Found this interesting article posted recently by Jason Kunz and just wallowing in the Linkedin mud (HERE):
The Zero Safety Paradox
This is instalment four in a twelve-part series on the future of the Safety and Health (S&H) profession, and the Safety and Health professional. Insights are based on one of the largest and most comprehensive ongoing qualitative research projects on leadership in the safety and health field. Review part one here, part two here, part three here.
par·a·dox: a statement or proposition that, despite sound (or apparently sound) reasoning from acceptable premises, leads to a conclusion that seems senseless, logically unacceptable, or self-contradictory.
Research shows the average person speaks at least 7,000 words each day, with many speaking much more than that. Many of those words will dictate how people perceive you. Many carrying with them the opportunity to make a positive difference, or no difference at all depending on the tone and intent behind them, on just how and why they’re delivered. Those words also have the opportunity to make a negative difference or erode ones credibility. When we speak paradoxically, how does that influence change, or deteriorate the trust and confidence people place in us when our actions don’t align with our words?
Recently, a customer and I engaged in a conversation in which the words spoken both shifted my perception, and made a positive difference. Following a trip and fall incident in their company parking lot, I received a call from the site safety and health leader. As the story goes, an employee had tripped over their own feet, on a clear day, in a dry parking lot, with no apparent or identified underlying root causes outside of “lack of situational awareness.” The trip and fall resulted in an ankle sprain, and a lost-time incident. When the customer’s boss heard about the incident, the site safety and health leader was asked to create a “safe walking” procedure and provide worker training to accompany that procedure. The customer’s response to their boss’s request was classic:
These people have been walking since they were two years old, we cannot possibly believe we can teach them to walk safely! I can do many other things to reduce risk, but I cannot do that. What would the procedure say? ‘Left, right. Left, right?’
I hope you get a good chuckle out of the irony of this. I use ‘irony’ intentionally, because at the same site where the trip and fall incident occurred, hundreds of employees at this exact moment are engaged in dozens of highly hazardous tasks and activities. Many of those tasks and activities are identified as precursors to serious injuries and fatalities (SIFs) if the hazard controls in place fail.
The words we use each day matter.
One of the words the safety and health profession has been using lavishly and maybe too cavalierly for decades is “zero.” Zero in this particular context being an artificial construct adopted (in a variety of ways) by organizations across various industries. It states broadly and bluntly that all injuries are preventable, hypothesizing that a flawless incident record yesterday somehow predicts employee safety today. In other words, an extended zero-incident period represents some aspect (arguably the supposed pinnacle) of safety and health performance. Consider that for a moment. The presence of “good” today, forecasts a “good” tomorrow. The absence of “bad” yesterday, seemingly equates to the presence of “good” today. Where else do we measure the absence of negatives, in order to predict the presence of positives? Is that the best known way?
We must celebrate success, especially as 48 percent of U.S. workers today feel mentally and physically exhausted at the end of the workday, while another 41 percent report feeling burned out from their work. Studies show, nothing contributes more to a positive inner work life (the mix of emotions, motivations, and perceptions that are critical to performance) than making progress in meaningful work. In other words, if a person is feeling motivated at the end of the workday, it’s a good bet that he or she achieved something, however small, and celebrated that something. The question the safety and health profession continues to wrestle with is this: does the pursuit of nothing (zero), equate to the presence of something (safety, capacity, engagement, motivation)?
What Does the Research Say?
It is not clear when “zero” first appeared on the scene, but recognized authors such as Manuele and Tarrants have challenged this position for years, arguing that a zero-incident rate is “impractical and unattainable”. Landmark studies as early as 1939 showed that setting a goal such as zero can ultimately prove to be demoralizing (Dollard). P.L. Clements concisely and thoughtfully questions the validity of a “Journey to Zero” mentality in his paper, “Zero-Injury Workdays.”
My question for your consideration today is not:
- Is zero workplace incidents possible?
