Adverse Events: Eliminate or Anticipate?

Adverse Events: Eliminate or Anticipate?

Blog by George Stavrou. Submitted as part of his assessment in Unit 5 of the Diploma in Social Psychology of Risk at The Centre For Leadership and Learning in Risk

In an endeavour to assist organisations better manage risk, the safety industry have designed various assessment tools to identify likely sources of harm, evaluate potential adverse effects and develop safeguards that mitigate or eliminate risk. These tools come under different names such as JSA, JSERA, JHA, TRA, etc. but all follow more or less the same rationale.

Typically, these assessments are carried out in liaison with the persons undertaking the job; to gain their input based on their experience, skills and knowledge, to examine foreseeable issues, and agree on risk mitigation actions. The methodology is designed on the flawed premise that a harm free workplace will be created once all hazards and risks are removed or harnessed.

The reality, however, is somewhat different. Despite the implementation of these conventional risk management tools, harmful and catastrophic events still occur. Consequently, the credibility of these tools have been diminished, becoming bureaucratic, tick and flick tools of no real value to safety. And even worse, with the persistence to have these tools implemented in workplaces, workers become more focussed on completing the paperwork at the expense of actually understanding the risk associated with their work (1). It is not unusual to have a risk assessment completed at the manager’s desk with no communication or consultation with those workers exposed to the risk.

To avoid misleading expectations, the scope and objective of risk assessment tools need to be well understood. Like with all evaluation tools, the assessment methodology is based on a set of assumptions. To reveal these assumptions let’s examine the questions asked in risk assessments:

a) What are the hazards?

“Hazard” is known as the condition, event or circumstance that could lead to or contribute to an undesired effect (2). The question implies that hazards contain harmful energy. It is assumed that the flow is constant, and once identified and contained it will not cause harm. The reality however, is that hazards evolve with time and action requiring continuous adaptation and adjustment (3)

b) What are the likely consequences (or extent of damage without protection)?

The question suggests that there is a direct relationship between hazard and consequences. We need to be weary, that risk evaluation is mostly based on personal biases and faith, rather than statistical correlation, and hence the strength of this correlation is questionable.

c) What are the control measures?

The emphasis is on material barriers. Decision-making and the Social Psychology of Risk are rarely taken into consideration. The question refrains from seeking information about the persons undertaking the task such as their skills, knowledge, alertness, adaptability, all vital attributes in managing risks. Interrelationship, trust, and communication are also important for a sound risk management process.

d) What is the residual risk?

The question provides some assurance or confidence that the suggested controls are adequate. The by-product however can result in risk arrogance or overconfidence.

Despite the above critique, risk assessments can be useful tools. They are valuable at the planning phase to help anticipate issues early. But they cannot, on their own, underpin an effective risk management process. To complement their limitation, we suggest utilising the principles of Karl Weick’s Collective Mindfulness. I will now evaluate the traditional risk assessment process using the 5 principles of Collective Mindfulness and suggest simple additions to the existing tools in order to become more risk intelligent

Preoccupation with Failure

Traditional risk assessment tools guide us through a “what are the hazards” checklist that assumes risk is static and disconnected. According to Weick, effective risk management demands the acceptance of equivocality, understanding that all possible outcomes cannot be known and the environment is continually changing. Therefore, and unlike conventional risk assessment tools where assumptions are examined once, people need to be constantly attentive by questioning and revising previously held assumptions and expectations. By asking the following questions in a risk assessment activity, we can become more preoccupied with failure:

• What cannot fail?

• What are the early signs of failure?

• How will we respond to early signs of failure?

• Do we have the knowledge to spot anomalies or deviations that could create a problem?

a) Reluctance to Simplify

“Safety” loves the KISS principle. Keep It Simple Stupid. When it comes to risk management this is dangerous. Weick points out the need to resist simplification and to see the world as complex, unstable, unknowable and unpredictable. Colour charts such as risk matrices and heat maps aim to simplify risk but give us a false sense of assurance or security, in particular when our conclusions fall in the “green zone”. Instead of colour charts, would it not be better to seek differing opinions and worldviews in regards to risk tolerance? The following questions should be considered:

• Is the risk acceptable? why/why not?

b) Sensitivity to Operation

Risk assessments are typically carried out before the task is undertaken and are rarely reviewed during the execution of the activity. Weick highlights the importance of sensitivity to operations. Seeing what we are actually doing regardless of intentions, designs and plans. This could be best achieved through frequent contact by front line management who need to be accessible when problematic situations develop and to build a richer picture of the constantly evolving situation. To be sensitive to operations, frontline managers must be competent communicators and foster trust and openness in their relationships.

c) Deference to Expertise

A typical response to the question on “what to do if you come across a problem” is to “see your supervisor”. Weick points out that subject matter expertise is not consistent with organisational hierarchy. When facing a problem, it is important to seek guidance from a person with the relevant experience. This necessitates good knowledge of people working with you, ease of communication and trust. In order to better respond to unforeseen events, ask the following:

• Do we have the necessary skills around to address any problems?

d) Commitment to Resilience

Traditional risk assessments assume that safeguards will work effectively and job objectives will be accomplished without interruptions. Weick is of the opinion that we should better be prepared to anticipate for the unexpected. This consequently, requires a different mindset. The combination of keeping errors small, continually adjusting and improving work around to keep the system functioning are the product of resilience. Resilience grows with reflection on your past experience. A simple evaluation of the assessment and related tasks at its completion can encourage reflection, learning and resilience. Typical questions that could be posed include:

• How did the job go?

In conclusion, it can be argued that conventional risk assessment tools have their place and role in a risk management process but integrating the principles of collective mindfulness can enhance their effectiveness. However, despite all efforts made, none of these assessment tools can realistically guarantee creating a totally harm free environment. Instead, changing our mindset to anticipating unexpected adverse events and work on developing the necessary skills to contain them before escalating out of control might be a better recipe for managing risks. The work of Karl Weick can help us preparing for this.

References

1) Roughton, E.J., and Crutchfield, N. (2008). Job Hazard Analysis. Elsevier Inc, UK

2) Smith, G. (2018). Paper Safe. Gregory Smith, Australia.

3) Weick, K.E., and Sutcliffe, K.M. (2015). Managing the Unexpected. John Wiley & Sons, New Jersey.