Lean, Green Safety Machine – Part 3

file0001066060124There are no secrets to success. It is the result of preparation, hard work and learning from failure.

As quoted in The Leadership Secrets of Colin Powell (2003) by Oren Harari, p. 164

Recently, I was discussing some issues with a colleague who was highlighting a number of isolation breaches on a particular project during commissioning. I suggested that the commissioning team actually rehearses the sections of the commissioning packs as planned for that day or the following day. It was taken as a novel idea, however in the context of completing commissioning tasks in a dynamic occupational environment, and hazards associated simultaneous operations, rehearsing is a realistic solution which works in high performing organisations.

There are a number of methods the military and other high performing organisation use which provide a learning experience in a controlled environment. The rehearsal is commonly used either prior to the actual execution of a mission or activity, or in exercising a particular scenario. The military context of the rehearsal allows leaders and their soldiers to practice executing key aspects of the concept of operations[1]. These actions help soldiers orient themselves to their environment and other units before executing the operation. Rehearsals help soldiers to build a lasting mental picture of the sequence of key actions within the operation. They also allow leaders and teams to identify shortcomings (errors or omissions) in the plan not previously recognised. A relationship with failure is built as something that is learned from, not to be scared of. Rehearsals also contribute to external and internal coordination to aid in identifying additional coordinating requirements.

The rehearsal approach also has other benefits which enable safe practices and culture. These benefits include building trust between the leader and the team, and also within members of the team. The rehearsal provides an environment where the pressures of operations do not inhibit communication, or an understanding of personal strengths and weaknesses.

The approach taken in the commercial aviation industry through the use of simulators and the ongoing training, are essentially rehearsals. High performing and highly reliable organisations habitually rehearse during training, or as training. It is not just about error hunting or ‘detecting anything that might signal a malfunction’[2]. Variability and abnormal conditions can be created and tested in a controlled environment in order to train leaders and workers in decision making, while providing them the experience on the capability and employment of techniques and procedures.

Another effective method which the military uses, and could be utilised in our workplaces, is quick decision exercises. Essentially it is a process where leaders respond to problems presented to them and how they address and/or utilise their knowledge and experience in the three critical areas. This approach and level of decision analysis occurs in a controlled environment rather than an operational environment. The latter is usually an investigation as the result of an event, and the perception of a decision gone wrong when it could be something associated with the detailed analysis, or experience and knowledge required to manage the situation. I have seen this approach used via toolbox talks by presenting ‘what if?’ scenarios, but this approach is generally piecemeal and not linked to a series of activities or controlled in such a manner to gain benefit from being immersed in the occupational environment at the time of presentation. The toolbox talk approach is further constrained if variation from procedures is not allowed.

One other observation I have made in relation highly reliable and resilient organisations, particularly reserved to the armed forces and emergency services, is the absence of ‘on-the-job’ safety related assessments, such as behaviour safety observations, task assessments, hazard assessments, safety checklists etc. If these safety practices and tools were used in the military context it would demonstrate that the leader, or the person involved in the task lacks the ability to recognise the issues and make a timely decision. This approach would also demonstrate a lack of trust in the capability of the team, but also the techniques and procedures. Therefore, the safety practices and tools used today do have the ability inadvertently foster disengagement not only from the leader, but also from the techniques and procedures to which they the very fabric of. From my own experiences in the military I conclude that through the course of training, rehearsals, and operational experience that the hazards and threats are understood and expected, and I was provided the necessary skills and experience to recognise them and vary my methods in order to ensure success. The old military adage of ‘improvise, adapt and overcome’ was always relevant and meaningful to success. The military approach is very much about people being the source of the solution and success, not the source of the problem and failure.

The approach that has been used by the military for at least the last century, and definitely the philosophy which is very much aligned to the Safety II approach, could be learned from and transferred into civilian workplaces. It is a possibility that any organisation that has an element of risk in which a fatality may occur can, or should, aspire to operate as a high performing and highly reliable organisation. This can only be achieved when leaders and workers, appropriate to role and experience, have the ability to make decisions more instinctively, and be allowed to vary techniques and procedures to ensure a successful outcome. To achieve this, organisations need to provide leaders and workers professional experience and training which is supported by developing a high level of competency and proficiency in the fundamental areas of techniques and procedures relevant to their profession. It has to be recognised that a leader or work may lack experience, not just because of their age or time in the workforce, but also experience which has not been gained in a controlled environment which allows mistakes to be made and learned from. Habitual training, repetitious in fact, encourages mistakes to be made and allows examination of the analysis and decision making process. Controlled environments are also beneficial in building trust and relationships within the teams; another factor for success.