Unfortunately, bad stuff will happen. There is no science proclaiming zero is possible, simply ethically and morally based beliefs. As Dekker writes, “there is no research within the safety literature that a zero vision is achievable. All accident theories from the past decades acknowledge that a world of zero bad consequences is out of the question. A focus on zero can actually lead to a blindness of real risk. Most organizations that have suffered big calamities over the past several years had exemplary performance before they blew stuff up. Their numbers of minor negative events were really low, in fact even zero for some time. But while counting and tabulating largely irrelevant low consequence events, the definition of acceptable engineering risk had been eroding under their noses. They were counting what could be counted, not what counted.”
The question I’ll ask you to examine instead, for your organization and customers, is this:
- Could a “zero incident” mentality be detrimental? If so, what are the possible unintended consequences or negative effects?
Consider the following study conclusion and excerpt by Dr. Fred Sherratt and Andrew R. J. Dainty:
You are actually marginally more likely to have major/specified incidents (SIFs) working on a large UK construction site operated by a company that has adopted zero within their safety strategy, than if you are working on a site without it. Secondly, it has also enabled the consideration of theoretical criticisms of zero to be placed within an empirical context, both in terms of safety outcomes (incident rates) and time. Within this study, there is no empirical evidence of greater improvements in safety management and resultant outcomes for companies that have adopted zero than those who have not.
If you take only one thing from today’s article, let it be this:
Your organization does not have a world-class safety and health culture because it has a low number of incidents. In fact, the opposite may be true.
Research in Human and Organizational Performance (HOP) shows that we make between 5-20 errors per hour on average.
“Everybody makes errors, everybody. The very worst performers make errors. The very best workers make errors. Error is a predictable and natural part of being a human being. Contemporary wisdom says that the average skilled worker, workers who work with their hands, make 5-7 errors per hour. That same wisdom says that a knowledge worker, workers who work with ideas and concepts, make between 15-20 errors per hour.”
If your company has 100 frontline employees, that’s ~4,800 errors per shift. That number of mistakes, coupled with the fact that many of our organizations conduct moderately to severely hazardous work within complicated to complex systems makes “zero incidents” not only seem unlikely, but implausible.
With that, we must acknowledge that as safety and health professionals and morally driven human-beings there is seemingly no justifiable goal outside of “zero.” Anything more (e.g. one injury per day) implies that our organizations accept physically injuring people as a cost of doing business. Imagine an organization with a “Journey to One” mindset, in which the organization randomly selects one unfortunate person each day/week/month/year who is going to “take one for the team,” putting a new meaning to “fall guy” and creating an unfathomable scenario for any company.
The paradox, as stated prior, is the fact that there is no theory nor science supporting that zero injuries and illnesses is practicable. Yet, the only morally and ethically responsible outcome to strive for is in fact, zero.
What if “is zero possible” isn’t the right question? How about “is zero relevant,” possibly detrimental considering the context? Could that be the better question?
Let’s look at a few tragic and often-referenced examples of the paradox of “zero.”
A gas release in 2014 resulted in the tragic death of four workers in the town of LaPorte, Texas. Two of the four workers being brothers, meaning one family was forced to organize two funerals in a single week as Sidney Dekker observes in his 2018 talk to Domain Driven Design, titled: The Human Factor: Pursuing Success and Averting Drift into Failure.
Dekker goes on to say: “The irony is there for everybody to see (see image above and timestamp 7:47 in Dekker’s talk). What are they actually telling their people to do when they come on-site? To reduce errors by taking extra precaution when driving or walking. But that’s not what killed their people. It’s a gas release that killed their people. Nobody got killed, or got their life changed by walking or driving on that site.” Dekker continues, when referencing the possible repercussions of a zero-safety paradox: “you could argue quite forcefully on the basis of the evidence that the absence of negatives predicts that a spectacular failure is more likely to happen. This is the risk when we focus, when we obsess on reducing negatives. When we obsess on making error and incident go away. We make ourselves deeply vulnerable to the big bang…”
Considered to be the largest oil spill in the history of the petroleum industry. For the seven years prior, the rig, operated by Transocean had not experienced a single lost-time incident in 7 years of drilling.
