Is Safety “a few tools short of a toolbox”?

This article was first published on Saferisk.net. The author of this post is a student at The Centre for Leadership and Learning in Risk (CLLR).

Collective mindfulness is an acceptance of equivocality; understanding that all possible outcomes cannot be known and that the environment is continually changing (a concept that “zero harm” organizations, by design and definition, are restricted from accepting or acknowledging). This acceptance of equivocality creates a mindset of active wariness and attentiveness through continual questioning and revision of previously held assumptions, plans, and expectations. Organizations are prone to failure when their attention is unfocused or distracted. Attention deficit can lead to misunderstanding, simplifying, and normalizing – or underestimating – the challenges they face, increasing the likelihood of error.

We can never eliminate ambiguity (just like we cannot eliminate harm), nor should we try; the key is organizing in a way that reduces equivocality and allows us to manage unexpected failure. To help implement an organizational worldview that uses Collective Mindfulness, Weick and Sutcliffe (2007) have identified five key principles that are used by High Reliability Organizations (HRO’s) (aircraft carriers, flight controllers, nuclear power stations etc.) to deal with the unexpected. The first three principles (preoccupation with failure, reluctance to simplify, and sensitivity to operations) address the anticipation of failure, where the remaining two principles (commitment to resilience, and a deference to expertise) describe how these organizations react to and contain failures after they occur.

The following is a critique of a “Toolbox Training” program from a large multinational organization that has recently been shared with me. I will compare this program to Weick and Sutcliffe’s three principles of anticipation in order to determine whether this activity is one that facilitates or hinders the organization’s ability to make sense of risk, anticipate failure, and manage the unexpected.

1.Preoccupation with Failure

It is easy to read “Preoccupation with Failure” and presume it is pessimistic. It is not. To move forward with this principle requires the willingness and capability to engage in critical thinking and enact values like faith, trust and confession. Only then will people be more willing and able to ask a question like “What are the byproducts and tradeoffs of that decision?” This is foundational for Collective Mindfulness.

Preoccupation with failure requires we exist in the dialectic between naïve realism and fatalism, so those who are caught in binary thinking will struggle with this principle. This principle develops a mindset that allows small failures to be identified and managed before they become larger, damaging failures. Furthermore, these failures are not viewed as solitary events, but instead they are taken as a signal that there may be deeper issues within the entire system and could result in widespread consequences.

Shining the Light on Toolbox training and preoccupation with failure

Failure must be embraced before it can be avoided. In the Toolbox Training’s instruction for employees, it states the “only acceptable level of safety performance is one that prevents employee injury and accidents.” The discourse here is one of blame and punishment for getting injured. There can be no trust and confession in a culture that shows intolerance for fallibility; and people will not feel comfortable discussing potential failures, mistakes, or reporting events and/or near misses. This bypasses the critical part of preoccupation with failure; honest discussion regarding mistakes provides for learning opportunities, reinforces the fact that humans, by design, are fallible, and helps reduce overconfidence

2.Reluctance to Simplify

This does not mean simplification is bad. Any activity that we put together will require some degree of simplification. However, if things are less simple, it does add to the depth and breadth of what we see. When we are reluctant to simplify, we take nothing for granted; because everything slows down, it can lead to discovery that would otherwise go unnoticed. We can now pay closer attention to what is happening in the moment. The positive byproduct of that is we are better able to label whatever is observed with more accuracy. Inviting and even encouraging skepticism and viewing things through a marketplace of ideas will support a more robust and rich environment that gives us a larger lens through which to view potential outcomes.

Shining the Light on Toolbox training and Reluctance to Simplify

The nature of this Toolbox is simplification, leaving large gaps of potential failures that can go unnoticed. For example, using pre-recorded videos for the Toolbox Talk ensures everyone gets the same, exact wording in the same exact timetable. Efficiency and standardization (both tools of simplification) is the driver here, and is held in higher esteem than making sense of risk. One of the byproducts of that is it leaves little if any room for conversations. This limits the identification of undesirable failures and the precautions taken to minimize these failures.

In addition, when a single person or select group (Safety) is the sole developer of these “toolboxes”, their biases, assumptions, agendas and worldviews are the only ones that are heard. This normalizes the developers ideology by reducing the opportunities for these assumptions and worldviews to be challenged, and doesn’t allow the group to take advantage of the knowledge and experience present in the toolbox training.

3. Sensitivity to Operations

Sensitivity to operations is being attentive to the “boots on the ground” where the real work is being done. Conversations and sensitivity to operations should precede every checklist and pre-hazard analysis. If leadership is going out to do the obligatory monthly or yearly audit, this not only wastes time and resources, it can create further distance and distrust between operations and management. This is where “Humble Inquiry” is crucial. Constant interaction and information sharing about what is actually happening in the workplace is critical. Practicing ‘Humble Inquiry’ allows managers to understand the nuances of operations, and can also help neutralize threats to sensitivity, namely automatic pilot, a focus on quantitative data, and overload through production pressure. There is growing evidence that many tasks get accomplished better and more safely if team members – and especially bosses – learn to build relationship through the art of humble inquiry. (Schein, 2013)

Shining the Light on Toolbox training and Sensitivity to Operations

As the Toolbox Training topics and format are predetermined, it becomes impossible to be attentive to see what really goes on in the field. These “Toolboxes” are reduced to a sermon of worship to the gods of “Zero Harm” with “Safety” playing the preacher and “telling” rather than “inquiring”. There can be no sensitivity to operations when “Safety” knows what is best. The hammer of “Safety” is the only tool needed in this toolbox.

The importance placed on “hitting the numbers” in regards to attendance and delivery frequency, increases the risk of “tick and flick”, where toolboxes are delivered with no real interest in learning or understanding the challenges that the “congregation” are tackling on a day-to-day basis; the signatures and date on the sign on sheet becomes the most important element of the activity and any opportunity for management to become sensitive to operations is lost.

Utilizing all of our Tools

So it’s clear that this organization’s “Toolbox Training” falls short of the mark when we look at whether it is an activity that can help us make sense of risk and anticipate failure in the workplace; in fact, this activity stunts the organization’s ability to learn and manage risk through honest discussion, confession, and the embracing of differing worldviews, skills and experiences. What can we do in order to transform the toolbox from a tick and flick activity, based on preaching, reductionism and fear, into an activity based on curiosity, learning and trust? Here are just a few suggestions:

1. Scrap the templates and pre-recorded messages. A toolbox should utilise all the tools available, not just the “Safety hammer”. Approaching toolboxes with a “clean-slate” encourages curiosity, discovery and understanding. Seeking differing points of view and encouraging healthy scepticism during toolbox talks will create a much richer understanding of our risks.
2. Stop preaching and start asking. Humble inquiry is critical for an organisations ability to anticipate failure. Let’s stop telling people what the problem and solution is and start asking intelligent and open questions like “What needs to go right?”, “What could fail?”, “How could things fail”, “How do we identify failure”, and “How would we respond to failure”.
3. No more KPI’s and signatures. Toolboxes should be about learning and making sense of situations, not achieving KPI’s and collecting evidence for future blame and punishment.

Until safety shows some risk maturity and embraces fallibility, curiosity and diversity, it will always be “a few tools short of a toolbox”.