In my last post I wrote about a recent presentation on human error that I attended.  The speaker was Dan McCune, VP of Safety at Embry-Riddle University and Director of Trianing for HFACS, Inc.  Not only is Dan a very knowledgeable and entertaining speaker, but he is passionate about learning as a key element for safety.  His background is in military aviation, where he was exposed to extreme risk.  As he spoke, many of his examples illustrating human error and their source were either from his personal experience or that of others. A key take-away that I got from his talk was about the importance of an organizational culture that embraces learning from mistakes, hopefully before they lead to serious consequences. Moreover, sharing what has been learned with others to imporve the good for all.

In James Reason’s book, Managing the Risks of Organizational Accidents, he writes about how to “engineer a safety culture”. (First, I digress: not only do I highly recommend this book, but when you read it please pay particular attention to Chapter 9.)  In this chapter he discusses the Organizational Culture and that “A safety culture is not something that springs up ready-made from the organizational equivalent of a near-death experience, rather it emerges gradually from the persistent and successful application of practical and down-to-earth measures. Acquiring a Safety Culture is a process of collective learning.” Reason then goes on to discuss other business books about culture that support the notion that a strong organizational culture begets a strong safety culture. Tom Peters, in his book In Search of Excellence, writes that a strong culture is one in which all levels of the organization share the same fundamental goals and values. “In these companies with strong cultures, people that are way down the line know what they are supposed to do in most situations. This is because the handful of values that guide behavior are crystal clear.”

Reason’s focus on organizational culture, and the underlying factors that allow a strong safety culture, stresses the importance of not only removing barriers to learning, but narrowing in on how we react to situations. In safety, how do we react to a near-miss or worse, an incident with injury? All too often we focus on what happened or the individual behaviors that preceded the incident. By instinct we want to find the cause, place the blame, retrain, fix the person, etc.  However, this type of reaction throws cold water on learning and as Reason argues, results in a short-term fix, such as “write another procedure” and the “blame and train” response cycle. Though many safety professionals know this all too well, understanding what they can do to change managment systems or reframe long-held beliefs is less clear and can be very difficult.

Several books on human error, including Reason, Dekker and Marx talk about the importance of institutional learning by creating a positive and just culture. (I’ll save this for another post, but you all should read the book by Edward L. Deci “Why We Do What We Do”. It may change your thinking about behavior based safety.)   Reason’s book details several subcultures that work together creating one positive and productive culture.  These include a Reporting Culture, a Just Culture, a Flexible Culture, and a Learning Culture.  Here is where I will take you back to the presentation by Dan McCune.

In aviation safety it is critically important that pilots feel free to share and discuss everything related to flying and their performance. Though being a pilot requires knowledge, skill, physical ability and mental capability, each and every pilot will tell you that they really do not have command of the plane and situational control until they have a great deal of experience.  This translates to thousands of flight hours.  What happens over time while they are gaining this experience? They are making mistakes; many, many mistakes.  It is the job of the flight  instructor to help each pilot recognize and understand their mistakes.  From this they learn about their perceptions, misapplication of knowledge, what could be done differently, etc. But how does learning occur after they graduate and are on their own?  Pilots and the FAA have a system of near-miss reporting. It is a no-fault system that recognizes that if there are barriers to sharing and reporting, knowledge will be stifled.  This reporting philosophy extends beyond the pilots to the entire crew, controllers, ground service personnel and anyone who could impact safe flight operations.

McCune shared that at Embry-Riddle, whether in their school of aviation or any other part of the University, they have embraced an important and unique philosophy: “No disciplinary action will be taken for reporting a safety hazard, concern or near-miss situation”. They realize that for the University to have a true safety culture it must be open to learning and sharing experiences. The safety culture must include just and open reporting, without blame or consequenses, so it can learn what is has missed or didn’t know. (of course situations of willful misconduct are dealt with differently) From the new employee and student orientation where the President of the University makes it perfectly clear, to the day-to-day actions that support it, everyone learns that ”Event reporting is very important. Everything, without risk to you or anyone else, should be reported.”   To support this Embry-Riddle has a simple and respectful system for reporting, providing feedback and thanks to the reporting person.  They also have a data base for tracking and sharing information about near-misses, and always investigate each situation using the HFACS system. With over 700 reports this past year from their two campuses and no serious incidents it must be working.

In closing, here is a fundamental belief that I have learned about Near-Miss reporting.  If you don’t have it in your organization and it’s not resulting in many hundred reports each year, you do not have a culture that values learning from mistakes. Further you don’t have an organization that really understands the nature of human error and designing work to expect it.

• Think about the barriers that exist and how you may get over or around them.
• Think about how your organization reacts to incidents or mistakes.
• Think about how your organization conducts incident investigations and what may be called root cause analysis.

If you see a culture that focuses on individual behavior, is quick to blame, stops short of looking for organizational solutions, adopts quick fixes, doesn’t encourage open discussion about problems and solutions, and
…… well you get it, you probably don’t have an organizational culture that can accept what it takes to have a true safety culture.

I apologize if this post has been a bit academic, or had the feel that I am preaching. Love it or leave it, I am passionate about this.   Developing an organizational culture that values information and knowledge sharing leads to success in safety. Having a robust system for near-miss reporting is an important element and one I hope you decide to implement if you haven’t already.

