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.

While on a family vacation I was discussing my work in safety with Paul, my brother-in-law.  He is a software engineer with a major defense contractor.   He shared that his worksite has earned VPP status and that the people there are very proud about the achievement.  I asked him about the VPP process and if he had much involvement given his type of work.  Paul smiled and told me that beyond seeing posters and newsletters about safety, he hadn’t been involved nor even very interested until recently.  To him safety had been buckling his seat belt and not speeding too much.    Then he sat forward in his chair and said “except for something just recently”, and began to tell me about it. 

The Incident

Every workday Paul enters the office building through the same entrance.  This day was like any other, briefcase in hand and swiping his security badge to gain entry.  As he proceeded he tripped on something, stumbled forward and caught himself before falling.  Looking back at where he had just walked, he noticed that the fixed floor mat system, designed to remove water and grit from shoes, had a section of frame that appeared to be sticking up or loose.  This must have been what he tripped on.

Just then a custodial employee that he had talked to before came up to him and said, “You know you should file one of those Near-Miss Reports for that.”   Paul had no idea what the custodian was talking about, so he asked her about it. 

The way the story went, the custodian had noticed the problem with the mat system when it was first installed a several weeks ago and reported it verbally to her supervisor.  She cleans this section of the building , mopping and sweeping this specific section several times daily.  The supervisor said he’d look at it, but nothing had been done to correct the obvious problem.  Paul said that the custodian went on to say that she had observed several people trip, thankfully with no injuries…..yet.

The custodian thought that because she was such a lowly employee that her supervisor and management discounted her input.  She said, “If a high level engineer like you reports it I bet they’ll do something about it.”  As they talked, she followed him to his work area a short way down the hallway and showed him how to access the Near-Miss Report system on the company’s internal website.

The Near-Miss Report

Filing the report was easy: name, ID, job title, department, and then a description of what Near-Miss happened and some more descriptive detail.  Paul read the report and then hit the SUBMIT button.  The custodian thanked him and went on her way back to work.  Paul had no idea what would come next.

Within 15 minutes he received a phone call from the safety department. They wanted to know if he had been injured or intended to file an injury report.  No injury, no report.  They thanked him for the report and told him that he would be informed of the progress in correcting the problem.  Next, the director of his department came to his office to see if he was OK.  Surprised, Paul said that ”of course I’m OK”.  Then, the director asked Paul to take him to the area and show him the problem.  When the got to the entrance the safety manager and a person from facility engineering were already there.  Within a couple of minutes a sign was put on the outer door warning of the trip hazard and an orange cone was placed over the loose framing.  After everybody there looked at the problem and decided it was legitimate, it was decided that the facility engineer would follow up with the contractor and have the frame replaced.  Problem solved!

Later that day Paul got an email from facility engineering (copying several other people) letting him know that the contractor would be in the next day to replace or repair the mat framing.  Again, he was asked if he was feeling OK.   Later that day, as he left the office a security person was at the door warning him and others to watch their step due to the loose flooring.  Paul found this all quite amusing.  After all, no one had been hurt.

Sure enough, when Paul showed up for work the next morning the contractor was already there and nearly finished with the new frame installation.  Problem solved…or was it.  When he he got to his desk and then later that day Paul received email progress updates.  Then, the next day he receive a copy of his initial Near-Miss Report with the corrective action listed and signed by facility engineering, the safety manager, and his department director.  All this over a loose floor mat frame! 

Uncovering Deeper Safety Issues

When he filed the Near-Miss Report there was a section asking if anyone else knew about or saw the problem.  Paul answered “yes’ and mentioned the custodian and her supervisor knew about it.  What happened next opened Paul’s eyes to just how serious his company is about safety.  About a week later he was asked if he could schedule to be part of a meeting in the safety department.  The meeting was to discuss the near-Miss Reporting system, reasons or barriers to reporting, how to increase reporting, sharing what is learned from the reports, and something they called “safety culture”. 

At the meeting the safety director explained that the floor mat problem should have been corrected immediately when it was reported to the supervisor.  For some reason the supervisor discounted the problem and didn’t take any action.  He said that he had thought about it though and figured he’d write up a work order later.  Later never happened.  The custodian feared that if she wrote it up herself that her supervisor would get mad and maybe fire her.  They discussed a few other situations that were similar, where fear or complacency got in the way of reporting, and what might be done about it.

