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I like to start off with this slide because it is profound and true and represents the
way we tend to view safety.
What is Safety to you?
Why is this slide true. If punishment is certain compliance will be too.
Why is this slide not true? Because we the driver will be focused on compliance at
the cost of SA in many other areas
areas.
The issue is that the boss (cop) will know everything you are doing.
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Guaranteed punishment to doctors and nurses … guarantees a the failure of the
reporting culture.
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In the late 90s in reaction to finding
g ((on the p
previous slide)) of the number of
fatalities cause by physicians, congress commissioned a study to see what
could be done to reduce the number. The greatest impediment needs to be
overcome for us to become a learning organization
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If you want to stop a learning culture, punish the error-doers
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With either of these “cycles” What is the most significant causality?
Hint, it is the life blood of a safety culture.
The flow and circulation of information on risks and close calls and hazards
and work-arounds.
With either of these “cycles” what is the most significant effect?
Safety becomes focused on controlling human reliability, That is: changing
the human condition rather than the condition under which humans works
(ref: Reason’s most famous quote)
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The first step in cultural change is to address the beliefs and paradigms that keep
us in secure in our present state. The “Generative Spiral” starts with seeing old
beliefs as unfounded. Christmas may have been easier to understand when there
was a Santa but it has a lot more meaning with a more accurate paradigm.
These statements come from the industrial age. It is a simplistic cause and effect
paradigm. Some sociologists assert it is our evolutionary response to adapting to a
hazardous environment.
Even our cross-cultural and archetypal stories such as the origin of sin and
the cause of humankind’s downfall. Adam and Eve made an otherwise
perfect system bad through their human-ness.
The expectation of causality is also the basis of our criminal justice system.
~Insurance rates based on fault.
~Planes
Planes crash because of pilot error,
error
~the catch all, “driving too fast for conditions”
With this paradigm, Safety can be defined as controlling human error.
The natural conclusion is to make everything robotic. But how would you feel about
a robot making Air Traffic decisions, or driving you to work on the freeway?
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The feeling and need to see our world and workplace as a secure and intrinsically
safe place to be can culminate in some of the most irrational behavior
imaginable.
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no comments
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A high reliability organization is preoccupied by learning where it is vulnerable. This
can only happen with unimpeded reporting. I.e., being a reporting culture.
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March 6, 1987 193 dead – crew member responsible to secure the forward bay
doors was napping during launch. Safety Officer failed to check, and Captain
ultimately responsible for all aspects of safe operations.
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Conclusion of inquiry into the ferry disaster. Emphasis on how blame was shifted
up to the organizational level. Could be the first real application of just culture.
Interesting this occurred in the same time period as Reason was developing his
swiss cheese model
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If it is irrational to expect error-free performance then why do we treat errors as
anomalies?
We need to understand how to treat human error is a normal system component
and manage accordingly.
Emphasis on the irrational… emphasis on the fact we can manage what is
predictable.
This is EASY risk management.
management Calculate the cost of accepting the risk and
calculated the cost of mitigation and compare the two.
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“There is a wonderful phrase, ‘the fog of war’… It means that war is complex;
it is beyond the ability of the human mind to comprehend all the variables.
Our judgments, our understandings are not adequate and we kill our own
people. It isn’t that we aren’t rational; we are rational – but reason has
limits”.
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At-risk is where management can be most effective in helping
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Hospital acquired infections is not the same as accidental fatalities. A different
statistic.
Are not doctors the ones we hold highest in our culture as models of ethical
behavior.
Are 80% unethical? Or, is compliance drift normal human behavior.
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Reason, Roberts, Weick, Sutcliffe, Dekker and others AND even OSHA!
all agree that how employees make choices is largely determined by operational
pressures and organizational norms.
Operational pressures and organizational norms are under management purview.
It is their responsibility and a “just” system recognizes they must redeem their
responsibilities.
Therefore this issue becomes how is management helping employees make safe
choices?
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The people that set the trade-offs between safety and production cannot possibly
know all the hazards they drive their employees to face.
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This is all fine and good but what’s the tangible value of a JC ?
It’s because it a necessary foundation to a safety culture.
So lets talk about what Safety means the how to achieve a safety culture.
