A technician spills a toxic chemical. She isn’t injured, but easily could have been. The Hazmat cleanup costs more than $10,000, and shuts down a critical building for a week.
An electrical engineer flips the wrong switch in a substation control room. He isn’t injured. But within seconds, a $50,000 transformer is destroyed.
Three financial clerks in two different countries are processing payments for a large bank. They intend to schedule a routine $8 million payment. Antiquated software makes errors hard to catch. The clerks accidentally wind up sending $893 million instead.
From Talk to Action
Talking about building a culture of safety and human reliability is easy. But how many great ideas get talked about and never actually get put into practice?
The real skill is to be able to transform good ideas into practical steps that can be immediately applied.
There is no one secret or solution. Instead, many successful companies around the world have built a culture of safety and human reliability using a “Consolidation of Subtleties” — a combination of practical steps like these:
Take a learning-based approach to errors. Those in a work culture that’s stuck in the old-school, control-based approach of eliminating all errors should consider labeling it that way: “Hey, are we stuck in a control-based approach as we’re discussing Tuesday’s incident?” The more we label it, the more we’ll be aware of it, and the less we’ll be stuck in it. Leaders can propose the alternative — the learning-based approach. How? After the next incident or unwanted error, instead of asking, “What went wrong this time?” leaders should ask, “How do you all get this job get done right 99% of the time?”
Create psychological safety. It’s easy to destroy and challenging to create. Yet research from Harvard professor Amy Edmonson, Ph.D., and Google’s Project Aristotle reveal that psychological safety is key to successful, safe, engaged and reliable teams. After an error, instead of saying, ”Joe failed to do [X]…” leaders should ask, “What did Joe do, and why did it make sense for him (at the time) to do that?”
Lead after-action reviews (AARs). For more than 30 years, these psychologically safe, semi-structured, post-job team debriefs have been used by an increasing number of high-hazard industries worldwide. After a successful, complex project, instead of asking, ”What could we have done better?” leaders should ask these four questions initially developed to accelerate learning in the U.S. Army:
- What did we set out to do?
- What did we actually do?
- How did it turn out that way?
- What will we do differently next time?
Transform investigations. Traditional investigations often “name, shame, blame & retrain.” The result? Fear, silence and box-checking on Corrective Actions. The alternative? Instead of asking, “What was the error and who made it?” leaders should ask, “How did our processes set that person up to make that error? And how can we improve our processes to set our people up for reliability and success instead?”
Apply defenses. Peer checks. Three-step communication. Checklists. These and other simple yet powerful defenses have proven successful for decades. They can be learned in a few hours, and get real-world results immediately. For instance, a leader could write or update the checklist for a particular job to include only the three to seven items most often missed. One physician from Baltimore helped save 1,500 lives in 18 months with this classic defense.
Improve systems. Instead of trying to “fix” the workers, leaders should improve their work processes and systems. Trusted front-line experts can help leaders brainstorm one low-cost, low-risk, low-fear, low-maintenance process improvement that would make it easier for front-line experts to do the right thing in that process. For example: Companies with fleets of trucks have dramatically reduced serious injuries and save millions of dollars each year by simply avoiding left-hand turns.
Build resilience (advanced). The world’s most “high reliability organizations” (HROs) don’t try to eliminate all errors. They don’t proceduralize everything, either. Instead, they build resilience so that most errors become easier to detect, recover from and learn from. One method they use is to look for “weak signals,” like the sound an engine makes when it’s just starting to develop a problem. Leaders may start by taking input from one or two trusted peers to identify one weak signal for a complex job that everyone does — then name it, decide what to do about, and teach that to employees instead of hoping they’ll discover it on their own.
Leaders may start by picking one step that resonates with them the most right now and discussing it with a few trusted colleagues — then trying it out in a low-cost, low-risk micro-experiment. A few small, quick wins will help to build momentum fast!
Jake Mazulewicz, Ph.D., shows leaders in high-hazard industries why errors are signals, not failures, and how to address the deeper problem so that everyone can work more reliably and safely. He keynotes and advises all across North America. He has a decade of experience in Safety for electric utilities, and served as a firefighter, an EMT and a military paratrooper.