Finally, having workers involved in the detailed analysis phase in some way or another is critical for good, quick decision making. The use of quick decision exercises is an approach that could be adopted easily, but should be sequenced with rehearsals to better support outcomes.

Is there a place in today’s working environment to be able to establish controlled environments which allow mistakes to be made and better the decision making process by workers, especially supervisors?

Do you think the military approaches to decision making in an operational environment could be employed to create a safe workplace?

Acknowledgement:

Thanks to Kelvin Genn and Daniel Hummerdal for supporting me in getting this series of posts written and getting the information out of my head and to the reader.

References:

Dekker, S.W.A., (2011). Drift into Failure: From Hunting Broken Components to Understanding Complex Systems, Ashgate Publishing Co

US Army (2011). Army Tactics, Techniques, and Procedures No. 5-0.1 Commander and Staff Officer Guide

[1] US Army (2011) p. 117

[2] Dekker (2011) p. 96

17 thoughts on “Lean, Green Safety Machine – Part 3”

  1. I appreciate the opinions of others, but they should contribute to the discussion and provide an alternative view to the reader, rather than dismiss another point of view. There is a certain irony in that a success factor in doing safety differently is about open engagement, intervention and being just. Yet, it seems the very people that dismiss the views of others with disapproval without justification based on practice merely flies in the face of not only what we are trying to achieve in our workplaces, but in fact the very practice that some tout as their core business.

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  2. Shane, if any discourse dominates the safety space it is the military metaphor, after reading your article I just don’t understand the sense of difference. Happy discuss off line, and not dismissive, I would appreciate the connection. I did not dismiss anything, I just stated I was baffled by it, if you can connect the two for me I would appreciate it. Rob@humandymensiobs.com

  3. I didn’t dismiss the comments made and concurred with Dr Rob Long as I don’t ‘see’ the difference by using military metaphors to safety. ‘Rehearsals’ and a U.S. Exercise Tiger that killed nearly 1,000 American servicemen and considered by US top brass to be so catastrophic in consequence that they warned any survivor with a court-martial; if they told the truth about the incident. Closer to home and the Australian Blackhawk helicopter where 15 SASR Regiment soldiers died in the one event with 3 other deaths from a support element. Deaths during training / rehearsal make up the majority of the SASR’s fatalities. For learning to take cannot it take be done in a controlled environment.

    1. The connection for me is firstly personal. I was in the Army for 18 years, of which an even more personal connection is the fact that I was a member of the Special Air Service regiment in 1996 when I lost several close colleagues in that accident. I, in the previous year, was involved in the same exercise with 3 Squadron as we were in our counter-terrorism rotation where we also had several people injured, but fortunately no deaths. So it is a topic of discussion I am very close too.

      So in just examining the 1996 Black Hawk incident, has their been a repeat incident since? In the last 18 years, how many similar exercises do you think there has been? Agreed that there was little room for error in that fatal rehearsal, but the complexity of systems from training, maintenance, competence, technology and so on all play a part in the accident. From this the army has learned, and it hasn’t stopped them from rehearsing. In fact they do it more often now.

      So, the connection I make to safety differently, is about a process which focuses on making things go right rather focusing on what goes wrong. It is about learning, adapting methods to improved. In the near two past decades, with the creation of the Army’s Combat Training Centre, there is a dedicated centre for ‘rehearsing’ in a controlled environment through independent staff (not associated with the unit exercising) which capture and pass on learnings from combat and training to others through rehearsals.

