zero incidents is possible for a period of time, but “impossible for any length of time,” says Dr. Timothy Ludwig, psychology professor at Appalachian State University. “Instead of counting down to zero we should be counting up all the safe actions as we adapt our human behavior and safety systems.”
“Zero injuries is a wonderful goal, but we need to be forgiving when an injury does occur,” says Dr. Krista Geller, president of GellerAC4P. “Find out the contributing factors, the error precursors and anything else that might have contributed to the event.”
Punishment fails as a tool for improvement. It suppresses reporting, speaking up, and learning.
If people inevitably make mistakes and human error is normal, punishment is not a tool for improvement, holds the new view. But “punishment” comes off as cold, even cruel, as opposed to “corrective feedback” and “progressive discipline.” Many pros make this distinction in definitions.
“No question punishment promotes a culture in which reporting is non-existent,” says Gilmore. “Speaking up about safety issues is completely discouraged; there’s no incentive to learn.”
An equal number of pros will add a “but” here, a caveat.
“But I have had to dismiss a handful of individuals who simply refused to come on board with the safety program,” says Gilmore. “These were cases that leaned to the extreme and are the exception.”
“Disciplinary and accountability actions, if used the right way, can result in improvement. The key phrase is: used the right way,” says Rowland.
It is more useful to know how an accident happened than knowing why it happened.
Doing safety differently shifts attention from “why” an incident occurred to “how” it happened. Learning is a fundamental tenet of the new view, and gaining insight and understanding to prevent incidents requires close study of how work actually gets done -- in reality -- not work as imagined or drawn up in a playbook. How do workers successfully adapt to changing conditions? How do they get the job right 99.99% of the time? How are successful outcomes achieved?
“Researchers or scientists typically avoid ‘why’ questions, and focus on ‘how’,” says Dr. Scott Geller, psychology professor at Virginia Tech. “How” uncovers the environmental factors, past or present, that enabled or motivated the occurrence of an event, behavior or attitude, says Geller. “In my view, clinicians and spiritual leaders deal with answers to the ‘whys’ of life and death.”
Many pros, while no longer so wedded to the old “5 Whys” line of root cause analysis, are pragmatic. “We need to know both ‘how’ and ‘why’ equally,” says Hansen. Knowing one without knowing the other leaves pieces of the puzzle missing, he says.
This is an example of how the new view or doing safety differently have no intent of tossing traditional safety practices in the dust bin. Advocates are quick to point out new philosophies and models complement tried-and-true staples -- not supercede or eliminate them. Continue to write rules and enforce procedures. Just don’t write tomes. Continue to audit, find and fix hazards, train employers and analyze incidents.
But don’t put it all on the safety department. The new view holds that safety is a system of interactions involving leadership, culture, processes, training, supervision, design and more. Safety is not housed in one department. It’s integrated into almost all areas of the business – procurement, contractors, maintenance, operations, engineering, human resources, legal and senior leadership.
Some pros see this as a threatening diffusion of their power. For others, integration, alignment and making safety invisible has been their thinking all along. And they will tell you, in essence, that they have been doing safety differently for years.
“An idea whose time has come”
ISHN interviewed by email Dr. Sidney Dekker, professor, Safety Science Innovation Lab, Griffith University, Brisbane, Australia, and author of “The Safety Anarchist” among other books. Dr. Dekker posts regularly at www.safetydifferently.com and is one of the founding fathers of the new view of safety.
“Over the past two decades, we have not seen any progress in reducing fatalities across many industries. Yet during those same two decades the amount of safety bureaucracy (petty rules, a growing clutter of procedures and checklists and invasive surveillance of frontline work through technologies everywhere) has doubled or even tripled. The problem is not going away. It is staying stubbornly the same.
“All these new ideas are pointing to us interfering less with how work is actually accomplished, and instead asking operational frontline people what they need to get it done safely (rather than safety professionals telling them what to do through all kinds of compliance). Safety professionals can actually feel a bit threatened by all this. It might have consequences for the relevance and importance of their role, after all.
“There is a groundswell of adoptions of these kinds of approaches. You can see this in incident reports, for instance, where it is increasingly illegitimate to say that ‘human error’ was the cause: people are demanding more explanation than that. How did the organization set the worker up for failure? Not many organizations have figured out yet how to learn from things going right, but we do see progress there.
“The greatest obstacles to progressing to Safety Differently include a fear of regulatory authorities that demand compliance (like OSHA), the opposition from safety professionals themselves who might see their influence diminished, and the fears of boards and managers of losing control over ‘accountability’ in their organization.”
“Nothing much foundational has changed”
ISHN interviewed by email Corrie Pitzer, CEO of SAFEMap International.
“Safety has been at a dead end before, or so claimed Dan Petersen, way back in 1975, when he stated that the ‘human era’ is (was) upon us. Yet, for the past few decades, maybe even since the 1970s, nothing much foundational has changed in safety management. We still set up a manual of policies and rules of work, set performance standards and require compliance – all with the same focus: to control and or modify behavior, especially that of the front-line workers.
“The way we define and measure safety has NOT changed. That executives and management are still rewarded for safety, as measured by accident rates, and we still show trendy graphs on injury rates, even at board meetings! I have not yet seen a business, any business, that defines safety in any other way.
“Safety is killing business. We are the millstone around the operation’s neck because it goes against everything we want the business to be: To be more efficient, smarter, leaner, more profitable. We want an agile production system that allows risk-taking and experimentation, in order to innovate, to prosper, to change and improve. We need people to be adaptable, operational systems to be flexible and performance goals to be stretched to the limit.
“Henry Ford famously said: “If I asked people what they wanted, they would have said, a faster horse.” If he asked the safety directors what they wanted, the answer would have been: ‘A slower horse.’
“Sadly, we are not part of the success, reach or stretch of the business, we are part of its restraint, its containment, its failures.”
“The OSHA stuff does not help small organizations”
ISHN interviewed by email Dr. Todd Conklin, author of “Better Questions,” among other books. He is a retired senior advisor at Los Alamos National Laboratory and one of the foremost authorities on human factors and human performance.
“If you ask bad questions you get bad answers. So one way to be better (that is more effective and meaningful) is by pulsing, validating, asking, looking at the right stuff. Our questions traditionally have been very focused on worker behavior - because we believed that worker behavior was the problem. Those questions always lead us to the same damn stuff. And that damn stuff does not make for long-term, sustainable improvement.
“The push is to get industry off the outcome bias. Safety is never (nor never will be) an outcome to be achieved. Safety is never over - you know that. Every day the clock starts again, so to speak.
“Shift the question from ‘who failed’ to ‘what failed’? Don't look down and in but look up and out. You will find new stuff to fix, and that is really refreshing.
“For way too long we have treated the workers as if they are the problem with safety. That is crap. The workers create safety all the time in all types of conditions. Pursuing the context of how work is done is vital to understanding how both success and failure happen.”