Читать книгу Delivering Safety Excellence - Michael M. Williamsen - Страница 15

Aaron is physically sick to his stomach as he attends the funeral of a 37 year employee who fell to his death at work on the weekend. As he stands just behind the tearful widow, Aaron and his fellow employees are equally in tears. This was their close friend who was known for a good work ethic, reliability and friendship. Aaron, the organization's new safety manager, could see it coming with a Recordable Injury Frequency (RIF)¹ of >10 for more than a decade, and yet the company leadership just kept doing the same thing and hoping for different results. Aaron's day only gets worse as he feels the guilt of living in a sick culture of denial that has now taken the life of a good friend.

Do you ever experience something that is wrong, something that you try to hide? To some extent we all do! Personally, an experience such as this brings to mind recently working in a third‐world country with a “challenged” work environment, while also traveling with family members after the work assignment. There were many excellent sights, people, sounds, and events wherever the vacation travels took us. And yet we experienced multiple troubles as well. While viewing a raging, dangerous river in a remote village the guide, Dalmiro, related that this was the location of a significant international extreme kayak event each year. Dalmiro then revealed that besides the boulders there was an added, hidden danger; the village of 10 000 or so people had no wastewater treatment and all the raw sewage was also a “secret” part of the raging river!

This “secret” comment brought to mind the story of a family member and her childhood obstinacy about eating certain foods. She hated hamburgers and refused to eat them. Her parents would “park” her at the table until she finished her meal. However, acting like the child she was, she crossed her arms and pouted. When her parents left the table, she would toss the meat behind the refrigerator and after a while call out to say she was done. All were happy as long as the subterfuge continued. One day her father cleaned behind the fridge, and the deception came to an end.

Unfortunately many people in the safety profession have experienced organizations which have hidden the ugly, rotten, stinking truth about their culture of employee injuries. The subterfuge works for a while and then……

Give some thought to your personal and organizational circumstances. In the long run there is no escape from reality. You cannot hide the truth because untruths will eventually be revealed. Let us be ethical in all we do; you shall know the truth and the truth shall set you free. The upper management approach of Aaron's organization of hiding injuries was living in denial. Their solution to injuries was to send injured workers to Employee Relations (ER) for a multi‐month review to see if punishment was warranted. This was truly counterproductive in many ways. Rather than focusing on what we all can do to eliminate a similar event from happening in the future, there were no reports of lessons learned, or issues resolved by searching out and identifying the actual blame. Additionally, the union and management both came to the same tragedy enabling conclusion – which was a lack of support for safety, and a lip service only approach to an understaffed safety department, eliminates trust and credibility. This denial approach only adds to the problem culture which continues to deliver the next series of painful injuries. Additionally, even if things do improve, beware, the lack of trust legacy hangs on for years. Our hourly and salaried people do not forget or forgive easily. Aaron has noticed that when there is an injury or mistake, there is always a contingent of the employees, at all levels, who immediately go back to the old paradigm of blame and shame. This included the ER function which was comfortable with the search for blame, and the potential for punishment. Change does not come easily.

The classic control, passive aggressive, old school challenges normally exist in these situations, and in other departments as well. Aaron's solution needs to not become angry, vindictive, or to go behind management's back. Rather, Aaron will have to persevere in upholding his values and his responsibility to do the right things that are effective in helping to resolve the safety and interpersonal issues. A part of this approach will require him to carry on a dialogue with the new incoming chief executive officer (CEO) and his staff. Aaron must use this method if he is to get them to support his desired approach to develop root cause solutions and a subsequent culture that includes a sustainable safety excellence commitment dedicated to significantly reducing injuries and associated incidents. It is no surprise that about 90% of these injuries happen in the operations group. As a result, Aaron will need to develop a solid adult‐to‐adult relationship with the operations hourly and salaried leadership personnel. Considering the history of the company, making such a turnaround in relationship excellence will not come easily. You will need slow and steady perseverance, Aaron.