      When I read Steven’s post on What Safety-II isn’t, (http://www.safetydifferently.com/what-safety-ii-isnt/), I draw a lot of comparisons with the military planning, training and deployment approach. I see that, as articulated by Sidney Dekker, seeing people as a problem to control, to seeing people as a solution to harness. In Part 2, I detailed the importance of people and their capability, knowledge and experience in the decison making process, rather than taking that away from them because they may make the wrong decision. I see Eric Hollnagel’s thoughts on efficiency-thoroughness trade-off being an approach the military uses in rehearsals and decision exercises, where Eric coveys ‘while in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions’. I see disruptive safety, as written by Kelvin Genn whereby the military creates an environment to make mistakes well – lets not focus on failure, but on success, remembering more often than not things go right, not wrong. In terms of resilience engineering, the military, through its processes they have a presence of a positive capacity to make things go right. The military understands complexity, and is consistently learning and evolving in this area.

      I would be interested in how you define safety being done differently?

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      1. Thanks Shane, I appreciate your apologetic and making the connection from your perspective. I personally don’t connect with military metaphors in understanding safety but appreciate how you do. How do I see safety differently? That would take a bit more space than here but I certainly don’t see safety through the lens of engineering, science, regulation, systems or law. I find the semiotics of ‘resilience engineering’ most odd and the notion that humans are a ‘factor’ within a system just as odd. Shuffling components within a systemic view that remains the same doesn’t really inspire that much, instead I think a complete paradigm shift is required to see and do safety differently. Such a conversation and discussion is really not for this space but thanks for your response.

  4. Shane, using the helicopter example that you had a lot of experience with; and as a trooper or officer with a ‘sandy’ beret in the elite SAS; you would have been personally exposed to a ‘can-do’ approach more than safety-differently. The way we do things, rather than doing safety differently is evident in the military context. Yes, there have been other crashes while just practising since the ‘big-one’. In 2004, a Black Hawk ‘exercise’ crash had six out of eight injured, two seriously; again while ‘rehearsing’ but simply passed-off as being due to ‘can-do’ attitude. In 2005 in Nias, what appears to have been a ‘cotter-pin’ not replaced during maintenance on the main rotor and nine more officers and other ranks died, which also killed a Mum and child. In 2006 another pilot and SASR trooper killed while landing on the HMAS Kanimbla. There isn’t a good military record of operating that much ‘differently’ about the safety and the ‘learning’ from prior experiences. But there has been clear evidence of limited understanding of complexity in the military. This was very clear as the 2006 crash-event was simply blamed, by the Air Chief Marshal at the time, on pilot error and a “can-do” culture in the squadron. There were fifty-plus recommendations from the investigations that showed the military don’t do safety-that-much-differently. Good organisations look for ‘red’ and address them, not just attempting to create a system that is ‘green’ and try to keep it ‘green’ or work away at turning ‘red’ to ‘green’. What is safety differently? It is knowing that some things are ‘red’ and will stay ‘red’ and there is a need to have discourse and dialogue in the organisation that takes into account the social psychological aspects that are not considered at the moment. I don’t consider that safety-differently is as you suggest “about a process which focuses on making things go right rather focusing on what goes wrong”. Perhaps there is a reason that the methods used at military airports for ‘checking-in’ personnel and baggage almost exactly follows the civilian procedures. It is because there are some things that cannot be done that differently. If the military services were conducting a civilian helicopter business, just in Australia, they would have been shut-down years ago. With great respect for your service, in my opinion, the military examples you use for safety differently in many ways cannot be regarded as guiding light examples.

  5. I did a National organisational survey for Defence in 2009/2010 and the report is on the DRN. I don’t think its highly classified but I cannot post it to you under my contract. Needless to say, the culture of bravo, desensitisation, double speak, scepticism, dumb down and calculative thinking permeate the ADF at all levels. I had a Brigadier tell me in one interview that: ‘safety is just hygiene, like brushing teeth and clean socks, something that had to be done to make men fit to kill people’. I document all the qualitative and quantitative data in the report, it was commissioned by DSA. I did like the ADFs approach to risk but the safety crusaders in the ranks help create a binary view that endorse risk schizophrenia anyway. I didn’t find anything in the military in my 6 month project across all layers of the ADF that could convince me to use them as an example of doing safety differently.

  6. I do not believe for a minute that the ADF, or any other military organisation, is a beacon on the hill when it comes to safety, but I do think that there are some aspects that can be learned from if put into practice properly. In say this I mean being put into practice properly would also include a different culture or mindset towards safety. I can only presume that because you have worked with the ADF and seen all the dirty laundry, that perhaps my posts have been seen as promoting the military way is safety differently. I do believe there are certain traits, good intentions, that could be adopted and improved upon.

