The Pain of Reporting…article by Paul Nieuwoudt (first published here: http://leadership-observer.com/index.php/blog/where-is-safety-leadership-headed) – raises some interesting questions about our current approach to our safety management and incident reporting systems.
More of Paul’s articles:
Earlier this week I met up with a friend who told me of a recent incident at his company. His account of the event was as follows.
A person was part of a work party that required the removal of some access doors. A JHA (Job Hazard Analysis) identified the weight of the doors as being a potential hazard because of the potential for injury while being manually lifted in-and-out of position. The JHA recommended that after unbolting the doors, two people were required to lift it from its place. For some unknown reason, one of the people involved tried to lift one of the doors alone and in the process sustained a back injury. This person contemplated the accusations, interrogations, paperwork and drama that would result from reporting the injury and chose not to report it. Despite suffering substantial discomfort, the person concealed the injury and continued working the rest of their shift and later sought private medical treatment where the doctor was told the injury was sustained at home.
No-one at this person’s workplace were any the wiser and their Health and Safety reporting system claimed an incident-free, and injury free, period. Their general management and safety management personnel congratulated themselves for maintaining an injury-free record. Meanwhile the injured person was still suffering; the reported safety excellence did nothing to lessen the discomfort to the person, nor negate the fact an injury had occurred.
In one sense there is nothing unusual regarding this event; after all, accounts of incidents being concealed pervade both industry forums and the internet. For some reason, however, I could not get this story out of my thoughts. I kept on wondering why a person would prefer to suffer substantial pain and discomfort rather than seeking assistance. The only answer that made any sense to me was that the “pain of reporting” was worse than the pain of the injury itself in the injured person’s estimation.
Without speaking with the person I cannot be sure, but I suspect the perceived “pain of reporting” may have involved some, or all, of the following:
- Disciplinary action for failing to comply with the JHA.
- Extended questioning, blame for failures, recriminations along with reams of paperwork.
- Perhaps their company had a Golden Rule or Life Saving Rule that may be perceived as having been broken. If so, this may have led to dismissal.
- Perhaps it was a perception that safety is about numbers and targets; therefore the negative impact of the incident on the numbers would incur wrath or recrimination.
- Perhaps it was a matter of personal pride and not wanting to admit having made a mistake to others.
Regardless of the individual’s motivation, I doubt whether anyone would want the above event for an outcome and I began to wonder if anything can be done to reduce the occurrence of such events.
There is an argument to say that the injured person failed to follow accepted practice and therefore deserved to be disciplined. A view that zero tolerance for violations will reduce harm has merit and deserves some consideration. I wonder though –
- Does the threat of discipline actually prevent procedural violations from occurring? Obviously not; otherwise we wouldn’t continue to have incidents like the one described above.
- Were those procedural violations committed with malicious intent? I have never heard any anecdotal accounts of violations being done for any reason other than to do the job.
- Does the threat of discipline inhibit free and open reporting of incidents? Yes, most certainly.
So if non-compliances are generally committed with good intentions, and if the threat of punishment does not stop violations from occurring but does inhibit the reporting of incidents, then where is the value to such an approach? Such an approach appears to end up in a lose-lose situation; the company is deprived of the opportunity for learning and improvement and the individual is deprived of care and support in a time of need.
So if that approach does not provide us with an outcome we want, what other approach could we consider? This is essentially a wicked-problem which makes finding possible improvements difficult. As a suggestion however, one alternative may look something as follows?
When someone is injured our first concern is for the person, their well-being, how we can alleviate their immediate discomfort and how we can assist in their ongoing recovery. Once we have satisfied that need, our focus moves to understanding what happened and what can be done to help reduce the likelihood of recurrence. Besides all the usual suspects (e.g. design considerations, equipment configurations and environmental factors) we would consider questions like:
- In what ways may our systems have contributed?
- Even though the hazard was identified the JHA did not prevent an injury – why not?
- What thoughts, drivers or motivations lead to the decision not to follow the JHA?
- Was there even a conscious decision not to follow the JHA; did the person forget or was there some other factor at play?
- Is there a shortcoming or fundamental flaw in the JHA process? Is a JHA the best tool for our circumstances?
- Why did the person’s actions make sense to them at the time?
- What other motivations, thoughts, priorities or distractions existed at that time?
- In hindsight, knowing what that person knows now, would they do anything differently? If so, what? If not, why?
This inquiry process is conducted in a non-judgmental manner and accepts that people do make mistakes. I make plenty of mistakes and I know every other human makes mistakes too. Blaming someone for making mistakes is essentially punishment for being human. Malicious intent is something different – if suspicions of malicious intent arise then these should be considered via a disciplinary process.
At no stage in this process is the impact on numbers considered; after all, we care about people – not numbers.
This approach it similar to our current aspirations, with the main differences being a greater focus on human factors, less blaming and an acceptance that our systems have shortcomings which may have contributed to the event. Could this change in focus, or something similar, lead to improvement? Is it worth testing this as an alternative approach to safety management?
Regardless of what approach we may choose to use, I believe there is a compelling reason to actively look for change i.e. we know our current approach doesn’t work very well. If you disagree and believe the current approach is fine, then consider the following questions and how they may apply to our various workplaces:
· What perceptions do the people on the ground (the trades, operators and support staff etc.) have regarding our approach to safety management?
· Do they perceive it to be an onerous, cover-your-back-type process or do they perceive the processes to be worthwhile?
· Do people perceive safety tools and safety systems to add meaning and value to their work?
· Do staff have a perception that investigations primarily focus on blame and judgment, or are investigations perceived as being collaborative and solution-oriented?
· Is management primarily perceived as caring for people’s well-being or about safety statistics?
In short, if we removed our safety management systems from use then would there be an outcry from the workforce? Would people say they cannot effectively and safely do their work without the system and angrily demand its return? The response to this is a sure sign of its perceived value!
The anecdotal responses that I have heard to these questions reflects poorly on us as leaders and managers. I suspect that you will have heard similar anecdotal concerns. The leads me to wonder where we are headed with regards to the management of safety and whether you see any need for change?
Do you have any different thoughts, concerns perceptions or experiences? Feel free to comment and share them with us. Do you agree – feel free to comment and tell us why!
More of Paul’s articles: