Category: assurance

Everything is Green: The delusion of health and safety reporting

~ My safety thoughts ~ 10 Comments

Over the past 12 months, I have been engaged in a significant amount of health and safety “assurance” work, helping organisations to try and understand if the health and safety risks in their business are effectively managed.  Perhaps the most enduring image to come out of the last 12 months for me is the misleading and dangerous assumptions people make based on health and safety reports. 

 Often, when people look to criticise health and safety reporting, they point to lag indicators such as injury rates.  I do not want to talk about injury rates as a measure of health and safety performance in this article, so I would like to put that issue to bed with this observation from the Pike River Royal Commission: 

“The statistical information provided to the board on health and safety comprised mainly personal injury rates and time lost through accidents … The information gave the board some insight but was not much help in assessing the risks of a catastrophic event faced by high hazard industries. …  The board appears to have received no information proving the effectiveness of crucial systems such as gas monitoring and ventilation.” 

Let’s be clear.  There are no major accident enquiries that have identified personal injury rates as a legitimate measure of the effectiveness of health and safety management.  Personal injury rates are a measure of how many personal injuries have occurred – no more.  Any organisation that assumes personal injury rates are a measure of the effectiveness of their safety management system is misguided.  We have known this for decades. 

The challenge is not managing personal injury rates.  The challenge is proving the effectiveness of our crucial systems for managing health and safety risk.  If our systems are effective to manage health and safety risks, improved safety performance should follow. However, the reverse does not hold true, and countless major accident enquiries have identified fundamentally flawed safety management systems disguised by good and improving personal injury rates. 

We have seen over time the development of so-called “lead” indicators as a counterpoint to traditional, lag indicators.  Lead indicators, supposedly designed to provide insight into the effectiveness of safety management systems. 

But do they? 

Overwhelmingly, lead indicators are nothing more than a measure of activity and the fact that our measures of activity have 100% compliance – they are all green – creates a dangerous illusion of safety. 

A popular “lead” indicator for safety and health is the number of management interactions.  These might be variously described as safety conversations, safe act observations, behavioural observations, safety interactions, management walk arounds and so on.  Inevitably, they show up in a health and safety report as part of a table of lead indicators or a dashboard of “traffic lights“.  These indicators, or traffic lights, are usually coloured red if the indicator has not been met, amber if it has not been completely met and green if the requirement has been met. 

Other, typical indicators might include: 

·    Corrective actions closed;

·    Audits completed;

·    Training completed;

·    Hazards identified; or

·    Pre-start or “Take 5” cards completed.

No doubt there are countless more. 

The difficulty with all of these indicators is that they are measures of “activity“.  Invariably, they tell us whether things have been “done“. 

They tell us nothing about the quality or effectiveness of the activity. 

They tell us nothing about the influence of the activity on safety. 

They make no contribution to proving the effectiveness of our crucial systems. 

One of the phenomena that I have observed about health and safety management over the years is the notion of the “safety paradox“.  The safety Paradox supposes that everything we do in the name of health and safety can both improve and undermine safety in the workplace.  A very good example is a frontline risk assessment tool such as the JHA. 

The JHA is a ubiquitous frontline risk assessment tool implemented by organisations all over the world.  At its best, it can be an effective mechanism to help frontline workers identify the risks associated with their work and develop suitable controls to manage those risks. 

Conversely, it also can disengage the workforce from the safety management message of the organisation and drive a complete “us and them” mentality. 

Research suggests that significant numbers of workers see frontline risk assessment tools like the JHA as a backside covering exercise, designed to protect managers from legal risk in the event of an accident.  In most workplaces, this idea does not come as a complete shock, and there is a general acceptance of the limits or weaknesses inherent in the JHA.  However, the use of the JHA continues to roll on without analysis, without thought, without critical thinking and certainly without any reporting at a managerial level about its effectiveness. 

I have never seen a health and safety report that provides information to the executive about the effectiveness of the JHA system in the business.  Given that the JHA is one of the most critical tools used by organisations for the management of high-risk activities (including working at heights, confined space entry, lifting operations and so on) I find this extraordinary. 

I am not going to advocate whether organisations should use a JHA.  But I don’t think there could be any reasonable argument for an organisation not to know whether their use of the JHA is beneficial to safety or is undermining it. 

What about incident investigations? Are Incident investigations an important system in safety management? 

Whenever I asked this question in training workshops, everybody immediately tells me that incident investigations are very important.  If I asked the question: 

On a scale of 1 to 10, with one being unimportant and 10 being critically important, how important our incident investigations? 

Inevitably the answer is 9 or 10. 