Thanks for reading and feel free to comment or share this with others.

About 3 years ago I began an in-depth study of Human Error Management, Human Performance, Cognitive Science and Prevention Through Design.  In the process it has become clear that we have not effectively learned how to create work processes and procedures that are error tolerant.  People will make mistakes and in fact are designed to process by trial and error as they go through their day.  Until we understand this fallibility and learn to create an environment and systems that allow our employees to have a bad day and still finish without injury, we will never take safety to the next level.  Recently, I had the opportunity to learn more about Human Error management, and want to share it with you.

Last week I attended a blockbuster PDC put on by the Northwest Chapter of ASSE.  The organizers did a great job of assembling top-notch speakers including Joel Tiegnes, Adele Abrahms and Dan McCune, the first keynote speaker.  Donna Heidel of NIOSH and their lead authority on the Prevention Through Design delivered the afternoon keynote.  With a number of other excellent local speakers the NW Chapter proved that by increasing speaker quality greater attendance would be achieved.  They set an all-time record by more than 100 participants!

The morning keynote and follow-up session by Dan McCune, VP of Safety for Embry-Riddle University and Director of Training for HFACS, Inc. was outstanding.  First, he provided an excellent discussion of human error and introduced the audience to a deep dive into the Human Factors Accident Causation System – HFACS.  Created by Drs. Wiegmann and Sheppell for the DOT/FAA, HFACS provides a taxonomy of analyzing incidents to find they key contributing factors beyond the actual human error.  The system goes beyond the root cause analysis that most safety professionals know and use.  The system allows the users to consider a number of additional factors, one being the “Normalization of Deviation”.  I have heard of this before from Todd Conklin, another noted speaker on human error and the design of work.  Conklin stress this two-way phenomena.  “Deviation” refers to the day-to-day variation from established work standards and procedures, better known as the way work is actually performed.  “Normalization” is just that; the deviation from the establish standard that has become habitual and is now the new standard for performing the given task;  the new normal.

In McCune’s discussion of Normalization of Deviation he was referring to violation errors, where accidents are easily blamed on the person who didn’t follow set procedures.  However, to be a violation you must pass the “3 Question Rule:  1) was there a standard or established procedure and was the employee aware of and trained to perform to that standard?  2) did the organization know that deviation was occurring?  3)did the organization intervene and enforce the rule or redirect the deviation from the procedure?  If you cannot answer Yes to all three, there is not an enforceable violation.

As we learn more about organizational control and process management as it relates to human error, we can see clearly how performance expectations and methods must be checked regularly to assure that normal deviation is acceptable and not setting up significantly increased risk.

Conklin uses a graph to illustrate the problem of deviation, especially in work where the level of risk fluctuates.  During a work activity exposure to hazards can vary, so if the worker takes short cuts for the sake of increased productivity, the risk of injury often increases.  Put simply, the margin for human error and resulting negative consequences is reduced.  Among his many suggestions, McCune believes that regular worker and supervisor job reviews, together with an active near-miss reporting system can effectively limit deviation and decrease the risks involved.

That’s enough for now, but next post I will cover more about McCune’s thoughts on Near-Miss Reporting.

A couple a year ago ASSE conducted its Culture Symposium in Costa Mesa, CA.  One of the speakers,  Joseph Cohen, PhD presented on the concept of  “justice” as it applies to workplace rules and the use of discipline.  Several times during the presentation he referenced Sydney Dekker and his book Just Culture.  I found the topic and Dr. Cohen’s presentation enlightening, so I decided to purchase and read Just Culture.  What an eye-opener!

I couldn’t possibly share all that I learned reading the book in this short post, but suffice it to say that those organizations or institutions that want to improve safety must develop trust throughout and learn from their mistakes.  I liked the discussion of what a learning organization looks like, and the importance of encouraging near-miss reporting as a part of the learning process.  The book also presented excellent examples of how to shut down learning and destroy trust, both detrimental to safety success.

Earlier this month, Mike Williamsen, Phd. with Caterpillar Consulting, Inc., an expert on creating positive cultural change, spoke on Near-Miss Reporting at the Direct Delivery Leadership Council (DDLC) conference in Las Vegas.  Dr. Williamsen summed up the topic very well and shared several important take-aways:

• In order for any organization to actually improve, it is necessary for it to openly share and learn from its mistakes.
• Since safety happens at all levels, every one must participate and share their mistakes.
• Sharing situations that “almost” or “could have” resulted in injury or loss creates opportunities to discuss what happend and to learn.
• It is very important that there be an open and trusting environment where all near-misses can be reported.
• Reporting near-miss situations should be encouraged and praised.
• It is necessary to have a system that evaluates near-misses by severity potential, establishes priorities, and leads to positive corrective action.
• If reporting near-misses results in disciplinary action or nothing is done to correct high severity potential situations, reporting dies and all related learning stops.

As SH&E professionals we have a terrific opportunity to help our organizations learn and improve.  And in so doing, we will help them not only improve safety, but all aspects of the business.   I think it would be worth your time to find out more about the concepts of a Just Culture and becoming a Learning Organization.   “Just Culture” by Sydney Dekker is a great place to start.

This was Reposted By Request from December 23, 2009.  I hope you enjoy it and comment back with your thoughts.  Thanks.