Cat Nap Safety
Professor Hudson agrees most organisations take safety seriously, want zero accidents and work very hard. However, they rarely 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 often there is little if any follow up or analysis on how to prevent similar accidents in the future.
Most antecedent factors for accidents 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 way to narrowly avoid prosecution or going broke’.
The previous graph represents the typical fluctuation zone that most organisations operate in. Even government departments and churches (eg not-for-profits), who may have a strong moral commitment to look after people 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 to them, or in the near future, but can predict financial difficulties more accurately.
When companies get away with lower standards for a period of time, they are more likely to “normalise” the lower level of safety until something goes wrong.
The above graph represents the typical fluctuation zone that most organisations operate in. Even government departments and churches (eg not-for-profits), who may have a strong moral commitment to look after people 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 to them, or in the near future, but can predict financial difficulties more accurately.
When companies get away with lower standards for a period of time, they are more likely to “normalise” the lower level of safety until something goes wrong.
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 slip, trip falls and not on what might cause a catastrophic accident.
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.
Deepwater Horizon Case Study
In relation to the Deepwater Horizon oil spill disaster in the Gulf of Mexico in 2010, Professor Hudson concluded that BP was ‘loss averse’, unlike its main competitors (Shell & Exxon) who were ‘risk averse’.
BP have spent more than $14 billion on response activities as a result of the Deepwater Horizon disaster and has been fined $4.5 billion for eleven felony charges (11 fatalities), which equates to approximately $41m per fatality. This is more expensive than fines under any Australian workplace safety laws.
Personal Safety vs. Process Safety
Personal safety is often and understandably the primary focus of the workforce, but unfortunately in high-risk circumstances this can and has led to catastrophic accidents. This can cause greater impact than many personal safety issues e.g. over focus on PPE.
Frequently there is an over-focus on PPE
In the lead up to the Deepwater Horizon disaster it is understood that workers were issuing one hundred (100) STOP cards per day on the rig, on primarily minor issues.
Some suggest this level of stop card activity shifted the focus of the team to dealing with the paperwork and local safety issues and contributed to relevant managers not seeing the warnings of imminent catastrophic events.
Professor Hudson has stated that zero accidents is the only acceptable target. But how, he asks?
Hope? or
Make a sacrifice to the gods? or
Manage the risk by understanding what the critical factors are?
Acknowledgement: This article is based on an earlier Safety Action News article and work by Professor Patrick Hudson arising from his 2013 Australian seminars, and updates.