After the funeral, Aaron is back at work and pulls out a report written by “the Doc,” a consultant he hired to interview more than 100 hourly and salaried personnel in Aaron's organization of more than 1000 employees. The report refers to honest one‐on‐one input from the whole range of hourly through salaried employees who discussed their organization's safety and morale truths with the Doc. The employees did not rip and tear during the process, but they were brutally honest in their confidential comments. Aaron hurts as he reads and digests these painfully honest and ugly facts that he and others shared as inputs about their sick safety culture.

Aaron sits at his desk head in hand with disturbing thoughts going through his brain that: nothing is good, just another day/set of injuries to read and evaluate with no support for himself being the safety manager. Aaron is the leader of a small safety department which has a ½ administrative assistant time allocation, one safety resource up from the ranks, and two safety trainers, one of whom is on the ropes for his poor performance in other departments that got him transferred (hidden) to safety.

What kind of day lies ahead? Good = no injuries, or bad = one or more injuries. Aaron is up from the ranks. He knows the people requiring his injury investigations, and it mentally and physically pains him to do so. The company has been in business for more than 70 years and is one of the top 25 in the North American continent when measured by sales volume. For these same 25 entities they are 12th in size, but number 24 in injury rate with only an independent offshore business operation being worse.

As typical to industry, management gets paid on results for cost, customer service, and uptime. The company has had no fatalities or disabling injuries for quite a few years. As a result, the just retired CEO left a weak safety department and associated weak safety culture. They are complacent and multiple years behind what industry leaders are doing to prevent injuries. The safety Recordable Injury Frequency (RIF) has been greater than 10 for more than a decade. The former CEO's legacy approach for an injury was: a quick injury investigation; a secret report sent to Employee Relations (ER); followed by a secret and protracted/lengthy analysis as to what kind of punishment should be given to the injured employee as a result of any perceived negligence.

Aaron remembers a recent safety article that used the phrase Paradigm Paralysis. The focus of the article was a complaint about the tendency we all have of using old (and outdated) approaches to solve current problems. As Aaron reads the blog article he reminisces about a war hero acquaintance, Tom, talking about his career in the armed forces. Tom's observation referenced military leadership's oft‐used approach of employing the same tactics for the next war that they used in the last war. Tom's conclusion was that this approach just does not lead to optimum performance, in war – or in safety.

Our safety profession history began in 1911 with a disastrous, multiple life‐ending tragedy at a New York garment manufacturing sweat shop (Triangle Shirtwaist Factory fire). Over the ensuing years “we” have experienced all kinds of research, regulations, techniques, technologies, leadership, education, training, and the like. Much of this information (but not all) has moved us to better downstream indicator safety performance.

Talking with past generation safety people, there is often a great reluctance to try new safety concepts that are outside of their experience comfort zones, ergo, Paradigm Paralysis. Certainly, the foundational approaches which have been developed in the past 100 years still apply. And yet, this decade's safety performance plateau is not satisfactory. We must relentlessly pursue better techniques and tools to eliminate the possibility/probability of injuries/incidents.

Our current war on injuries and incidents is being fought by a new generation with new cultures, different workplaces, and a myriad of other differences from what the older generations experienced. We must be open to considering and trying new approaches which can help us win the important safety battles that face us now and in the future. And yet government and some industry safety bureaucracies seem to often stick to the use of regulations followed by punishment as the predominate model with respect to safety improvement. In truth, a very conservative approach is influenced/hindered by the “standard practice” approach that is greatly influenced (hamstrung) by the litigious nature of society, i.e. not trying something out of the ordinary in order to minimize lawsuits! Such, “Standard Practice” cultures built on conservative tradition can be VERY difficult to change.

Since the 1970s' Occupational Safety and Health Act (OSHA) became law, OSHA has tried a number of approaches in an effort to improve safety in the United States:

 The regulations have set a foundational standard that has definite merit.

