Reason, James (1990). The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 327(1241): 475–484.
Safety systems have barriers (filters) which help prevent injuries and incidents. These include management systems, working conditions, and human behaviors. In a 24/7 operation, or any other for that matter, these filter plates are spinning as the work dynamic and process relentlessly continue. However, each filter piece has some holes (weaknesses) in it, and when the spinning holes line up, an incident occurs. When someone is in the wrong place, at this wrong time of weakness alignment, an incident (near miss/close call) or an injury (hit) also occurs. Aaron realizes that his employing organization has way too many holes in its safety barrier filters.
He remembers his friendship with an excellent skier, Tim, who gave him a great lesson in the facts of achieving performance greatness. Tim loves skiing moguls and by his own standards is “pretty darn good at it.” In an effort to improve his abilities, he paid for coaching from a professional skier. Much to Tim's chagrin the pro's evaluation of his “pretty darn good” technique and ability came back as “a closely linked series of recoveries.” They had a good laugh, and then discussed another acquaintance who decided to become a pro golfer even though he never really played golf until later in life. His professional coach advised a need for 10 000 hours of concentrated practice to raise his skills to a point where he could make a valid decision, whether or not “to continue to try and become a pro golfer.”
Tim and Aaron reached some conclusions out of their dialogues about professional performance. You need dedication, practice, drive, ability, good technique, and a relentless pursuit of excellence to even come close to the execution levels of professionals. These dedicated professionals are able to daily achieve measures accomplished by only the best of the best. Or in street language; “My commitment is stronger than a bumper sticker, but less than a tattoo” is just not good enough to get anywhere near great results.
Is there any parallel in safety performance? You bet! Those organizations which routinely go years without lost time or medical incidents have a leading edge engagement culture that has their entire organization focused on dedication, practice, drive, technique, and daily safety leadership development at all levels. This kind of safety culture delivers an end result which visibly demonstrates a relentless pursuit of zero errors (incidents). Every day they practice and live models of process excellence in operations AND safety. They are always in search of ways to improve their performance in every aspect of what they do, including safety. They do the fundamentals well and then go way beyond the basics. The rest of the pack of safety professional wannabes, who have safety cultures that are pretty darn good, seem to just live a culture where there is a closely linked series of recoveries instead of emphasizing a culture of prevention excellence.
Aaron racks his brain. It all seems so hopeless. He begins to dig deeper on many of the other road blocks that stand in his way of stopping the injuries of his friends in the field. Aaron needs to make a choice: “Never, never, never give up” thank you very much Winston Churchill or “When you wake up tomorrow you will still be ugly.”
Notes
1 1 RIF Recordable Injury Frequency ([number of injuries requiring medical/doctor treatment] x 200 000) divided by total hours worked.
2 2 The Voluntary Protection Programs (VPP) recognize employers and workers in the private industry and federal agencies who have implemented effective safety and health management systems and maintain injury and illness rates below national Bureau of Labor Statistics averages for their respective industries.
3 3 James Reason (2000) proposed the image of “Swiss cheese” to explain the occurrence of system failures, such as medical mishaps. According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese. These weaknesses are inconsistent, i.e. the holes open and close at random. When by chance all holes are aligned, the hazard reaches a person and causes harm.
4 4 This additional publication material is “Reason, James (1990). The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 327(1241): 475–484”.
2 No Support for Safety
The week after the funeral Aaron tries to de‐stress by going out to dinner with his wife. As he sits down the images of the funeral, the fellow workers, the widow… flood into his mind. As he crumples into the chair, internal emotion erupts and he bangs his head repeatedly on the table. Finally, he gets back into some small level of mental control, but couldn't eat. They apologize to the waiter, and Aaron's wife drives toward home as he struggles with the impossible task staring him in the face: neither management nor labor is willing to do anything to improve their miserable safety record. Sure, there is no lack of talking heads and condemnation on both sides. However, a decade of complaining without any substantial actions has delivered absolutely nothing (no improvement) to any real safety culture or employee injury reduction.
Back at work, Aaron chairs this month's joint safety committee meeting. As ever, the union and management safety leadership sit on opposite sides of the table and the joint safety meeting becomes a classic grievance meeting. The union vice president pulls out a three‐page typewritten list of complaints that has not changed substantially from last month's list, or the many similar ones from months before. Two hours later the bickering comes to an end as the lunch hour signals the end of another worthless union‐management monthly joint safety battle. Aaron looks over the latest union three‐page condemnation of management inaction. He cannot blame the union for continually bringing up the lack of any action on numerous small and large types of items such as a lack of adequate lighting, or no training of emergency crews who participate in emergencies, or, or, ad infinitum. The union leadership rightfully believes this lackadaisical, no action management culture to be the precursor to injuries and near misses/close calls which continue to occur. Aaron mentally reviews the OSHA 300 log and sees numerous repetitive injuries which could have been prevented if they would have spent some discretionary dollars on simple things such as lighting, barricades, and correct boom tool attachment.
In truth, management wages a constant battle for any safety spending to support this 1000+ employee company. In their view safety is a cost center which lacks any Return On Investment (ROI). Aaron replays the management diatribe in his mind: “We just pour dollars in while counting injuries, Workers Compensation (WC) costs, and payroll costs.” He knows that WC costs have averaged up to and beyond a million dollars/year for more than a decade. Why cannot management understand that fixing these small and large problems would save an incredible amount of money and improve net profit? These fixes would also eliminate the intense amount of pain experienced by frontline workforce employees as a result of last year's 39 lost time injuries. Additionally, these fixes that result in many fewer injuries would also greatly improve employee morale. Why cannot the union leadership pitch in and fix some of the issues that face them every day, instead of making up next month's “no‐action list” and rubbing it in the face of their opponents? Aaron begins to realize a sports analogy: there is an intense offense and an intense defense, but no team work. Consequently there are no victories to celebrate because status quo is all that is expected. The organization continually lives a WYSIWYG culture (what you see is what you get) as the two dysfunctional organizations routinely lock horns in an ongoing rutting contest, which just keeps rolling on at a miserable Recordable Injury Frequency (RIF) of 10+.
