What are Your Truths? Step One in Establishing a Safety Culture.

A few years ago a group of us safety professionals interested in moving safety to the next level met in London for a two-day workshop to look at the future of safety and how we could incorporate into our prospective businesses. I also got my friend the renowned Dr. James Reason to join us for an afternoon/evening to share some of his wisdom. What came out of this workshop was an agreement of Our Truths that we could take back to our own organizations. In order to build a strong safety culture in an organization, it is important to get all of the members to agree on not only the vision (No Harm, Target Zero, Zero Defect, etc.) but to detail the specifics of what makes a safety culture. Organizations with weak safety cultures tend to have all types of differing interpretations. Understanding this is the first and most important step if you desire to build your safety cultures as well. This is best in written form that will become your organization's centering document and should be well communicated with the expectation of holding everyone to this standard. Differing interpretations will only cause confusion and delay the benefits of having a safety culture.

I shared this last year at an ASSE webinar that still may be available to members: https://learn.asse.org/products/a-shifting-paradigm-systems-thinking-about-human-error-an-asse-virtual-symposium#tab-product_tab_overview.

The following are The Truths as we agreed upon. They don't necessarily need to be your Truths and may differ depending on where you are on your journey of safety maturity. Do what works well for your organization. They can always be updated as you progress in your journey.

We began our Truths with "No one comes to work to cause a safety or quality incident" followed by "People want to do a good job." While there may be those who are taking risks far beyond their allowance, they are not doing this to cause an incident. They may even think that their shortcuts or work-arounds are actually what management may want. As long as there is not an incident, many times these people even get rewarded for this behavior. Low level violation becomes the norm. Holding to this doesn't excuse willful violation, but this will give some new thinking once an incident has occurred.

Next we agreed on "You can't stop cognitive errors but you can be incident-free" and "You can always intervene between error and an incident." For far too many years safety was about training, influencing, rewarding, and punishing employees with the false presumption that you can stop cognition errors (human error). Early Human Performance programs were no different than Behavior-Based Safety programs. All were based on the incorrect premise that if you fix the workers your problems will go away. During this time frame many of what were considered the leading companies for safety were conducting countless observations with the idea that this would improve safety. While a small difference was observed it did nothing to stop errors. It's time to accept that your workers, as human beings, will have errors in cognition anywhere and everywhere along the cognition pathway - observation, assessment, design, implementation, and feedback. Since error is unavoidable, if you truly want to be successful you need an intervention between error and incident. Management systems create these interventions and there is no limit to the number of possible interventions with the caveat that too many can put a company out of business. Jim Reason once said to one of my managers "If you want to truly be safe, stay home!" Understanding what management systems and how many interventions to implement is risk management. If we deploy too many we manage ourselves out of business, use too few we run the risk of an error making it to incident. Those who successfully manage tradeoffs and risk, ultimately win in the game of business.

Following the next Truths we agreed upon was that "People don't think and act alike" and "Perception of risks varies from person to person, and what is deemed acceptable varies as well." We have to remember we are dealing with humans coming from various backgrounds and social systems, each of which will have their own norms and limits for thinking and action. We can't change their background nor should we; however, we can create an overriding culture once they come to work. We have to make sure they understand and adhere to our standards for behaviors, not just bombard them with slogans. Everyone living and holding to the same standard while at work will eventually become the new norm; one that is aligned with your Truths.

Next, we recognized that most organizations were missing one of the greatest opportunities for learning thereby establishing "Accepted past and current interpretations are not proof of truth." As many of you know I have been closely engaged with the work of Dr. Erik Hollnagel, whom I hold as one of the greatest minds in safety today. Utilizing my studies in cognition along with his work has led to the understanding that every task, regardless of outcome, holds information about the organization's management systems and their use. In addition, viewing employee behaviors as an outcome of the organization will begin to reveal weaknesses long before there is an incident. We must begin to accept that the outcome of a task has almost no relationship with how the hazards, risks, and error-likely situations are being managed on a moment by moment basis. Are the necessary adaptations that are occurring in every task within a level of expertise and authority (LOEA) of the individual performing the task? Are they reporting back where they exceeded this to complete a task? Are you setting them up for success or failure? Every task will contain data but only if you look for it. This continuous motivation of employees to somehow be safe through all situations has merit but this is your missed opportunity to bridge the gap between work as imagined versus work as performed. Engage your workers and require them and others to report on their work realities rather than simply outcomes and look for what the management systems can do to ensure they are set up for success.

With our increased understanding of human behavior we accepted that "Violation is a normal event that increases with experience." Dr. David Woods and John Wreathall shared a story with me a few years ago on the term violation. Jim Reason was going to use this term to discuss aberrant behavior in an opcoming book. After review by David and John he agreed to not use this term; however, the book was published with this and we are now stuck with this term to define a behavior element that is not really as bad as the term implies. We generally accept the five levels of violation to include: necessary, practical, cowboy (cowgirl), malicious, and sabotage. Maybe we should be using the term "work-arounds" that do better explain what is occurring. We also know that it is normal for humans to look for shortcuts, which if successful become the new norm. Knowing all this we can observe that experienced employees are taking shortcuts, Sometimes these shortcuts will beyond their LOEA but if nothing happens no one seems to be aware. Sometimes this low level violation may even be a best practice. Regardless, unless you are actively engaged with the worker you will not know where they are exceeding their LOEA or where they are holding onto a best practice. More experienced workers need to recognize their own behaviors. I have found that once you bring forth this distinction they can't help but notice.

Lastly, this group recognized where we are on our journey agreeing to "You can't fix safety by focusing on safety." Traditional safety is still very important but this will only take you so far in your journey, especially as we delve into the fourth and fifth ages of safety. The safety domain has progressed significantly over the last 20 years or so and more so in the last five years. It is truly becoming a domain where there needs to be specialty as with environmental. Thirty years ago someone working in environmental pretty much covered all aspects. Now there are those who specialize in air, water, compliance, permitting, remediation, and on and on.. This is where safety is headed as well. We know as safety professionals that we have to be open to new methods and approaches and that our focus is no longer just preventing incidents. We are the carriers of bringing forth how to create more robust and successful organizations to reduce the potential of harm to everything - our company, our employees, our customer, our contractors, our shareholders, and the environment.

Once again these were some of Our Truths to take back to our respective organizations to build their truths, a starting point for building our safety cultures.

Tom McDaniel