But does your system of incident investigation work?  If it is such a crucial systems, how do you prove its effectiveness?  This was an issue that the Pike River Royal Commission wanted to understand, and they looked at it as follows: 

“The workers reported many incidents and accidents.  The commission analysed 1083 reports and summarised a selection of 436 and a schedule. …  there were problems with the investigation process … Incidents were never properly investigated.” 

If you are interested, an extract of cross-examination from the Royal Commission asking questions about incident investigations is available here.  It provides an interesting insight into the sorts of issues managers need to address when their safety management systems are being critically analysed. 

Again, I have never seen a health and safety report that provides information to the executive about the effectiveness of an incident investigation process.  Would it be so unreasonable to expect, and given the apparent criticality of incident investigations, that once or twice a year somebody will prepare a report for executive management summarising incident investigations and forming a view about their quality and effectiveness? 

Finally, let’s go back and consider management interactions.  As I indicated above, these are a very common lead indicator for safety management, but they are also very limited, often nothing more than a measure of how many interactions have been done.  There is typically no measure or analysis about whether interactions were done well or whether they have added value to safety management. 

It seems universally assumed management interactions around health and safety are a good thing but are they? 

What is their purpose, what are they designed to achieve and how do we know that they are achieving that purpose?  Is there a risk that management interactions could be undermining safety in your workplace? 

How do you know the or managers are not just wandering around practising random acts of safety, reinforcing unsafe behaviours and generally just pissing everybody off? 

A green traffic light in a health and safety report as an indicator that everybody who should have had a management interaction has done one is misleading and fuels the illusion of safety which underpins so many catastrophic workplace events. 

When was the last time anybody provided health and safety reporting that made any meaningful contribution to proving the effectiveness of crucial systems?  Have any leaders ever received a report showing a detailed analysis of lifting operations over a 10 month period with a formal, concluded you about the effectiveness of the safety management system to control the risks associated with lifting?  What about dropped objects?  What about working at height? 

What about the efficacy of your permit to work system?  Has that ever been analysed and reported on, other than on a case-by-case “reactive” basis following an incident? 

For your next health and safety “reporting” meeting, try this: Scrap your traditional health and safety report, pick a critical risk such as working at heights, and ask your safety manager to provide you with a presentation about whether, or to what extent, the risk has been managed as far as reasonably practicable.

What is your health and safety reporting really telling you, as opposed to the assumptions you choose to make?  Is there any evidence that it is proving the effectiveness of your crucial systems?

 

 

 

 

 

Welcome to the intellectual vacuum that is political comment on WHS

~ My safety thoughts ~ 7 Comments

Today (29 October 2016) the ABC had an article on the ongoing coverage of the tragic loss of lives at Dreamworld in Queensland.

I have commented before about the disconnect between the loss of life in this workplace accident and the near weekly loss of life in Australian workplaces that the coverage of this incident highlights. That disconnect was underscored by a picture of the Federal Opposition Leader, Bill Shorten, laying flowers outside Dreamworld. I do not begrudge Mr Shorten the opportunity to express his condolences (or advance his political position depending on your level of cynicism), but I cannot recall too many times political leaders have given similar public displays of solidarity when people die at our construction, mining, agricultural or any other workplaces.

But what has prompted this article is the simplistic, reactive, leaderless response that politicians trot out in the face of these types of events.

The ABC Article reports Queensland Premier Annastacia Palaszczuk as saying:

“It is simply not enough for us to be compliant with our current laws, we need to be sure our laws keep pace with international research and new technologies,”

“The audit will also consider whether existing penalties are sufficient to act as deterrents, and whether these should be strengthened to contain provisions relating to gross negligence causing death.

“Because we all know how important workplace safety is and how important it is to have strong deterrents.

“That’s why Queensland has the best record in Australia at prosecuting employers for negligence – and we are now examining current regulations to see if there are any further measures we can take to discourage unsafe practices.”

The idea that we “should not be compliant with our current laws” is both a nonsense and a failure of policy makers to properly accept the findings of the Robens Report published in the mid-1970’s. The reason our laws cannot keep pace with “international research and new technologies”, is because governments continue to insist on producing highly prescriptive suites of regulation which in most cases are adopted by organisations as the benchmark for “reasonably practicable”.

For most businesses, particularly small and medium-sized businesses, technical compliance with regulation is the high-water mark of safety management – an approach reinforced by the “checkbox” compliance mentality of many regulators.

WHS legislation is a leading example of this failure of policy, in so far as it increased the number of regulations in most of the jurisdictions where it has been implemented.

Flexible, innovative safety management requires a regulatory framework that promotes it, not limits or discourages it.  How can a regulator have any credibility when it calls on industry to keep pace with “international research”, when it continues to define safety performance through the publication of lost time and other lag injury rates?