    I do like that we have managed to thrash out some aspects of what doing safety differently looks like. Everyone’s relationship to safety is different, and that is definitely something I am conscious of whether I am on a construction job in Asia, or working with company executives.

    I would like to think that creating an environment where supervisors and workers can build trust and relationships away from daily operation pressures is a good thing? I believe that if supervisors were adequately trained and given the option to run through scenarios with their teams, with a level of competent oversight, that this would too enhance safety performance? I would have thought by empowering supervisors and workers to vary their methods rather than solely rely on procedures would ensure that work can be completed in changing conditions, or stopped if dangerous (something the Army doesn’t do well because everything is ‘mission critical’)? I could be wrong on all these counts. I think too, and this is reading between the lines in regards to you thoughts on resilience engineering, that the safety-II approach does not necessarily resonate with you, and again I accept that everyone has a different relationship to safety.

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  7. I worry that ‘safety II’ or whatever you want to call it, could become a version of safety I. To me safety II is about working with people to come up with the best possible solution to support those people in being successful. Who are we to say that one approach is safety II while another isn’t? As you say Shane, everyone’s relationship to safety is different. To me this act of labeling is in itself a safety I approach.

  8. I commend Shane for working to tease out certain aspects of how Resilience is developed in the Military setting; methods that do seem quite rare in the more expansive civilian work places.

    I suggest that in attempting to discern if Safety II or Safety Differently is ontologically sound it will be necessary to recognize that in the basic process of:

    INPUT — PROCESS — RETURN

    There is not simply one kind of RETURN; there are at least three that I can identify as distinctively different.

    – Return on Investment (RoI)) is the measure of success for value propositions which lend themselves to commercialization and, as well, to competitive pricing for products and services which are both substantially interchangeable and yet notably different at the feature level. Numeric comparisons are straightforward with RoI.

    – Return on Objective (RoO) is the measure of success for value propositions which have qualitative features in both Inputs and Process Controls – Actual war-fighting fits in the RoO category, but so do many social good value propositions such as poverty amelioration.

    – Return on Engagement (RoE) is the measure of success for value propositions which are believed to have qualitative features correlated to future effectiveness. RoE practice builds relationships. Much of the preparedness activity in the military, plus practice on crew-based simulators cannot confirm actual readiness for RoO encounters, but, it is well understood to strengthen mutual understanding amongst the team, often on an intangible level such as camaraderie and esprit-de-corps.

    RoE is very much a two edged sword as the kind of bonding involved can be quite agnostic with respect to the moral measure of the mission being prepared for; it is not overdone by the best Commanders.

    A realistic view of how Assurance of Adequate Protection is optimized (there not being any obvious asymptote to such efforts) includes provision for RoI, RoO, and RoE in degrees and with provision for co-evolution of these methods with the variation in the actual, and ultimate circumstances of the mission work to be done.

    RoE training in support of RoO military effectiveness is dangerous in its own right even though it is intended to maximize Mission achievement.

    There are some emergency services, such as Smoke Jumpers, and EMT’s in hazardous urban settings (or entire countries) which resemble the challenge-landscape that warfighters prepare for. Safety management in these settings can have direct benefit from understanding how responsible Commanders mix RoI, RoO, and RoE elements.

    My belief would be that there are many other Complex High-Consequence Circumstance situations where finding a suitable mix of Reliability promoting and Resilience nurturing can benefit from those aspects of military craft and from the somewhat inescapably costly human contribution to national security even in peacetime. Mindful tailoring of lessons learned in other settings is always called for.

  9. It appears that my blogs are being used for cannon fodder so it would only seem fair that i have the opportunity for a rebuttal.

    Perhaps some people have, and falsely for that matter, chosen to purely associate the blog as being one on leadership and culture. Perhaps they are blinded by their own previous observations, and cannot see that the intent of the blog was to communicate a method of rehearsing and developing decision making skills as practices that may be used in the ‘real world’. To my point in fact, that there are aspects of this approach which are found in HROs. As for whether its safety differently, it not may be cutting edge, but its definitely not part of the everyday real world of safety management at the coalface of the industries I work in, and it is a potential practice that could be used to improve safety. Would one think that the ability for a work team to practice work, communicate their thoughts, ideas, knowledge and practice in a controlled environment prior to working in a live environment, in situations such as brownfield commissioning, or process operations, would in fact be a way of managing safety differently? Regardless, through two blogs you have shown that some are trying to be on the ‘jedi council’ of safety and that what ever they write is correct. Their leadership in the field of safety may in fact be no different to what those people assume I have written about… Authoritarian!