Compare that to the following 6 “lost-time incidents” in the past 12 months within my own household. Injury 1: displaced right fibula fracture. Injury 2: grade two right ankle sprain (anterior talofibular and calcaneofibular ligaments). Injury 3: bee sting, right medial thigh. Injury 4: bilateral plantar fasciitis. Injury/Illness 5: symptomatic COVID-19 virus infection. Injury/Illness 6: asymptomatic COVID-19 virus infection.
126 workers in a highly hazardous environment (an offshore oil rig), zero lost-time incidents in 7 years. Two “workers” within the confines of their own home, 6 lost-time incidents in 12 months. Paradox? Or unacceptable premise?
At the same time, certain organizations seem to be facing the opposite challenge, and finding it justifiable – preventing significant injuries and fatalities (SIFs) at the expense of minor, yet lifelong debilitating ergonomic injuries. Is it possible to overfocus on preventing high hazard mishaps, dismissing “minor” injuries and justifying their acceptability?
According to officials, at the time of the explosion, 126 people were on board the rig, of whom 79 were Transocean employees, seven were from BP, and 40 were contracted; several of the BP and Transocean executives were on board just hours prior to the explosion for a tour of the rig, maintenance planning, a safety campaign, and to congratulate the senior staff of the rig for those seven years of operations without a lost-time incident.
A total of 115 people were evacuated. Lifeboats took 94 workers to a supply boat with no major injuries, four were transported to another vessel, and 17 were evacuated by helicopter to trauma centers. 11 people tragically never made it home.
In 2005, BP was touting an injury rate many times below the national average at its Texas City facility.
At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at the refinery during the restarting of a hydrocarbon isomerization unit. The explosions occurred when a distillation tower flooded with hydrocarbons and was over pressurized, causing a geyser-like release from the vent stack.
Piper Alpha was an oil platform located in the North Sea approximately 120 miles (190 km) north-east of Aberdeen, Scotland. It was operated by Occidental Petroleum Limited and began production in 1976, initially as an oil-only platform but later converted to add gas production. An explosion and resulting oil and gas fires destroyed Piper Alpha on July 6, 1988. During the investigation inquiry following the incident, the rig manager stated:
“I knew everything was alright, because I never got a report that anything was wrong.”
What is Your Definition of Zero?
At this point, it may seem as if I am leaning in a particular direction on the subject of “zero,” while encouraging you to follow. That is not my intent. My intent is to pose more questions than answers, inviting you to take a hard, risk-based approach to defining what “zero” could mean to you, your organization, and your customers. I don’t know your organization personally, which means I cannot possibly understand the complexities and intricacies you manage each day – I won’t pretend to. What I believe to understand, and the research shows, blindly adopting a “zero” mentality can have repercussions. For this reason, whether you consider yourself a safety and health professional or not, I cannot urge you enough to engage in this conversation. Not just here, but with your senior leaders, customers, and stakeholders. We have an opportunity to move past zero as a polarizing metric that often leads to divisive monologues, to zero as a starting point for crucial conversations and humble dialogues. Doing so, not for the sake of moral high ground or righteousness, but for the purpose of benefitting those at the sharp end of the stick.
So, I’ll ask, what is your definition of “zero?” Please comment below with your perspective.
I posed the same question to a handful of the research participants to understand theirs. Once again, the words spoken both shifted my perception, and made a positive difference. In a world driven by data, you might be surprised at the high-level of subjectivity across their responses.
