Many people immediately respond to the question about the effectiveness of their safety program by citing the great (low) LTI or “Recordable” rate they have achieved over recent years. Interestingly, a feature of many disasters is the subsequent finding that despite good statistics, no one noticed or reported the gradual drift towards unsafe operation.;
So we need to ask again, how do know your safety program is effective? Apparently, it has little to do with LTI, recordable or even first aid injury rates. BP had very good work injury statistics prior to the Texas refinery explosion and fire (2005) and once again prior to the infamously disastrous Deepwater Horizon oil rig blow-out in 2010.
Identifying and focusing on the “critical few” things which are vital for safe operation is key, and is contrary to the common over-focus on minor safety issues. For example, prior to the BP disaster in the mGulf of Mexico, the CEO was reported to be personally involved in a company-wide program to train everyone how to correctly use chairs, because someone had fallen off a chair. This is often described as the “decoy phenomenon” which distracts attention away from the major risks.
What do most people do when an accident happens? Usually they hunt for “broken parts”, and when found they stop investigating. For example, finding a faulty instrument on a panel and replacing it, and possibly adding it to regular inspections in the future.
Emerging new techniques offer different ways to look at accidents. One such approach is that outlined by Sidney Dekker (2011) in “Drift into Failure”. Some of the interesting insights offered by Dekker include our culturally-based ethics which make us think that a person(s) must be really bad people, if the outcome of the incident is more serious. This is despite that many other people may have been doing the very same thing, but were lucky and did not suffer the same consequences up to that point.
More fascinating is why did none of the (gross) deficiencies strike anybody at the time? The answer lies in the fact that the drift into failure is slow, comes in small steps, and often goes unnoticed by those inside the organisation. After the event, the failures are always very obvious with the benefit of “20-20” hindsight for independent auditors, regulators, community, commentators and the courts.
Another interesting insight offered by Dekker is that “incidents do not always precede accidents, normal work does”. You have to think about this and consider it from the perspective of the workers faced with the pressures, limitations and practical difficulties of the job in front of them at the time. What is obvious after the events, is not necessarily so beforehand.
So what are the strategies that will help avoid the drift into failure?
- Train all managers and supervisors to display good safety leadership across every level of the organisation.
- Be suspicious of good work injury rates; they may be a symptom of under reporting.
- Build a culture which is prepared to sacrifice short term production goals when genuine safety issues necessitate, as opposed to punishment or subtle pressure to prevent any interference with operational objectives.
- Build in redundancy to ensure high reliability. For example, provide back-up person, secondary safety devices or multiple layers of checks.
- Decentralise decision making authority for safety issues as low as possible. For example, train and authorise staff to assess and vary procedures (within limits) to ensure safe operation when faced with local difficulties.
- Build a strong culture of compliance with agreed safety rules, as opposed to “cherry picking” the rules people like.
- Implement non-stop education and training and rotate staff through roles to periodically introduce a “fresh perspective” and new ideas.