Most organisations take safety seriously, want zero accidents and work very hard. They do not however achieve the desired safety performance – many by a long way. So why does this happen?
Accident reporting typically provides good data on the persons affected and their injuries with a brief description of what happened; but usually, there is little if any follow up or analysis on how to prevent similar accidents in the future.
Most accident antecedent factors describe the ‘immediate’ causes e.g. breaking rules or fell asleep. However, many omit or provide little information about the ‘latent conditions’ e.g. the long-standing problems that have been hidden in the organisation for some time, which promote and support the existence of ‘at-risk’ practices.
Many organisations that have experienced risky or competitive operating environments for a long period of time have evolved practices which conform to the principles of ‘Cat Nap’. Cat Nap is another way of saying: ‘cheapest available to narrowly avoid prosecution’.
The previous graph represents the typical fluctuation zone that most organisations operate in. Even government departments and churches (or other not-for-profits, who may have a strong moral commitment) have limited resources and cannot spend unlimited amounts on safety.
As a result, they bounce between trying not to spend so little that they could cause disaster, or spending so much that they risk going broke. Most organisations operate closer to “disaster” as they don’t believe “bad things” will happen, but can predict financial difficulties more accurately.
When companies get away with lower standards on one occasion, they are quite likely to keep going until an accident happens.
Another problem is scorecard driven businesses. Having clear objectives or KPIs is good, but many organisations over-focus on things like LTI rate, cost reduction, or slips, trips and falls and not on what might cause a catastrophe.
Most approaches to safety culture focus on attitudes and beliefs, and as a result any gains tend to be short lived.
Effective safety programs on the other hand, focus on behaviours – good and bad, not attitudes or beliefs.
Despite being at the opposite ends of the spectrum, generative and vulnerable cultures have a lot in common. It is the subtle differences in each organisation which make the differences.
A major characteristic of larger organisations is their tendency to plan, but not implement. Sound familiar? This is because strategy has a higher status in most organisations than tactics and action.
Transition from calculative to proactive culture is difficult, as it requires a change of many fundamental processes, systems and especially ways of thinking.
Deep-water Horizon Case Study
Professor Hudson asserts that BP was ‘loss averse’, unlike its main competitors (Shell & Exxon) who were ‘risk averse’.
As a result of the Deep-water Horizon disaster in the US, BP have already spent US$14 billion on response activities and has been fined $4.5 billion for eleven felony charges (11 fatalities), which amounts to approximately $41m per fatality.
Note: This is more expensive than fines under any Australian workplace safety laws.
Personal Safety vs. Process Safety
Personal safety is often (understandably) the primary focus of the workforce, but unfortunately in high risk industries or circumstances this can (and has led) to catastrophic failures which cause greater impact than many personal safety issues e.g. over focus on PPE.
In the lead up to the Deep-water Horizon disaster it is understood that BP workers were issuing one hundred (100) STOP cards per day on the rig, on primarily minor issues, but head office appeared to ignore the worrying signals in regard to operational safety. For example, prior to the disaster, BP flew a team out to the rig to investigate a crane incident, but didn’t react to serious process failures and warnings about possible catastrophe. Some have suggested the managers had already shifted their focus to the next project.
Professor Hudson has stated that zero accidents is the only acceptable target. But how, he asks?
- Make a sacrifice to the gods?
- Manage the risk by understanding what the critical factors are?
Kitty = ½ Alive + ½ Dead
Schrodinger’s cat is a term arising from a thought experiment dating back to 1935. It postulates in part that after an accident, all other possibilities immediately become non-existent, leaving a simple causal link.
This makes others believe that those who were involved had some level of certainty of knowledge before the event, just like those who witness the event after. Investigators always look back with the benefit of ‘20/20 hindsight’ and all seems clear and simple e.g. Theories 2 & 3 look like Theory 1.
Professor Hudson points out that;
Theory 1 = 80% of all accidents (simple theory)
Theory 2 = 80% of remainder accidents = approx. 96% (complex theory)
Theory 3 = 80% of remainder accidents = approx. 99.8% (very complex theory)
Success with risk makes people more willing to accept greater risks.
Acknowledgement: This article is based on selected work by Professor Patrick Hudson arising from his 2013 Australian seminars.