- “It’s not zero injuries, I don’t believe that’s attainable. But it is zero serious injuries, fatalities (SIFs), and / or environmental impact. This is a more meaningful and attainable goal.” Obed Varela
- “Zero is an altruistic goal. The place to strive for, but realize that when dealing with people, it is not attainable or achievable. One can get close, but it is very hard to sustain.” Brad Giles
- “An aspiration that leaves little room for failure or unforeseeable circumstances, and may inhibit growth. Depending on the organizational culture, zero can even become a fear tactic.” Subena Colligan
- “Zero blame when it comes to investigating workplace injuries and incidents. Although we have been conditioned to think ‘zero injuries and incidents.'” Diana Stegall
Weighing the Pros and Cons
I would be remiss to not cite the organizational benefits of a zero incident goal, mentality, or vision. Especially as hundreds of well-regarded organizations, run by incredibly intelligent people continue their passionate pursuit. As it stands today, lower reporting risks can have several benefits for the organization. Dekker references some of those in The Field Guide to Understanding ‘Human Error’. Showing low numbers of incidents can:
- Lead to significant cost-savings on healthcare, insurance and other compensation costs
- Create a better chance at getting contracts renewed or securing additional work
- Reduce the likelihood of regulatory inspections
In addition, if your organization or industry is insured or self-insured for the cost of incidents and injuries, there are significant incentives to not having any. With that, there are challenges, even consequences with frivolously adopting a zero incident goal or aspiration, especially if your organization’s actions are not aligned with it’s ambitions. Before simply adopting a “journey to zero” campaign or mentality within your organization because it feels like the “right thing to do,” the following might be considered.
A “zero” mentality may:
- Create a culture of incident secrecy, in which the workforce fears sharing bad news with the boss or their frontline colleagues
- Create skepticism in frontline workers whom have been shown to become calloused to zero sloganeering without evidence of tangible change in local resources or practices. A survey of 16,000 workers revealed widespread cynicism in the face of a zero vision. Not only does it not engage workers in any meaningful way, there is nothing actionable in a mere call to zero the frontline can identify and work with (Dekker). In other words, doing nothing in order to achieve something is simply not possible.
- Cause investigation resources to be misspent as the result of a zero-incident goal. If zero is assumed to be achievable, then everything is preventable. If everything is preventable then everything must be investigated. This includes minor sprains, rolled ankles, paper cuts, and bee stings.
The Four Horsemen
In certain contexts, it may be logical, even beneficial to study the absence of negatives in an effort to create positive results. Case in point, research by The Gottman Institute can predict whether a couple will divorce with an average of over 90% accuracy, across studies using the Four Horsemen.
According to the research, married couples whose communication styles include criticism, contempt, defensiveness, and stonewalling spell disaster for those relationships. Gottman writes, “being able to identify the Four Horsemen in your conflict discussions is a necessary first step to eliminating them, but this knowledge is not enough. To drive away destructive communication and conflict patterns, you must replace them with healthy, productive ones.” Thus, in this particular context it can be useful to study divorce in order to understand how to successfully be married. But, the critical point to understand is that the absence of the Four Horsemen is not nearly enough. They must be replaced with the presence of their antidotes (gentle start-up, appreciation, responsibility, and physiological self-soothing).
This begs the question, have you considered what the “Four Horsemen” could be within your organization? Not for the prediction of relational calamity, but to understand the precursors of serious injuries and fatalities (SIFs). Indicators that could help determine, even predict your vulnerability to the next SIF with a high-level of accuracy. What if identifying these triggers, and then replacing them with their “antidotes” was a necessary step towards enhancing your organization’s capacity, and thus your ability to protect people, property, and the environment?
See below for a few of the research participants “Four Horsemen” of safety and health. What are yours? Special thank you to Josh Franklin for his support in synthesizing these.
- Horseman #1: Target Alignment Error, e.g., incentive programs in which workers receive prizes or awards for reaching a zero-incident workplace.
- Horseman #2: Passing the Buck, e.g., signs, sloganeering, mirrors, banners that read: “You are the person most responsible for your own safety.”
