Can our regulatory agencies be a contributor to fatalities?

I was hoping that this headline would grab some attention. We all know that most regulatory agencies have and continue to focus on compliance. This is very important but not any more important that many of the other aspects of safety. It only works when we take multiple approaches and many of you are doing excellent work. However, there is a problem today that maybe, just maybe, is being somewhat exasperated by this archaic focus on rates.

As we are slowly progressing into the next stage of age of safety, something that stands out is that we have always taken the position that a task completed without incident was successful and a task completed with an incident was failed. This is a very simple assessment, but unfortunately it's not entirely accurate. Not so much for the failed side, but certainly for the presumed successful side. Waiting for failure to learn is no longer necessary.

As with many of you, I began my journey into Safety-II and all of its possibilities many years ago. I was actually fortunate to know and work with Dr. Erik Hollnagel when he asked me to review his first book on Safety-II before publication. It was at that time that I was attempting to build a more accurate incident causation model and investigation process, one that would better reflect organizational management and cultural system weaknesses. After working with Erik and Safety-II, it became apparent that we in industry were missing this entire world of possibilities for learning, both for what was weak and what was strong in any organization.

It was well proven that an advanced level of learning was possible from every task but that most safety professionals were still only focused on failures. Yes, there are some valid reasons for this including that is all the time that is possible, that is what is expected from them, etc. Additionally, we have taught our management to only focus on failures giving them the monthly updates with rates and little red, green, or yellow arrows. Would it even be possible to open up their thinking to accept a different view and assessment? Would it be possible for them to have a new insight on the value that the safety professional could bring to their organization? Would they be open to understanding the underlying organizational systems leading to success and failure?

People don't change unless there is a breakdown (having a valid concern). Organizations are just people. We have accepted the interpreted truth of the value of rate assessment for many years and unfortunately with the recent emphasis this only continues. So, what is the harm? Should we be focusing on reducing all injuries or should we refocus our efforts to improved understanding of how organizations function, how breakdowns are created, identifying the specific drivers to potential serious injuries and fatalities, how people are actually working, etc, and doing all this before an incident occurs?

First, the drivers for a fatality are seldom aligned to those of general injuries and illnesses. When we focus on incidents, which just happen to be less and less severe in many companies, we are giving our attention to less important aspects of safety. As previously stated, very seldom do our investigation or review processes pick up these drivers or underlying weaknesses. We tend to find what or whom we believe is broken and fixes this either with procedural change, safety message, coaching, warnings, or even terminations. I find very few who truly understand how systems create the reality for the workers setting the norms and limits for thinking and action. Many still think that they can fix people. While behavior is still an important aspect of safety, the focus on the employee to determine behavior is very antiquated.

Rates give a false sense of security, especially for those companies that have actually done very well in reducing the overall number of incidents. If learning is limited to failures and there are not obvious failures, the mode or practice of learning ceases. It becomes even more important to adopt a derivate SII approach to learning if your company is in this same situation. Continuous learning is very important. Now if your company is still at a point of having numerous incidents per year with overall incident rates greater than three, maybe you are not ready for this and that is fine. Traditional approaches may be adequate for your needs.

Many years ago I did take investigation training from from the late Bill Corcoran. Today I certainly do not agree with what was presented back then (root cause, etc.); however, one item that has stayed with me is that you only need to conduct two to three organizational level investigations per year to truly understand your organization. I would add today that will the inclusion of Safety-II, we have an even greater opportunity and responsibility to not allow rates to manage safety nor manage our managers.

The pathway many regulatory agencies have taken for increased focus on rates and injury reduction could be placing the incorrect emphasis on safety management. The focus on overall injury reduction due to rate emphasis reduction, both self created by our management and that of the regulatory agencies, may be steering us to reduce the low severity high frequency events as opposed to the high severity low frequency events. This is a very dangerous place to be. We can all accept that the next fatality is just waiting to happen. I have seen this many times when presumed safe companies have gone five or more years without an incident, even a first aid, suffer a fatality. I will gladly accept a higher incident rate with no fatalities then a low incident rate with a fatality.

A derivative of Safety-II that focuses why tasks succeed and fail, along with advanced task review and investigation techniques, can help reveal what organizational issues and strengths exist to improve our safety management possibilities.

Best Regards, Tom