Last month I provided the beginning of Conklin’s tools for changing the way your organization reacts to failure. Additional tools2 include the following:
Look for high-consequence activities
As Conklin notes, high-consequence activities normally involve “high risk hazards or high value materials.” I’m sure most of you have identified your high consequence activities, but have you evaluated them in the context of failure and what defenses are in place to control or mitigate high consequence outcomes?
Look for small signals that can indicate system weaknesses
Small signals as Conklin describes are those near misses, errors, close calls, etc. that reveal, if attention is paid, possible weaknesses in the normal flow of work processes. An excellent point Conklin makes regarding small signals is that they can provide those “systems that are confusing, conflicting, or potentially flawed.”3 Unfortunately, many “near miss programs” spend more time defining and tabulating so-called near misses — with little to no time spent on analyzing the meaning of near misses and how to address them.
Look for error-provoking system steps and processes
Have your safety and health procedures grown to such specificity that even you have trouble keeping the procedural steps in order? Just think, if you are having trouble with your safety procedures, what in the world do you think your operators and mechanics think about the procedures? They probably ignore them.
Look for error-likely conditions
Error-likely conditions are everywhere, so focusing on workspaces and conditions are critical to improving workplace safety. Indeed, as Conklin writes, even well designed safety systems may actually set up workers for failure. Ask yourself, is your safety system for accomplishing tasks an effective accounting system or a good management system? If it is about accounting, you may want to give attention to that system
Listen to your workers
Ask your operators where they think the next accident will occur. Trust me, they know where it will happen because they have been working around it probably for years, but no one has ever asked their opinion. Once you ask, operators will expect something to happen to eliminate the accident from occurring. Listen closely and avoid defending the system over the workers. Remember, safety is all about what workers do when no one is looking.
What keeps you up at night?
Ask your managers and supervisors what they believe are the most risky activities on the plant floor. As Conklin notes, the closer one gets to the actual work, the risk perception decreases. Managers and supervisors provide a better understanding of the system and interrelationships of the workers within those systems and how these systems produce the outputs.
Do workers cause failure?
According to Conklin, workers do not cause failure, workers trigger failure.
What exactly does Conklin mean?
Conklin’s systemic take is that workers trigger a series of weaknesses that exist in the system that ultimately leads to a failure. He is not suggesting workers be given a free pass for their actions. These weaknesses can be the job site, the environment, processes, systems, the work, and the organizations overseeing the operations.
For Conklin the issue is our obsession with finding the cause of the failure. We must have something or someone to blame for the failure. Conklin points out that those who rely on root cause analysis will deconstruct a failure down to the smallest parts, analyze the parts, and fix whatever is broken. In Human Performance, one does just the opposite. Instead of deconstructing the event, you construct the event context and, rather than focusing on the parts, focus on the interrelationships of the parts.4
From a systems thinking perspective, focusing on the parts of an event using a cause and effect methodology is known as mechanistic thinking. As Conklin points out, cause and effect approaches are very useful for determining mechanical failure, but fall short of being an effective approach for analyzing human interactions that have led to a human failure. A more holistic or systemic approach to discovering how something happened involving humans will provide greater insight to the system(s) humans are interacting with which have led to a failure.
As Conklin notes, and I firmly agree, machines have very little variability in their day-to-day operations in their performance; however, humans have a great deal of variability in performing their work based on their need to be agile, adaptive, and be able to improvise in order to deliver performance day in and day out.5
In closing, Dr. Conklin shares an insight he received from a company he assisted in successfully introducing Human Performance. The company told Dr. Conklin that they had established “four principles” they use every day to go from worst in their industry to best.6 These principles are relevant for organization:
We are fixated on where the next failure will happen. Constantly look for confusing, super-risky, or high pressure and places that “just don’t feel right.” Rather than predicting the next event, focus on predicting environments where events and failures will occur. Then place meaningful attention on that job site.
We constantly strive to reduce complicated operations. The key is figuring out how to diminish complexity so workers can perform their work. Complexity can be in the actual operations of the equipment; or complex rules, processes, procedures and methods. Focus on performance of the mission.
We respond seriously to low-level signals. In the case of this company, senior leadership receiving a call from a field supervisor saying, “We have a problem that could get bigger,” was one of their low-level signals. In addition to listening, management engages with the supervisor to address the problem before it becomes a serious issue.
We respond to events deliberately. Once a failure occurs, Human Performance companies respond deliberately. Responding deliberately means to not get emotional and don’t go out to fix the worker. Further, don’t enact policy and rule changes immediately. Take a breath and deliberately learn how the failure occurred in order to make purposeful adjustments to the system.
Consider exploring the field of Human Performance and give serious consideration to introducing it into your organization. I strongly believe it will make for a dramatic improvement in your overall view of failure and safety performance.
1 Conklin, T. 2012 (Re-printed 2014). Pre-Accident Investigations – An Introduction to Organizational Safety. Ashgate Publishing Limited, Surrey, England.
2 Ibid. pp. 46.
3 Ibid. pp. 47.
4 Ibid. pp. 66-68.
5 Ibid. pp. 71.
6 Ibid. pp. 131.