- Horseman #3: Counting the Trees, Missing the Forest, e.g., workplace signs or scoreboards that track the number of hours or days without a lost time or recordable injury.
- Horseman #4: Behavioral Fallacy, e.g., programs where workers observe co-workers and record their safe behaviors or unsafe acts, focusing attention away from workplace hazards and reinforcing the broken, “Old View” that incidents result from workers bad behavior, rather than from hazardous conditions (Dekker).
If there were a “Fifth Horseman”, what would it be? A blatant disregard for workplace safety and health policies? Please share your perspective below.
Where Do We Go from Here?
7,000 words each day. Each one carrying with it the opportunity to make a positive difference, or no difference at all. The words we use each day matter, and influencing change happens by way of conversation, not on account of pontification. If you were asked today why your organization has adopted a “journey to zero” mentality, how would you respond? Similarly, if you were asked why not, what then? The paradox continues; no theory nor science supporting zero injuries and illnesses is possible, yet the only morally and ethically responsible outcome to strive for is in fact, zero.
Let me offer, a true zero endgame isn’t focused on an outcome, but instead deploys time, energy, and resources into the processes we can “control”, while balancing organizational dialogue where “zero” is expected in certain aspects of the business (reliability), then juxtaposed with other aspects of operations. When defective parts are “incidents” – we focus on processes to drive them out. We don’t reduce defective parts by [just] saying “zero defects” – we focus on the process that produces the product.
If your aspiration is zero SIFs, how? If you are committed to zero unsafe conditions, have you identified where they reside? Great, your senior leaders, site managers, and frontline supervisors are committed to zero negative management influence, who will help show them the way?
In order to achieve any outcome, you must monitor the inputs – reverse engineering the outcome with your daily decisions and actions. Far too many organizations continue to obsess over the product (“zero”), but aren’t committed to emulating the processes required to produce it. When we obsess over the outcome, we often fail in our obedience to the process.
“Zero” cannot solely be about achieving an improbable outcome. But it can drive adherence to proven processes. Processes that effectively engage the frontline worker in authentic conversation, versus suspicious observation. Processes that drive the implementation of effective and efficient hazard controls, thus creating capacity within our systems. Processes which celebrate the presence of that capacity, instead of obsessing over the counting and tabulating of the absence (or presence) of negative outcomes. We cannot engineer systems (nor workers) to be perfect, but we can create systems in control.
If you insist on measuring zero, zero what? Strains, dropped loads, rolled ankles, falls from 6 feet, paper cuts, SIFs, spills greater than 1 gallon? Clarity is power. When looking at a snapshot in time, many believe with deep conviction that zero is possible. What do you believe?
As you engage in conversation with your senior leaders, customers, and stakeholders on the topic at hand, consider another paradox:
“By working towards zero injuries, you’re still focusing on injuries. ‘Don’t get hurt, don’t get hurt,’ meaning you are still calling into the non-conscious, ‘getting hurt.’ Instead, a 100% healthy workforce is a focus on the outcome we truly desire. But how do we get there? 100% of our workers returning home both safe and well each day/week/year/career. It’s well-studied in neuroscience. Take for example a golfer saying, ‘don’t hit it in the water, don’t hit it in the water.’ That ball is 100% going in the water. Get clarity on the outcome; commit to the necessary inputs.”
- Keith Mercurio, Senior Director, CEO, research participant with nearly 20 years of experience in human performance and development
We’re never going to be perfect – if there is even such a thing. “Our pursuits should be aimed at progress,” Ryan Holiday writes, “however little that it’s possible for us to make. Perfectionism rarely begets perfection – only disappointment.”
Perfection is not the goal, progress is. What conversations do you need to have to progress your organization’s performance? In those conversations, what words will make a positive difference, and who do you need to be in order to shift perceptions? What would that person do to create an environment that not only protects people, property, and the environment, but keeps them out of the water? We must not allow perfection to be the enemy of progress, and we have significant progress to make. Paradox, or acceptable premise?