Paul had been included in this meeting because as a more senior software engineer his thoughts and ideas were valued.  When he was told this he recalled what the custodian had said to him, “ because she was such a lowly employee that her supervisor and management discounted her input”.  Maybe she was right.  He shared this information, as well as how eager and helpful the custodian had been.  The meeting lasted an hour, focused on the barriers to reporting, taking action to remedy hazards, the fears that are inherent to supervisor/direct reporting relationships, and how to increase reporting.

Paul was asked to attend one other meeting on the subject.  Here he learned about a new training initiative for all employees, including all levels of management.  It would focus on the importance of driving fear from the organization, similar to some of the quality and “lean” training they had received earlier.  It seems that there were much deeper safety issues and problems than a simple loose floor mat frame.

Expand The Number Of People Involved In Safety

When Paul finished telling me the story I asked him what he thought about the whole ordeal.  He was glad that he had made the report and now actively looks for safety stuff that could be reported.  Before, he never would have thought to even look for, or much less report hazards or near-misses.  He said he now feels involved in the VPP effort and really looks out for others.  Then he asked me if I knew why they are called them ”near-misses” and not “near-injuries” or “near-hits”.  I smiled and told him it was time to go to the beach and enjoy the afternoon.

Near-Miss or Near-Hit reporting can have a huge impact on your safety program.  Done in a non-punitive, learning and rewarding manner can greatly increase the number of employees actively involved.  Paul provided a great example of how the system can work well.  Though the story was a bit long for a blog, I hope you found it helpful.

The Future of Training Today

Training of employees is perhaps the single biggest challenge to the safety professional today.  Time is always an issue, and making the training experience relavent to the individual worker is difficult.   We all agree that the training content and delivery methods need to ensure that employees are able to recognize workplace hazards, follow control procedures/processes and use any necessary PPE to work safely on the job.  However, work and the nature of work are changing.  With change comes the need to reassess our training methods.

Traditional classroom training with a credible instructor is still the best way to assure that learning takes place.  The instructor can employ a number of techniques to involve the workers in the leaning.  He/she can also include demonstrations and hands-on exercises that validate an understanding of the proper control methods, etc.   However instructor led classes are often infrequent, delivered from a fixed location, and can be epensive particularly when travel time is involved. More and more the workforce of today is becoming dispersed with jobs that don’t always have a home base, so traveling to take training is almost cost-prohibitive. The instructor led model itself has some inherant problems. Mass training of employees with a one-size-fits-all curriculum does not always meet the learner’s specific needs. To address these unique situations companies are increasingly relying on distance learning supported by one-on-one supervisory discussions, team interactions, observable exercises and demonstrations.  Essentially, the nature of training is changing.

• Training needs to provide learners with what they need to know when they need to know it.
• Training content must be relevant and specific to their work tasks.
• The training experience needs to include interactivity that requires the learner to engage with the content.
• Demonstrations, exercises and hands-on learning must be considered, even with distance learning
• Periodic testing or quizing should be built in to validate that the information is understood.
• Employees need the flexibility to take training when and where they want.
• Training content needs to be delivered on a variety of electronic devices from laptops, tablets, and mobile phones to the normal fixed workstation.

To meet these needs, many safety trainers are considering newly developed web/cloud based learning system.  These systems are available from a few top safety training companies, including CLMI.  Whatever system you choose, it should allow employees to control their learning, educating themselves in a manner that gives them rapid access to the information needed to keep themselves safe.  The system should also provide the flexibility to adapt the information to the specific needs of the organization.  The newest systems now support the delivery of a wide variety of content from written documents, videos,  interactive training from any content source including vendors, producers and in-house.  They also include information and tips for supervisors and managers to help them bring the training to life for their remote workers. 

The CLMI “cloud” learning system is called ResourceNow and was developed as a content mangement system for clients so they could upload, store, assign and deliver hazard control information and activities.  Utilizing a “content-on-demand” model,  now it is used to deliver all types of training to dispersed workers, primarily in the direct delivery industry.  One major client uses this method to train over 20,000 route drivers on several key safety topics, including defensive driving.  Another insurance company provides this service to its clients all over the globe.

For more information click to the CLMI homepage or on the ResourceNow link.