Originally posted on February 21, 2023 @ 8:50 AM
3 years on and nothing has changed………….
One of the things that Safety does well is keep the doors closed to critical thinking outside of its own paradigm. Dialogue within the discipline of safety is tight, engaging similar worldviews, ensuring that nothing changes. This was confirmed recently with the release of the Brady Report to Qld Parliament on 6 February 2020, Boland Report in 2018 and the release of the AIHS BoK on Ethics.
If you want to know anything in Safety just keep your exploration within the disciplinary club. In that way you can predict the same kind of review with the same kind of outcomes. That way nothing will change but Safety looks really busy on the pathway to zero. The Brady Review is a good example.
The first thing we learn in the Brady Review into fatalities in Queensland Mining over the last 20 years is that the review takes a particular view that it doesn’t disclose. This view, though not openly disclosed, is entirely consistent with many other safety reviews. The review is fixated and endorses the Regulator, data myopia and naïve mythologies believed in the sector eg. sustaining the ideology of Zero, human error and that ‘accidents are preventable’. Of course, the review makes no connection between safety mythologies and later concerns in the report about excessive paperwork, problems with reporting, blaming and problems with measurement.
Indeed, the report has no discussion at all about any of the safety mythologies that influence culture creating cultural norms such as ‘tick and flick’, hubris, ‘flooding’ and risk naivety. Further, the review says nothing about culture at all except to project the naïve idea that a culture can be a ‘reporting’ culture. The report doesn’t define culture.
Aspects of the report accept the construct by Dekker that organisations ‘drift’ into failure. Of course, there is no such thing as ‘drift’ into failure, the metaphor conjures up this idea organisations were somehow ‘successful’ and now slowly and ignorantly, they are not. Brady then takes the Dekker thesis and applies it to data. One could easily get the opposite view by applying the data to a construct such as ‘wicked problems’. Yet people will read this review from the engineering-regulation bias and deem that is somehow objective!
At no time in the review is the ideology of zero explored as a causal factor in the increase in fatalities in Qld. This is despite the fact that the Regulator committed to zero in 1999 and has clearly failed by any measure. The ideology of zero projects a fixation on: minutia, counting and numerical claims of success eg. catch any plane to western Qld and see all the shirts with zero mantra and ‘1 millions hours with out injury’ etc. Thereby creating mythology that injury rates are a measure of safety.
The cultural norms of counting, fixation on minutia and numerics are indeed part of the problem but will never be entertained by such a review. One of the most important things in safety since the global ideology has been made zero (http://visionzero.global/node/6) is to ensure this sacred mantra remains untouched. So, 20 years later after the Qld Regulator embraces zero (https://www.worksafe.qld.gov.au/construction/articles/zero-harm-at-work-leadership-program ), fatalities continue to increase but zero remains unquestioned? Hmmm. Questioning Zero is the great taboo!
Another bias of the Brady review is the way it interprets the works of Prof K. Weick through the lens of Hopkins. Weick comes from the discipline of Social Psychology. One needs to frame what one knows of Weick through such a lens. Weick’s first book The Social Psychology of Organisaing is a must read (1969) and this helps one understand the way in which he thinks about High Reliability Organising. He makes it clear in his later writings that there is no such thing as a HRO! There is no such thing as a static High Reliability Organisation. There is no stasis for humans nor place where we ‘arrive’. There is only HROing. You can read here how his colleague Suttcliffe explains the problem: (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3388695/)
‘Despite everything we know about HROs, there is no recipe for transforming an organization into an HRO. Put another way, there is no easy path to achieving safe and reliable performance. Some HRO scholars emphasize the idea of high reliability organizing rather than high reliability organizations to highlight two issues. First, high reliability is not a state that an organization can ever fully achieve; rather, it is something the organization seeks or continually aspires to. Second, reliability is fundamentally a dynamic set of properties, activities, and responses’.
In the Weick meaning of HRO, one never arrives or can arrive. All organisations are fallible and grouped around fallible people. There is no ‘drift’ into failure. Yet, the Brady review states: ‘In all industries there is a tendency to simplify – in part because of a Newtonian drive to break a system into components (7.4 p.70)’. The opposite is the case. The reason why there is so much excess of paperwork in the safety industry is because Safety loves bureaucracy and minutia. This is because Safety trusts no one and believes that knowledge in risk is cognitive. The opposite is the case. There is no discussion in the Brady Review on intuitive knowledge and the part heuristics play in incidents.
Weick was right, the human disposition and that of organisations is a ‘reluctance to simplify’. One thing I will predict from this Brady Review is that paperwork and complexity will further increase. We can see this in the logic of the recommendations:
Recommendation 1. Drawing causal connections between fatality rates and increasing or decreasing vigilance is unfounded (p.iii). There is no evidence to demonstrate that fatalities are due to a lack of vigilance but that’s what Brady asserts. So, what comes with increased vigilance? More policing, more detail because the culture of Safety is dominated by a lack of trust. It’ s only Safety who knows what is safe.
Recommendation 2. Shows the engineering worldview in the review. Once again the focus is on a fixation with causation and systemic failures.
Recommendation 3. More training of course will lead to more paperwork, again the assumptions is that fatalities occur due to problems in cognition.
Recommendation 4. Similarly a focus on more supervision under the rubric of vigilance will lead to more policing.
Recommendation 5. Predictably, in comes the ‘enforcement’ of controls and the mythology of the Hierarchy of Controls. Just what safety wants to hear.
Recommendation 6. Is founded on the mythology of the HRO. There is only HROing. Organisations never ‘arrive’ neither do they ‘drift’ into failure. Such constructs imposed on organizational life come from an assumptional positions of either completeness or perfection. Perfect for the ideology of zero.
Recommendation 7. In comes the focus on the Regulator. Regulators are not institutions of learning, neither are they able to approach the challenge of risk through a methodology of learning. To shift the Regulator from its current punitive focus would take nothing less than a cultural revolution.
Recommendation 8. The key question here is: Why is it that people and organisations don’t report? Of course, one would need to look here at deep cultural issues, something the review doesn’t do.
Recommendation 9. Next incomes more measurement and different measurement. Shifting a measure from LTI to LTIFR changes nothing. Indeed, now the mining industry will not drop the old measure but start fixating on both. Neither are connected to safety. There is no relationship between injury rates and safety, it is all an attribution.
Recommendation 10. Again, more measures this time Serious Accident Frequency Rate SAFR as a measure of safety in the industry. Read the sub-text, more measures and more paperwork.
Recommendation 11. High Potential Incident Frequency Rate (HPIFR) as a measure of the level of safety in the industry. Read the sub-text, more measures and more paperwork.
So, that is it. There you are Mining Qld, you have your review. Keep up with zero even though fatalities are increasing, keep up your vigilance, counting and measures, keep up with more policing and mystically hope that things will improve. Keep thinking within the disciplinary bubble that creates for your own intellectual and cultural comfort because the next review from within the club may be in 5 years.