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  10. I think Shanes posts are a fantastic example of how any organisation (in this case the military), with Incredibly complex systems, high performance expectations and extreme risk environments, perform successfully through a balance of strict procedures and adaptability at the point of risk.
    Forget the military metaphor for a second and pretend it is any other high risk industry – the only difference is that the military have been doing this for generations and kind of have a captive workforce that they can make successful.

    You have an incredibly hierarchical structure that has every aspect of life governed by procedure and rehearsal, whilst simultaneously giving each group/platoon/squad/crew the ability to assess, adapt and react independently of the greater organisation, and can be trusted to do so.
    Imagine for a second, that your workforce were all literate and numerate, with high levels of discipline and excellent physical conditioning, who were trained to be able to think for themselves, to recognise risk and react according to training and rehearsal. Men and women who were passionate about their jobs, who when separated from their management/supervision, were able to work independently and adapt their working methods (within an operating framework) to complete their tasks to a high standard with every member returning safely.

    If we think about it – it isn’t so different from say the mining or construction industries… A high risk environment, with a strict hierarchy, incredible amount of procedures and training requirements. Why are we still killing so many? I think the military might be an interesting template to apply to these other industries to work out how we can training people – at the point of risk – to be more successful. And how the organisation/military can give these people the tool, training, and belief in themselves to succeed.

  11. Hi Shane, thanks for sharing these thoughts and to the others who have contributed their perspective. As a voice or insight to another arena where I can see this train of thought offering new insight, I work in the Outdoor Education sector where everyday we are taking young people on adventurous (in what maybe perceived/real high risk environments and activities).

    The people I meet and know in this arena are on the whole all literate and numerate, with high levels of discipline and excellent physical conditioning, who have trained extensively to recognise risk and react according to training and rehearsal. Individuals who are passionate about their jobs, who when separated from their management/supervision, work independently and adapt their working methods (within an operating framework) to complete their tasks and ensure every member returns safely.

    Our sector has (naturally) become increasingly regulated, with rising pressures upon procedural compliance and policy to mitigate fears (both perceived and real) and control/define practices an educator/instructor must adopt in the field (my own team carry a procedural reference manual in the field as an internal compliance requirement in addition to their HIRA and other venue safety support information to help maintain both a safe working environment and safely run program)…a good case on increasing levels of ‘command and control’.

    Unfortunately across the sector (in part due to growth and demand) there is also an increasing realisation that staff taking up the role of leader or instructor are often coming with less and less actual field time (even though their time in training may conversely still be relatively high.) They may even have the recognised qualifications meeting compliance needs i.e they may have 2years of training but only 6 months actually managing groups. This latter point alone for some adding more fuel to increased concerns for more control measures (‘variations to policy’ seems to be a favourite request)…more command…more control.

    Another train of thought is to increase training further, but as noted this only adds to scales on the side of training vs field time. The circle of command and control rises because of concerns of less field experience and training rises because this is seen as a counter balance, yet doesn’t address the real problem which is ‘quality of decision making in the field’, in real environments, in real time.

    We have started to experiment more with scenarios (though admittedly they are still not real time, but are in the field) and allow time for less prescribed or pre-determined responses. Were also seeking ways to increase this strategy in real time by providing more coach/mentors alongside leaders/instructors where team members are encouraged to consider their own thought processes and responses to changing situations or potential incidents.Training at the point of risk.

    I note this, and link to Shanes and Matt’s thoughts because the bind I think we find ourselves in is that ‘command and control’ seems to breed for us a false sense of systems thinking as opposed to truly understanding what can inform and support decision making and judgment calls in the field..and to understand approaches/strategies that can be adopted to really support and inform this. Were searching for new ways of thinking that will really inform decision making in environments that are quick changing, not always predictable (in fact we can count on them not being predictable), that could present very real and serious potential consequences whilst managing the welfare and safety of young people.

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