Safety incident example:
- Incident: Rupert, a plant mechanic twisted and broke his ankle while completing the task of hanging pipe below the in-pit-crusher.
- Investigation results: Employee was negligent. Rupert was rushing through his tasks, and was not being careful. When moving from his ladder he inadvertently stepped on loose pipe that was on the ground.
It is not uncommon to hear managers and supervisors describe a situation such as this as an example of poor performance. They would describe Rupert as negligent, unmotivated, and in need of discipline [for his poor behavior], believing that the act of discipline would correct his “attitude” and change his future behaviors.
When employees err [and they will make errors] how the organization responds will determine the likelihood for future similar events. Leaders can establish either a “prevent” or a “punish” safety environment.
Punishment by itself, as a response may discourage self-acknowledgement of error. When punishment is combined with extrinsic [reward/punishment] there is a tendency withhold anything that would cause a loss of reward [or would engage punishment triggers]. This means that the organization has less knowledge about reality and is less able to learn from past events. As a result, the organization is less likely to actively engage resources to prevent repetitive incidents from occurring.
Let’s take another look at our safety incident example.
Detail: It is a long walk down the conveyor belt to access the work area. Rupert leaned several of the pipe segments against the wall where they were to be installed. He them began installing them on the wall connecting each section to the other. The pipe was to be installed high enough to require a ladder during the pipe installation process. While working alone during the process, one of the uninstalled segments leaning against the wall fell onto the floor damaging the pipe threads. Rupert became frustrated and angry when he discovered the damaged threads. Now, he would have to stop the job, walk out of this remote area, and rethread the pipe. This upset his schedule for the day. Trying to stay on schedule he rushed to the shop and completed the repair then return to the job site. To prevent further damage and delay he placed all the pipe segments on the floor. As he progressed he moved the ladder but was now behind schedule and rushed. During this process he failed to notice he positioned the ladder too close to a pipe segment lying on the floor. As he stepped down from the ladder he stepped on this pipe and rolled his ankle. The ankle was broken.
So, we can acknowledge that this incident was preventable. There are steps the employee could have taken that would have prevented the injury. One key area to review is the intention [or motivation] of the employee. Was the employee deliberate in seeking the outcome that resulted? Probably not. Who would rationally want to injure themselves?
It’s bad enough that an injury occurred. What makes it even more frustrating is when a good employee is involved. Someone who works hard, tries to support the business goals, and is involved in an incident can be harder to deal with than that lazy employee we all seem to want to blame.
So, if this incident was not intentional what contributed to it? And what could have prevented or defended against it? Looking at the error antecedent factors we can see that there were several potential contributing elements. [Think potential problem point-of-origin items like: demands of the task, capabilities of the individual, the work environment, or simply human nature traits.]
Leading the way to safety
The person in charge is either leading or impeding it. Impeding indicates the presence of obstacles and barriers. And many times this is our experience [especially in mining and manufacturing]. We unintentionally make it hard [or harder] to do the right thing. Whereas leading means that we make it easy to do the right thing. What would have prevented, or defended against doing the wrong thing in this instance?
Many times we find that the high performing employee acknowledges their contribution to the incident. They are willing to be accountable and take responsibility for their error. If we are not careful, we can find relief in their response and close the books on the event. For the safety leader though this is a good opportunity for a fruitful conversation.
Good employees feeling accountability for their error is commendable. However we really need to learn is why the decisions that were made [up to and during the event] seemed good at the time? That is the valuable conversation for a leader to hold. Until we learn what defenses can be taken to guard against the inevitable errors that good intentioned people will make, we cannot have a totally reliable environment.
As a leader; do you lead or do you impede? Are you having productive and empowering conversations that develop shared learning?
Mark McCatty, Leadership & Team Advisor
http://www.mccatty.com/
Leadership Results through People