 The punishment by legal fines structure got some corporate attention, but it has led to a negotiating game which does not have its focus on improving safety, merely negotiating cost.

 Unannounced on‐site inspections have had little to no discernible impact on personnel safety rates. It appears that OSHA inspectors, with little in‐depth knowledge of a company's real hazards, lack credibility and instead often deliver derision.

 The Voluntary Protection Program (VPP)² system had merit, as it focused on assisting those who were seemingly serious, to improve their regulations compliance.

 The shame and blame approach only seems to anger the guilty, while adding glee to the segment that revels in a seeming punishment to corporate entities.

Untold billions of dollars spent on OSHA have resulted in minimal improvement in personnel safety numbers. The plateau in safety performance is not improving with a “trouble equals government/business leadership punishment” model. A number of safety professionals and managers committed to safety excellence, who have experiences in various industries in multiple countries and cultures, have settled on a better working model. This approach is more along the lines of a safety culture where “trouble equals value added assistance.” Subsequently, if the leadership cannot improve performance when given such assistance, their poor performance leads to a change in leadership.

Details from such innovative accountability‐based safety cultures are revealed in a significant number of large global companies. These organizations have done far better in safety performance by definitely employing manufacturing fundamentals while also improving their safety culture. They have discovered the need to go beyond the “one trick pony regs (regulations) and punishment models.” An easily available search approach would reveal the industries, cultures, and locals which need focused assistance. They are likely the same ones that traditional approach only leaders think are in need of more of some kind of punishment. “High injury rate plateau organizations indicate the beatings will stop when the safety performance improves” model, is not effective in the long run.

OSHA birthed the value‐added regulations fundamentals by copying (and adjusting) the policies, processes, and procedures of companies which were successful in safety. The models that successful companies have used in improving their day‐to‐day safety performance work for the laggards as well. Across the board, engaged safety leadership which goes beyond the necessary strong regulations base drives a safety culture of excellence. It is time to try a similar approach for improving safety cultures by copying and adjusting what has been shown to work and applying this model to those company cultures that are in need of value‐added assistance.

Over time I have been faced with a few new OSHA directors who view themselves as “The new sheriff in town.” A common thread of the new sheriff is a promise to punish industries as their way to safety success. At the end of their term I have had difficulty seeing any real statistical difference in safety performance. Since the 1970s there have been incredible continuous improvements in multiple technologies worldwide which have delivered amazing performance improvements in just about all that we experience and do. That is except in safety, where the old, tired, low performing approach of the seventies remains the outdated norm. Continuing the beatings, which have proven to be unsuccessful in improving safety performance, is a kind of leadership (either governmental or industrial) insanity which needs to be changed. Doing the same thing and expecting different results just does not make sense.

As Aaron reflects on the above safety culture reality of his company, he has also reached the conclusion that the union which represents the workers is a part of the poor safety performance culture where he works. They are safety complacent too because of a good technology apprentice program, no critical injuries for a number of years (except for now), and a good company medical benefits system which pays for fixing the injured employees and gets them back to the job. However, in Aaron's company there is a huge separation/gap between frontline employees and upper management. The high injury rate, a lack of caring, along with a focus on punishment with no real action by management, has become an angry boil that keeps the safety department as the object of festering unhappiness by all.

The general feeling across the organization is that: this is a great place to live; the pay is good; the work is not all that hard; and the frontline employees are well trained, highly skilled and have a good work ethic. However, the huge gap and lack of respect between the frontline employees and management have morale in the tank and skilled frontline employees leaving for other companies who need their skills and have a better culture.

Aaron realized doing the same thing and expecting a different result just does not make sense. But he is up from the ranks with little safety background and his upper management just does not seem to care or want to get involved in anything that is troubling. There is no apparent silver lining in the dark foreboding clouds surrounding the safety reality. He reflects on the safety filter³ discussion he had with the Doc.

Figure 1.1 Work on the job site.

Source: 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.”