In the US our fatality rate has been flat (total fatalities are actually up a bit the last couple of years) for a decade despite our incident rate’s steady decline to an all-time low. In addition recent disasters such as the chemical exposure fatalities at LaPort Texas, the Texas City Refinery explosion and the Deepwater Horizon have demonstrated serious weaknesses in how we are dealing with major risk - and, I think, safety overall.
How We Got Here
In 1931 Heinrich postulated that 88% of all accidents are the result of unsafe acts. Prompted by the rise of behavioral safety in the 1980s many have accepted claims that unsafe acts are the cause of up to 98% of all incidents. The safety profession, and the companies they represent, have largely embraced this view of workers as safety liabilities. Thus many safety efforts are little more than stacks of procedures, cardinal rules, threats and punishment, incentives, motivational schemes and behavioral observations - all principally aimed at controlling or "fixing' our misbehaving employees. But is worker behavior really the problem or rather a symptom of deeper trouble.
Symptoms vs. Systems Thinking
Safety is an organizational challenge not a personal problem. If you primarily focus is on the worker, without addressing your organizational culture and system weaknesses, you are only dealing with symptoms. Ignoring more fundamental organizational issues makes it less likely that you’ll achieve sustainable safety - or do much to reduce potentially more serious injuries and incidents. Nibbling at symptoms, rather than their systemic causes, is like playing whack-a-mole safety. The same problems keep popping up time and time again.
Over 30 years ago safety icon, Dan Petersen, and management legend, W. Edwards Deming, both recognized that unsafe acts and human error were not so much personal failings as the product of system weaknesses - in short, symptoms, not causes! Way back in 1981 Deming said it especially well:
“The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs the way they were taught. Pleasant dreams. The workers are handicapped by the system and the system belongs to management.”
What you look for is what you find. If your looking is primarily limited to addressing worker behaviors it's unlikely you'll discover much in the way of systemic weaknesses that help set workers up to fail AND are often precursors to more serious incidents and injuries.
Systems and System Influences
An effective system isn’t just a collection of stuff. Effective systems are made up of interacting or interdependent elements coherently organized to accomplish something. But you have a safety system whether you recognize it or not. The question is, is your system helping you to continuously improve or is it an impediment to progress.
When you look at serious incidents and fatalities it becomes evident that there are many system factors that often set us up to fail, or succeed, that are generally completely beyond the influence of the worker. Just for example:
- Work hours and shift duration
- Availability of resources (personnel, support, etc.)
- Adequacy (and hierarchy) of controls
- Production pressure
- Availability of safety equipment
- Procedure adequacy
- How safety issues are identified (or not), communicated (or not) and corrected (or not)
- Maintenance of safety critical equipment
- Adequacy of monitoring devices, alarms, etc.
- Human factors in design
- How employees are hired, compensated, trained and supervised
These, and other fundamental systems issues, not only factor largely in many catastrophic and fatal incidents, they are also principal determinants of worker behavior. Unfortunately, rather than taking a deeper look at systemic factors impacting safety, we’ve kept doing pretty much the same traditional worker-focused tactics for at least 30 years. Our workplaces are increasingly more dynamic and complex, however, and are populated by a new and different generation of workers. Our safety efforts have not kept up.
WHAT CAN WE DO?
First there are some things we should stop doing, such as believing in quick fixes and that workers are the source of every safety problem. Donella Meadows, in her excellent book, Thinking in Systems a Primer, describes the desire for quick fixes as addiction.
"Addiction is finding a quick and dirty solution to the symptom of a problem, which prevents or distracts one from the harder and longer term task of solving the real problem. Addictive policies are insidious, because they are so easy to sell, so simple to fall for."
So easy to fall for indeed! Quick symptom fixes often come with seductive promises such as “70% incident reductions in the first year”, “Measurable results in 14 days”, or “Zero incidents after the first year.” Unmentioned are the generally high cost in dollars, time and other finite safety resources it takes to implement and maintain these “fixes,” or that they are mostly unsustainable and frequently fail.
Safety deserves active strategic management like other important business priorities (e.g., sales, production, market share). Strategies for developing organizational cultures that include supporting systems working together toward continuous safety improvement remain, however, exceptions to more common worker/symptom focused approaches. Reducing our disturbingly high fatality and serious incident rate compels us to look at safety in a deeper and more holistic fashion. But to make this transition companies need better guidance from their safety professionals than they often receive. More than ever those in the safety practice need a strong grounding in systems theory and basic management principals. Just doing more of the same is no longer (if it ever was) acceptable and the stakes couldn’t be higher.