Moments that matter: Debating the significance of near misses.

There are certain moments in your day that are more important than others in terms of preventing fatalities. One such moment is debating the significance of an incident with your leadership team.

Consider the following real scenario. How would you respond?

During the major shutdown of one of your processing plants, a large machine cover is being lifted into position by crane. It slips from the sling, falls down a level, bounces, and lands inside the drop zone. Luckily, no-one is hurt. No equipment is damaged. The team conducting the work have sent through an incident report ticking the ‘significant’ box.

Ticking that box is probably a big deal in your organisation. ?A ‘significant event’ means it could have been fatal (given a slightly different set of circumstances). The event would receive a more detailed investigation, the findings will be presented across the business, sometimes wider… and the CEO and board need to be informed.

The next day, there is fierce debate about the importance of the event amongst the leadership team. They have very different views on the risk. On one hand, the Plant Manager believes this is a success story. In his eyes, the team foresaw that the load might slip, and put a drop zone in place. He argues the control (the drop zone) worked as intended. After all, the machine cover did land inside the drop zone and no one was hurt. He sees the event as low risk and not significant. ?

In contrast, another lead team member argues that the event could have killed someone given a slightly different scenario. He points out that he attended the shutdown meeting this morning and had a discussion with the team. They are concerned about the machine cover landing so close to the edge of the barricaded drop zone, which is adjacent to a pedestrian walkway. Additionally, there are differing views between the workers about why the load slipped with the way it was rigged up.?

Check this out in video here.

This is a common debate at all leadership levels. Both perspectives seem valid and reasonable. But your response to this debate is a moment that matters in shaping your culture, by demonstrating that what you value most is learning from failure. This event had potential to be fatal – the workers could see that. It is a valuable free lesson.

Here are two questions to explore with your team in the moment.

1. Are we considering the potential (what could have happened) or defaulting to the actual outcome of the event? ? When there hasn’t been injury or damage, it is easy and often comforting to think of an event as less important because the controls worked. Unfortunately, ‘easy’ and ‘comfortable’ are two places where learning rarely occurs. In the case of the lifting incident discussed above, the work team have done the imagining for you. In their eyes, the cover could have landed on the walkway and hit a person walking by – it didn’t, but it is reasonable that it could have done.
2. Are we comfortable to reach the last line of defence when the stakes are so high (a worker could be killed)? If you have no more layers of redundancy left in your risk controls, this is a dangerous place to be. You can see this as either ‘Success! Our controls worked and we didn’t have a fatality!’ or ‘We don’t want to be at our last line of defence. What can we learn from this?’

Keep in mind that there are often other influences swaying the level of importance given to an incident. How much extra workload an investigation will cause, if the person perceives it could negatively affect their career, or the response of their leader can all be major factors.

Having lots more high potential events without harm (significant near misses) means more opportunities to learn and prevent a fatality. This is in direct conflict with what feels natural, so seize the moment – seek out the high potential events. These are significant moments for your organisation – moments to listen, to demonstrate your commitment to learning, and to act.

Jodi Goodall is the Head of Organisational Reliability at Brady Heywood.

Brady Heywood provides expert advice to boards and senior business leaders on how their organisations can move towards higher reliability.?Organisational reliability helps companies consistently achieve predictable and safe operational performance and avoid catastrophic failure.

This article was first prepared for Quarry Magazine, June 2022.

Go to our website www.bradyheywood.com.au to find out more.?