Ms Palaszczuk then adopts the standard “tough on safety” call to arms, without taking the time to recognise inherent contradictions in what she is saying. She boasts that “Queensland has the best record in Australia at prosecuting employers for negligence”, but hints at tougher penalties still.

If the considerable penalties under the WHS Legislation and the “best record” of prosecuting employers are not a sufficient deterrent, why would “tougher” and “better” be any different?

I have written about these types of matters before, and would just ask that before policymakers go charging off in pursuit of higher penalties and more prosecutions, we stop and take the time to see if this tragedy can provide the opportunity lost during harmonisation and introduction of WHS legislation.

That lost opportunity was a chance to stop and consider the way that we regulate and manage health and safety in this country.

And can we start with the question of whether criminalising health and safety breaches and managing safety through a culture of fear driven by high fines and penalties is the best way to achieve the safety outcomes we want?

What is the evidence proving high penalties and prosecutions improve safety outcomes?

Are there ways that we can regulate safety to provide significant deterrents and consequences for people who disregard health and safety in the workplace, but at the same time foster a culture of openness, sharing and a willingness to learn and improve?

Can we redirect the time, money, expertise and resources that are poured into enforcement, prosecution and defending legal proceedings in a way that adds genuine value as opposed to headline value?

This is a chance to stop and think. This is a chance for the health and safety industry to stand up, intervene and take a leadership role in health and safety.

If we do not, the intellectual vacuum will continue to be filled by the historical approaches that have brought us to where we are today.

Systems as Imagined v Systems in Practice

~ My safety thoughts ~ 1 Comment

The recent NSW Supreme Court decision, Attorney General of New South Wales v Tho Services Limited (in liquidation) (ACN 000 263 678) [2016] NSWCCA 221 is another in a long line of decisions that highlight the disconnect between safety management systems as they are documented, and what occurs in practice.

Documented safety processes are important.  They provide guidance on how safety is managed and evidence that an organisation is meeting its obligations.  However, where an accident reveals long-term, systemic non-compliance with obvious safety expectations documented safety processes do not provide a defence, often they do not provide mitigation, and in cases such as this they are an aggravating circumstance.  As the Court noted:

The vast range of induction and supervising protocols adopted by the respondent or in force at its premises serves not to relieve the respondent of its responsibility for safety but on the contrary powerfully reinforces the extent to which the respondent failed to put them into practical effect.

For documented safety processes to add value they must:

Be consistent with the organisations risks and obligations;

  1. Be completed correctly; and
  2. Reflect what actually happens in practice.

All too often, documented safety management systems are one of the biggest contributors to the illusion of safety: the gap between the management of health and safety risk as we imagine it and what actually occurs in practice.

These are concepts that I have explored in my recent book, Risky Conversations: The Law, Social Psychology and Risk, and its accompanying video.

You can access a more detailed article about the case here.

 

Work as it is actually performed: investigating when nothing happens

~ My safety thoughts ~ 1 Comment

There has been some discussions and commentary in various online forums recently looking at the issue of “positive” incident investigations.  Although there seems to be a variety of nuances in the description of positive investigations they focus on “what went right“.

Some of these investigation models have also incorporated a broader management technique of “appreciative enquiry“, which, as I understand it, came to prominence in the late 1980’s (see HERE for examples and information about appreciative enquiry).

The discussion about these frameworks describes the “what went right” philosophy as a positive view of investigations. It is a philosophy that does not focus on blame, but promotes discussion:

The benefit of that approach is that the conversation with witnesses is an entirely positive one. It is not about what could have happened. Not about the doom and gloom narrowly averted. Rather, it is about their heroic act, well designed process or lucky event that allowed us to avoid the adverse outcome. People love talking about positive things particularly if they had something to do with them. (https://www.linkedin.com/pulse/investigate-your-serious-near-misses-positive-way-michael-tooma?trk=prof-post)

 In my view, when organisations are not mature enough to talk about issues in a non-judgmental way, without attribution of blame, the “what went right” enquiry may present a risk.  It may be seen as a contrivance, with the facilitator spending a lot of their time saying things like “remember this is not about blame“.

In “mature” organisations the need to construct a system of enquiry to focus on the positive and avoid discussion of blame is largely redundant because the participants are aligned with and support the goals of the organisation.  Their desire to support the goals of the organisation overrides any petty, personal concerns about individual praise or blame.

If you have ever been privileged enough to work with high-performance sporting teams or elite military forces, you will understand this idea.