I like this sign because Continued work on getting employees to be more and more
reliable is an investment with diminishing returns. As Reason said you can’t change
the human condition but you can change the condition under which humans work.
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Either watch for predators or eat
We don’t exist to be Safe. We exist to do work, accomplish stuff.
If our sole objective was to be safe we can be extremely thorough in that endeavor,
but producing work involves some compromise. Driving is an easy one to imagine,
but how about the variable
variable, uncontrollable and even unknowable risk associated
with the Forest. What about the work a LEO does? Can they be thoroughly safe
and do anything?
The key message is that risk is a byproduct of producton.
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This is a pr statement. he knows to make a perfectly safe toyota the car would cost
so much as to bring volume to zero.
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With experience you learn lots of things… there are two faces to safety.
Ask Audience: “Like What?” like maximization, elimination of unnecessary steps,
how to make the job more comfortable, how to better please the boss (more
production) how to do more with less, how to work smarter, and perhaps
most importantly: 1). how to get as close to the edge without crossing over.
2) If you don’t die, how to recover (resilience and expertise)
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Everybody knows somebody that has been killed in a car wreck.
Doing preparedness reviews I always ask LTs what is their greatest risk, where is
their next accident likely to be rarely I’ll hear “helicopter crash” almost always I’ll
hear “driving” . If you have teenagers it will keep you up at night. It is a giant risk
factor.
This is not a presentation on Risk Management. But rather on how we are always
making production / safety tradeoffs
Or efficiency / thoroughness tradeoffs.
Risk is a by product of production and especially a by product of efficiency.
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How often do you hear the word “gap” in a discussion safety?
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A long term and very dependable “durable” seasonal was involved in a pretty
significant accident. He was doing 80 mph in a 65 mph highway and involved in an
accident with multiple people hurt. What does his supervisor (say the ORA) think
and feel about it. Then the Ranger, Forest Safety Officer, Forest Sup to the
Regional Safety Officer, The Chief? The degree of blame (“that stupid employee”)
and culpability (“the SOB was reckless”) increases at every level.
Point is JC is necessary to have learning. It keeps the information flowing. Under
the protection of a JC we can see and understand how employees made sense of
their world between safety and the competing objectives.
Doctrine demands we give people latitude and authority manage the trade-offs be
safety and production.
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Note the official speed limit and my speed and the fact I’m in the slow lane! This is
rush hour between Orem and Salt Lake.
The point here is the trade off between efficiency and safety. You can move a lot
more cars through a congested system at 80 mph than at 65…. about 23% more or
120 cars per minute more.
You’ll never, see a cop on this road during rush hour unless there’s an accident.
They don’t want to interfere with efficiency.
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Guy has been making and refurbishing signs for 15 years. Estimated has cut 15 to
20,000 pieces of wood with the table saw. Teaches others to use a push rod. Is on
the safety committee work on all sorts of “shop safety”
This is about employee “compliance” but also understanding non-compliance.
Experience = safety?
If you job is sign making we can engineer an almost perfectly safe work
environment.
JC says you can’t change it by whacking it. Again risk is a by product of efficiency
and production and values are way more effective than rules in guiding behavior.
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Reason, Roberts, Weick, Sutcliffe, Dekker and others AND even OSHA!
all agree that how employees make choices is largely determined by operational
pressures and organizational norms.
Operational pressures and organizational norms are under management purview.
It is their responsibility and a “just” system recognizes they must redeem their
responsibilities.
Therefore this issue becomes how is management helping employees make safe
choices?
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Accepting Marx’s statement has huge implications for a “JUST” response in the wake
of an accident.
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Summary of what we’ve been talking about.
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If your job is to refurbish FS signs I can prescribe in explicit detail every step you
need to take to make sure your all risks are virtually zero.
The as long as you comply ~ we are good.
{Story of the 15 year table saw user} But the forest “wildland” (sic) environment
could never exactly match the memory and imagination of the rule makers. The
more unpredictable the workplace and the more diversity in the job, the greater the
disparity between work as imaged and work as done.
Here is where J.C. is extremely compatible with “doctrine”.
*They both recognize we need to employees to interpret the ambiguities within
the prescription when the are operating at the sharp end.
* We expect (facing reality) a divergence between the actual system and the
system model that the rule makers, JHA writers, and Green-book authors
imagined.
imagined
• We know that the greater the gap between the top of the iceberg and the base will
result in a great gap in terminology and paradigms-we can see the same risks
but see them differently.
• An finally we want employees to intelligently tinker and innovate (better, faster and
cheaper) as a continuous practical process evolution.
So there
S
th
are a bizillion
bi illi
sharp
h
end
dd
decisions
i i
th
thatt are made
d in
i a high
hi h risk
i k
environment – if values are aligned then mgt and field will have coose to the
same risk management decisions.
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As Sydney Dekker says, the fundamental tension of a Just culture is this:
Management needs to know what is going on but
management cannot accept every thing that is going
on.
The real world on the left, so what do we do with it?
That depends on your paradigm of safety.
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As Sydney Dekker says, the fundamental tension of a Just culture is this:
Management needs to know what is going on but
management cannot accept every thing that is going
on.
Information is the life blood of a safety culture.
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Instead of workarounds you could call these trade-offs.
There is a whole host of adjectives you could interchange here.
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Its impossible to overstate the importance of trust. And the role of JC in creating and
sustaining that trust. With it an organization can hold learning as a value.
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Remember the first time you heard the term Evil-Doer?
After 9/11 to describe a person who seemingly does evil intentionally.
I like to call people who had the last best chance to prevent accidents error-doers
because they seemingly commit errors intentionally.
Error-doers are always the cause of all accidents.
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no comment
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Its impossible to overstate the importance of trust. And the role of JC in creating and
sustaining that trust. With it an organization can hold learning as a value.
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The we is what is emphasized here.
The planners and rule makers and employees and safety officers (all of us in the
system) are not seeing or understanding risks the way we think we are.
If the substitution test would work after a close call or accident then it’s a good
indication of WE have not managed the risks well.
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In the wake of an accident (in a Just culture) management needs to see the
accident from the error-doers viewpoint. 99% of the time the substitution test would
show our employees are behaving predictably considering the
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So, if this is you new world view, who is accountable?
How important is understanding the gap?
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Riding in the back of a PU truck was not perceived to be at-risk behavior when I
was growing up. Even though it is still legal in many states, you essentially never
see a Forest Service employee riding in the back of a government truck. In contract
to say, seat belts, the agency has instilled the values of risk – an appropriate
perception of risk concerning this behavior. If these were FS employees we’d likely
conclude they were acting recklessly.
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Values in action.
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Values in action.
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The way we think about the war on terror is the way we need to see safety it will
never be won. It is continuous, dynamic, evolving and requires constant vigilance.
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in fact overwhelmingly it is intuitive. think about driving for example… and the
thousand of decisions made ever minute on the freeway. These intuitive decisions
enhance reliability (the reliability of an intended outcome) to the extent your
perception is aligned with reality and to the extent your values are aligned with the
principles of rule compliance, alertness, defensiveness, situational awareness, etc.
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Creativity and how one sees the world (your beliefs system) is strongly driven by
values. … not rules. Though in some situations a value can be strict compliance.
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Creativity and how one sees the world (your beliefs system) is strongly driven by
values. … not rules. Though in some situations a value can be strict compliance.
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Creativity and how one sees the world (your beliefs system) is strongly driven by
values. … not rules. Though in some situations a value can be strict compliance.
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So, if this is you new world view, who is accountable?
How important is understanding the gap?
Management can work on all of these if they know about them and understand
them.
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This is the paradigm of Doctrine and Just Culture.
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The way we think about the war on terror is the way we need to see safety it will
never be won. It is continuous, dynamic, evolving and requires constant vigilance.
Some of the most brilliant safety folk say you can’t change culture you can only
coax it to one direction or the other. I can’t debate that but key point is that at
every evaluation period we need be able to say that we are closer to a just
culture than we used to be.
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Culture is not something that is uncontrollable. It is very much controllable and a
managerial responsibility to manage.
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key point is that at every evaluation period we need be able to say that we are
closer to a just culture than we used to be.
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You’ve got to keep the information flow alive.
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