Safety and Resilience. More than the absence of events.
Background
Safety measures currently used in industry commonly measure negatives, such as the number of events and injuries. An example is the ‘Total Recordable Injury Frequency Rate’ (TRIFR), which measures the number of lost-time injuries per million hours worked during a financial year. The assumption is that safety at the workplace increases as TRIFR moves towards zero. Like most safety measures, TRIFR is aiming for zero. When reaching zero, however, nothing remains to be measured. Consequently, a safety measure is required that moves away from zero.
The Safety & Resilience Indicator (SRI) is a new indicator that builds on contemporary safety theory and practice, namely the principles of Human and Organisational Performance (HOP). HOP is an operating philosophy and way of thinking about how organisations can improve safety in the workplace. It’s a way of understanding how humans perform and how organisations can build systems that are error tolerant and forgiving when people make mistakes. People in organisations are considered the problem solvers rather than the problem to control. Safety is the presence of capacity – not just the absence of events. Capacity is the availability of unused resources to successfully deal with eventualities. Organisations need to continuously learn from everyday operation and understand the availability and/or lack of capacity and controls by consulting with the involved stakeholders, from workers to leaders. The resulting knowledge from operational learning can be utilised to address and resolve safety challenges. The SRI operationalises the six (6) HOP principles.
Even the Best Make Mistakes
No matter how well-trained people are, everyone can make a mistake. To err is human. A mistake is an unintended deviation from an intended outcome (intended deviation that leads to failure is sabotage, not human error). Mistakes are mostly benign and do not affect safety critical operation, but sometimes they do. Organisations are more resilient and able to prevent harm when they assume that people sometime make mistakes and put controls in place that prevent actions by individuals to result in harm (single point failures). In contrast, organisations that rely on people to always work flawlessly are poorly designed and have limited resilience.
Guilt Hampers Improvement Efforts
Someone who feels like they are ‘on the chopping block’ for something they did or did not do and that led to a negative outcome are likely to protect themselves, and unlikely to disclose information critical to improve safety and resilience within the organisation. Leaders can choose to blame and punish, or learn and improve, but not both at the same time. Allocating fault to someone who has made a mistake does not fix the problem. The same actions might make sense to another person and the event may reoccur.
Learning is Vital
Most organisations operate in an environment that requires constant adjustment. Examples are changing expectations from customers (e.g. demand for green energy), new legislative requirements (e.g. new Code of Practice), or the use of new products or equipment. Organisations need to continuously learn to successfully adjust. Learning must result from events along with normal, everyday work. This allows organisations to identify successes and challenges experienced by those who do the work during daily operation.
Context Drives Behaviour
People’s actions are influenced by the context they find themselves in. Someone who never usually jaywalks, for instance, might cross a road on red when being late for a job interview. Also organisational factors influence people’s actions. Staff do what makes sense at the time, with the experience they have and the present knowledge they possess about the unfolding situation. Prior to an event, nobody has the benefit of hindsight. It only becomes clear after an event what everyone knew, versus what people should have known, and what they did, versus what they should have done. Organisations are more resilient when they understand the reasoning of their staff about the decisions they make and the actions they take.
Leadership Response Matters
How leaders respond to people’s successes and failures shapes the culture within the organisation and people’s willingness to disclose safety-critical information and concerns. If people feel they can freely speak to leaders about the challenges at work, leaders are better informed about what is going on in the organisation and they can intervene if necessary. In contrast, learning and improving safety is hampered when leaders regard people as a problem to control.
Controls Save Lives
Controls are crucial for the safe execution of work, and necessary to effectively manage hazards and risks. Work can only commence if the controls are in place. Controls are vital as they prevent harm.