A precondition of belonging to these groups is the willingness to say and hear things that support the group’s objectives without personal agendas or taking personal affront.  The newest member of the team has a license to speak frankly about the performance of the most senior, and the most senior is expected to accept that conversation, not in the context of them personally, but in the context of the overall objectives of the team.

The extent to which organisations have to contrive a system whereby participants are corralled by a “what went right” narrative says a lot about the culture of an organisation and the “buy in” that people have to team objectives.

That is not to say that appreciative enquiry or investigating “what went right” does not have a place in organisations, nor that it could be an important building block along the way to developing something like an elite performing team.  But as a word of caution, you should also understand some of the paradoxes involved.

The Safety Paradox supposes that any initiative done in the name of health and safety has the potential to both improve and damage health and safety in a workplace.

Having sat through appreciative enquiry “management brainstorming sessions” and incident investigations there is a strong sense of “flavour of the month” initiative as well as an even stronger sense of avoiding accountability.  An overriding impression of a process delivered without context or explanation – why this and why now?  The end product is a wall of butcher’s paper populated with sweeping motherhood statements and management speak, completely absent any meaningful desire to manage known problems.

The pendulum, it seemed, had swung too far the other way.

Again, that is not to say it is not an idea that should not be explored and applied.  But it needs context.  It needs explanation; it needs skilful facilitation, and it needs, perhaps most importantly, dedicated and meaningful follow-up with implementation.  Otherwise?  Well, we have all been in “those” types of sessions.

Another aspect of the “what went right” investigations is the requirement for something to have occurred.  There needs to be an incident or near miss to trigger the enquiry.

A risk in the “what went right” enquiry (without more) is that it can contribute to the illusion of safety.

The illusion of safety is the gap between safety management as we imagine it in our organisation and what happens in practice.  Incident investigations can be a powerful tool in exposing the illusion of safety because they have the potential to illustrate the disconnect between what we think happens and what is happening.  By just focusing on “what went right“, particularly in near miss incidents, we may fuel the illusion of safety and create a narrative that our systems are working to protect us from these incidents – effectively papering over the cracks in the edifice.

While avoiding blame and promoting open discussion is important, so too is avoiding sugar-coating the situation.  Again, balance, transparency and genuine enquiry ought to be the goal.

I would like to suggest something different – investigating work as it is performed; investigating when nothing happens.

An investigation framework that I find useful uses systems as opposed to causal analysis.

It supposes that organisations have systems and processes in place to prevent certain things from happening and tries to understand:

  1. What should have happened: how should these are systems and processes have been applied in a particular case to prevent the particular thing from happening; and
  2.  What happened: how was the work performed in the particular case.

From there, we identify and try to explain the “gap” between what should have happened and what did happen.

This framework is not concerned with “causation“.  All identified gaps are given equal attention and analysis, regardless of their potential causal relationship with the incident.  They are all important because they all represent a potential systemic weakness in safety management which, given a different factual matrix, could be causal.

The attractiveness of this framework is that it can help you identify systemic weakness when nothing has happened.

A few years ago I was involved in an incident leading to the prosecution of a client following a working at heights incident.  The incident and the various investigations that followed revealed the usual list of suspects:

  •  Training not followed;
  •  Procedures not followed;
  •  Risks not identified;
  •  Lack of supervision;
  •  Documentation not completed properly, and so on.

As part of working with that client, we applied the systems analysis framework to a range of other, similar high-risk work, including:

  •  Examples where the same task had been performed;
  •  Examples of different working at heights tasks; and
  •  Examples of other high-risk work tasks, including lifting operations and confined space entry.

In every case, the work had been performed “successfully“, without incident or near miss.

However, the analysis of the gap between how the work should have been performed and how it was performed demonstrated the same types of “failures” in the way that work was ordinarily performed as when the incident occurred.

In other words, even when work was “successful”, procedures were not followed, risks were not identified as well as they could have been, training was not complied with, documentation was not completed and so on.

The systemic weaknesses were not just present at the time of the incident.  They were characteristic of the way work was performed in the days and months previously.

The incident was not a one-off departure from an otherwise “good” system – it was simply evidence of otherwise broader, systemic failures.

Moreover, this system analysis approach highlighted weaknesses hidden by the traditional safety metrics – injury rates, action items closed out, hazards reported, management site visits, etc. – all of which were “green“.

I have applied this method of review from time to time over the years where I have been able to convince clients of its value.  On every occasion it brings to light the gap between the safety as imagined and safety in practice, lifting the veil on the illusion of safety.

In the Pike River Royal Commission, the Commission carefully examined Pike River’s system of incident investigation to understand if it “worked“.  They reviewed 1083 incident investigations and did a detailed examination of 436 of them.  Managers were subject to examination of their understanding of the investigation process, and ultimately the Commission found that “incidents were never properly investigated“.

