For many of the leaders I know, it’s serious incidents happening far too frequently that most keep them awake at night. All the great things they’ve done with automation, isolation, re-engineering plant and equipment, tightening critical procedures, training and re-retraining their people, and still somehow the same kinds of incidents reoccur – some of them very serious. Organisations like these often see a steadily decreasing TRIFR trend suddenly compromised by a succession of serious incidents, and somewhere in the dashboard of safety metrics and KPIs, there’s a nagging suspicion that the numbers are not telling the whole story – not a true reflection of how risk is managed in the field.
One senior manager recently acknowledged to me:
“I can’t believe that with everything we’ve done on the safety front, our people keep putting themselves in the line of fire! There’s something about our culture we’re not quite getting and waving the compliance stick at them isn’t the answer.”
It’s not hard to understand this frustration. Sure, a positive lag metric trend in some organisations might actually represent the fruits of some excellent exposure reduction effort, but in many organisations, it is typically achieved only on paper, with deeply entrenched exposure to harm fundamentally unchanged. But if you’re not truly learning from these negative events when they happen, and you don’t have the right metrics that accurately tell you about the reliability of your operation and your people, you will continue to be victim to the vagaries of inadequate systems and bad luck.
In short, if you want to reduce the risk of serious incidents occurring, first learn WHY they’re happening.
What’s the quality of your investigation process?
When seriously bad things happen – and I mean both actual and potentially bad things – there has to be a real commitment to the learning opportunity that is available, and meaningful action that reduces the exposure to harm. This might all seem like the bleeding obvious, but in our experience most organisations barely scratch the surface of the available learning from serious incidents, and then pay scant attention to assuring that the response to that learning actually makes a difference!
Let’s take your organisation as an example. Ask yourself whether a cursory peek at your last hundred or so incident reports would deliver a confident tick to the following:
- Categorisation of incidents is accurately based on serious consequence potential, and consistent investigative depth occurs proportionate to that potential (and frequency).
- A comprehensive analysis of the human error factors occurs so that mistakes and violations are properly understood in a way that avoids the blame game.
- A deep-dive into the event causes is done across task and organisational factors – focused on how and why the operator may have been setup to fail in the first place.
- Corrective recommendations are made in all cases with serious consequence potential, and they are designed to substantially improve the control of exposure.
- Clear evidence that those corrective recommendations are put into action and are actually performing the intended purpose of reducing exposure.
- Safety-related metrics show the true state of critical risk management in (close to) real time, and provide actionable business intelligence before the next incident occurs.
Thoroughly analysing these events is one of best strategies to learn about the true state of your safety culture: whether your safety strategy is prioritised on the right things; how aligned frontline leaders are about acceptable risk tolerance; and how effectively your critical risk controls are working. Now that neuroscience can inform so much more about the nature of human error, we can even analyse how hard-wired brain limitations play themselves out in the workplace and what to do about them (more about this in my next post). Once you know the true causes of critical errors you can’t unknow them, and effective action is far more likely!
Four good places to start:
- Expose the real risk of serious incidents by systematically looking at ‘potential’, not just ‘actual’ events
- Develop a rigorous approach to teasing out the causal factors – human, task and organisation
- Make it easily repeatable by systemising the key processes, data analytics and metrics
- Use the learning to powerfully educate leaders in risk alignment and the frontline in risk tolerance
The good news is you don’t have to boil the ocean on this to begin with. Power Projects has the experience and can show you and your team where to start, how to refine and align your existing systems and processes, and what low hanging fruit opportunities you can get after that will immediately have an impact on your risk profile.