One of my colleagues (Jenny Kemeny) was recently introspective about how
she has improved her capabilities over the years. She concluded, "It's
the library of case examples I've built in my head. Now, when I see a new
problem, I have a richer set from which to draw comparisons.
Let's try to build our own library of cases, examined by the group from
the various learning perspectives as a resource we can all use.
-- Rick Karash, rkarash@world.std.com, host for learning-org
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This post attempts to describe an organization performance problem
(worker injuries), the perceived systemic forces at play, and what
might be some key fundamental solutions to improving safety
performance. I would be interested in your comments, questions, and
opinions on improving the attempts to systemically describe the
structures and the fundamental leverage points for sustained
improvement.
I would also be interested in hearing stories from others about their
practical, real life problems and what they see as the systemic forces
at play and leverage points for sustaining improvment.
I work at a very large site (14,000 workers) for a primary contractor
that works for the federal government. The primary contractor took over
from the original contractor in 1989, which built in operated the site
from the early 50s until '89. The original contractor had a very
strong safety culture. It was obvious to everyone (and to no one's
surprise) that the managers of the new contractor were less than
prepared to reinforce this safety culture when they came on board.
Furthermore, they came at a time when the site was beginning to go
through major changes on how to conduct business. The new federal
department head was an ex-Navy admiral who decided the federal sites
would adopt the commercial nuclear/Navy nuclear standards. Neither the
new contractor, nor anyone for that matter, could have understood the
enormous task they had in front of them. To make matters worse, this
massive amount of change had to be undertaken at numerous federal sites
with many autonomous facilities, with new, large hierarchies, and with
significant amounts of external auditing based on vague federal
headquarters guidance. A real recipe for organizational disaster.
That's not all. With all the demands for management's time to change
the systems and operations culture and deal with external review boards,
they also had to deal with numerous startups and restarts of various
facilities and attempt to meet schedule commitments (which were all but
impossible because the interpretations of the rules kept changing each
time an external "expert" oversight board came in to assess). As you
would expect, the previous contractor's industrial safety culture took
a hit for lack of management time.
In the last ten months, our division (one of about five large facility-
based organizations within the site) was on track to set a new record
of 10 million work hours without a Lost Workday Case (LWC). We were
being hailed as an organization who put safety at the top, etc, etc.
Then we had our first LWC. Site E-mails came out from our site
management noting that even though we had just missed the record, we
should be proud of our achievement. Then over the next four to six
weeks we had four more LWCs.
Recently our department manager had a safety "stand down" meeting with
all employees. He talked for fifteen, emotionally filled minutes,
emphasizing with a pointed finger at least fifty times how concerned he
was about us having another injury and how we must turn this situation
around. Some responded with cynicism saying he must have just attended
drama class to learn how to put this fire out. Most people got the
message that perhaps the old safety culture is back. Time will tell.
>From a systems perspective, I have been pondering the cause or causes
behind the downturn in safety performance. I have discussed it with a
number of people to get different perspectives and opinions.
Below, in no particular order, are some of the causes suggested.
Following that are my comments.
Possible causes
* injuries are random events
Statistically, events do not occur evenly spaced over time. They occur
in clusters. If one does not keep a large enough time horizon, the
clustering of events can be misconstrued as indicating a severely
degraded situation when in fact, the condition is no worse than it was
six months ago. Using this reasoning, the department's safety culture
did not change "overnight" from great to terrible, but is most probably
the same.
* schedule pressure
People are under sever pressure to get work done under a tight
schedule. They take shortcuts, management looks the other way. It
catches up with you sooner or later.
* complacency
The organization goes through a cycle of high safety sensitivity to low
safety sensitivity (complacency). Then a LWC occurs. A second one
occurs. Management gets excited. People are told safety is a condition
of employment. Sensitivity goes back up and then slowly drifts down
until the next LWC. An analogy is getting a speeding ticket. For a
while, sensitivity to driving speed is high. Over time, sensitivity
goes down, until you get another ticket. Then the cycle starts over.
This sounds like a balancing loop that may reflect a natural trait of
humans/organizations.
* psychological letdown
The goal was lost, so people lapsed. We just got over a RIF, so people
lapsed. We just achieved a major startup milestone for the department,
so people lapsed. When there is a lapse, LWCs occur.
Below are my views.
I like the analogy to the speeding ticket and the balancing loop model. If
this is a useful model, then the question becomes, "what are the
precursors that indicate an increase in complacency and could be monitored
over time ?" Possible precursors could be the quality of housekeeping,
the number of unsafe acts observed (or safe acts observed). The previous
contract had programs that tracked performance in these areas. They died
under the new contractor. Another question may be "what can you do to
keep the sensitivity up, ie, tighten the swings in the limits on the
balancing loop ?" Perhaps the old contractor had it right. They had
safety policies that were obvious overkill. "Keep to crosswalks, even if
you have to walk an extra hundred yards." They would go to extraordinary
lengths to get a person to work to prevent an off-the-job injury statistic
from occurring (and keep the safety record intact). The safety engineer
had tremendous authority - which helped to keep a high sensitivity level
in the field (sometimes it had a negative effect - "stop work, here comes
the safety engineer"). Although these practices seemed a little
outrageous, and perhaps not cost-effective in isolation, they definitely
served to sustain an ongoing high sensitivity level amongst the
organization.
So the high leveraged thing to do seems to be to design a bypass around
the LWC behavior by monitoring "precursors", ie, behavior indicators
that show the direction of safety behavior. Possible precursors are
unsafe acts and housekeeping. By monitoring the quality levels of
these precursors, downward trends can be identified before things get
bad. Perhaps just the act of monitoring them would keep the
sensitivity level high and complacency level low. Having to live to
seemingly outrageous rules and having a safety engineer whose authority
is never questioned (which seemed to keep the sensitivity level high on
a daily basis) may be daily structures that keeps the the safety
behavior at a balance below the LWC threshold.
-- Geof Fountain TFYY93A@Prodigy.com