You can see an example of the examination of management HERE.

Weakness in incident investigations, amongst other important systems elements, formed the basis of significant criticism of Pike River and its management:

 Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands.  Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that the health and safety management was not taken seriously enough at Pike.

 What do your philosophy and implementation of incident investigations say about you?

The Safety Paradox and the challenge of health and safety assurance

~ My safety thoughts ~ 14 Comments

I am currently working on a new book on practical health and safety assurance, which I hope to have out by the end of the year, but I recently came across an article published through LinkedIn entitled Six Mistakes H&S Managers Make with Occupational Health & Safety.

I do not want to comment on the article itself, although it is worth a read. It was the following paragraph that caught my attention, and goes to the heart of what I am trying to explore in the context of health and safety assurance.

Habits are what save us when our mind is not consciously on the job. Many of the health and safety systems we use (such as Take-5s, prestart talks, and health and safety observations) are aimed at creating habits in people’s minds so that they are constantly aware of hazards in the work environment, and can react when they see something that is about to hurt them. Each little action and health and safety discussion might not prevent an incident itself, but they all add together to create valuable health and safety habits. Do not think that you are repeating this training or talk for the millionth time and that you are wasting time and money. When the crisis hits it will probably be these repetitive sessions that will prevent great harm or loss.

First, let me explain what I mean by the Safety Paradox. The Safety Paradox is my theory that all health and safety initiatives have within them the potential to both improve and undermine safety, and one of the significant ways that safety initiatives undermine safety is by contributing to the Illusion of Safety.

The Illusion of Safety is characterised by the Gap between the safety system as we imagine it, and the system in practice, and it is often caused by activity: Because we are doing a lot of stuff for safety, it must all be good and positive and lead to a good safety outcome.

We know that not all safety initiatives are always good, and that safety initiatives can undermine safety.

Research into JHAs and other frontline risk assessment tools shows how they can disengage the workforce from the organisation’s health and safety message, but at the same time create an unfounded sense of comfort in management that workers have – and are using – appropriate tools to manage risk (See for example: D. Borys, Exploring risk awareness as a cultural approach to safety: Exposing the gap between work as imagined and work as actually performed).

The Baker Panel Review into the BP Texas City Refinery Explosion referred to “initiative overload”, identifying that many well intentioned safety initiatives may have overloaded refinery personnel to the detriment of safety.

To my mind, the assumption that we are doing something in the name of health and safety, and therefore it must be good and it must be achieving the purpose for which it is intended is one of the foundational building blocks for the Illusion of Safety, and must be challenged.

So, in this case when the author says:

Many of the health and safety systems we use (such as Take-5s, prestart talks, and health and safety observations) are aimed at creating habits in people’s minds so that they are constantly aware of hazards in the work environment, and can react when they see something that is about to hurt them

Health and safety assurance requires us to understand that this outcome, this purpose – creating habits in people’s minds so that they are constantly aware of hazards in the work environment – is actually being achieved. The assumption that the purpose is being achieved flies in the face of the Safety Paradox, contributes to the Illusion of Safety and undermines safety and health in the workplace.

Health and safety assurance requires us to understand the potential negative outcomes of these safety activities. For example, to what extent does the constant requirement to fill out a piece of paper before every job (i.e. a Take – 5) desensitise the workforce to risk, trivialise risk or make the workforce think that management doesn’t trust them? To what extent does the workforce believe that these pre-job processes and signature collections are management’s attempt to, adopting the language of the Borys article above, “cover their arse”?

It is wholly insufficient for the safety industry to say that these safety initiatives are theoretically good processes, but not understand the potential negative outcomes nor to invest the time and energy to understand whether the safety initiatives are achieving their intended purposes.

And when the author goes on to say:

Do not think that you are repeating this training or talk for the millionth time and that you are wasting time and money. When the crisis hits it will probably be these repetitive sessions that will prevent great harm or loss.

surely there must be some onus to understand whether this thing that has been done for the “millionth time” is not having a negative effect? I can think of nothing more damaging for health and safety in the workplace than doing something for the “millionth time” and not knowing if it is achieving its purpose, or more damaging, undermining its intended purpose.

The safety industry must be accountable for its initiatives, and management must hold the safety industry accountable. It is simply unacceptable to continue to pump initiatives and processes into organisations on the theoretical assumption that they are “good” for safety without being able to demonstrate that those initiatives and processes are achieving the purpose which they were designed.

By the way, your injury rate performance is not a measure of whether your health and safety initiatives are achieving the purpose.