In January of 1986, along with my coworkers outside of the Kennedy Space Center
Headquarters Building, I watched the Space Shuttle Challenger catastrophe and
was brought to tears. It was an event
that I will never forget!
Cues to this national disaster have become increasingly evident with regard to the faulty O-ring design. Initially, O-ring concerns were not highlighted, but once reported and analyzed, the issues remained largely unabated. At one point, engineers pushed back with their concerns but senior leaders pushed back as well – “let’s launch,” seemed to be what really mattered! Eventually, an O-ring “burn through” occurred and an unforgettable tragedy erupted. At various stages and levels, open communications and relevant actions were constrained by fear.
Cues to this national disaster have become increasingly evident with regard to the faulty O-ring design. Initially, O-ring concerns were not highlighted, but once reported and analyzed, the issues remained largely unabated. At one point, engineers pushed back with their concerns but senior leaders pushed back as well – “let’s launch,” seemed to be what really mattered! Eventually, an O-ring “burn through” occurred and an unforgettable tragedy erupted. At various stages and levels, open communications and relevant actions were constrained by fear.
Precursors -
Observable Cues
For more than 15 years, there has been a growing body of knowledge
regarding serious accidents and their precursors. Largely, precursors provide observable cues
and manageable signals that something very bad might be about to happen.
In similar ways, precursors seemingly coexist with almost
every serious accident. Often times, precursors are more readily apparent when dealing with high hazard
concerns inherent to kinetic, nuclear, thermal, electrical, explosive energies,
and the like. And in nearly every case,
when analyzed, various precursors signaled an eventual gloomy outcome.
The Evolution of a
Serious Event
There is rarely one pathway or root cause associated with serious accidents or fatalities. Often times, a significant event has multiple hazards or activities that are poorly controlled within a complex organizational framework and support systems.
There is rarely one pathway or root cause associated with serious accidents or fatalities. Often times, a significant event has multiple hazards or activities that are poorly controlled within a complex organizational framework and support systems.
In most industrial operations, front line supervisors and
workers are closest to the hazards and the catastrophic events. And it’s here, where lateral communications
between co-workers may first reveal “certain cues” that signal - something’s wrong!
Cues may come in the form of an electrical arc, a flash volatile solvent vapors, a noisy piece of equipment that previously failed, inappropriate or at-risk behaviors – the list is nearly endless. The bottom line, precursors have to be communicated, recorded, and analyzed so that hazardous conditions or activities can be controlled and mitigated.
Organizational
Defenses and Precursors
Well known psychologist Chris Argyris and others have
realized that certain workplace discussions are “not discussable” and become part
of various defense routines that limit organizational efficiencies. I will argue that many organizational defense
routines are driven by fear. There’s
fear of individual embarrassment, fear regarding the perceived value of
individuals or groups, or fear that future work may be lost if it is not
completed on time. Ultimately, fear helps to
produce certain defensive mechanisms and routines that impede critical forms of
communications. Think about the various defense routines and behaviors in your
own organization that are often created by fear?
When it comes to safety, precursors may not be reported
outside of one’s immediate work area or amongst coworkers because of fear. Serious events and near misses often go under, or unreported to management. If
the concern is reported to management,
it may not reach an appropriate level from which abatement can be initiated. When a concern is “fed back,” communications
may become filtered, fractured, and misun-derstood in ways that leads management
to believe that a serious event is unlikely to occur, or that it’s being
appropriately abated. Within these same
filtered communications, management may manipulate what has been discussed or rationalizes
the risk as acceptable. Management may even
take part in self-serving communications, viewed as bullying. As a result, event precursors are not accurately communicated, analyzed, managed, and
controlled.
A Culture of Fear
In every organization, cultural elements of fear produce organizational
defenses that can impede the abatement of serious incidents. Even with the recent Penn State debacle, fear
was a formidable barrier to appropriate reporting and action.
I’m certain that many of us recognize the effects of fear in the workplace and its impact on productivity, quality, morale, and of course, safety performance. At times, fear can strongly influence finger pointing, blaming, mistakes and miscues, job stress and overload, under-reporting of near-misses and accidents; and in turn, the evolution of various forms of serious accidents, even fatalities. All of this is especially true in times of economic frailty, when there is fear of job security, and potential job loss. Fear immobilizes, impairs important communications, and limits critical decision-making.
I’m certain that many of us recognize the effects of fear in the workplace and its impact on productivity, quality, morale, and of course, safety performance. At times, fear can strongly influence finger pointing, blaming, mistakes and miscues, job stress and overload, under-reporting of near-misses and accidents; and in turn, the evolution of various forms of serious accidents, even fatalities. All of this is especially true in times of economic frailty, when there is fear of job security, and potential job loss. Fear immobilizes, impairs important communications, and limits critical decision-making.
What Good Leaders Do
In some cultures, fear may be a prominent dimension that
will never become well managed. In other organizations, leaders may be
encouraged to diminish fear and build
trust. It’s trust that leads to
openness, engagement, creativity, and a desire for safety excellence.
I’ve highlighted three essential, fear-diminishing and
trust-building tactics that will help you in your own quest for limiting the
risk for serious incidents and building a culture of safety excellence.
1. Lead by Listening. Listening and being open to what is heard is
required for serious accident abatement.
Listening well without interrupting, manipulating, swaying, or bullying
a discussion is a learned skill that must be well monitored and managed.
2. Honesty is Essential. When it comes to safety-related
communications, be open and honest. Honesty
and openness, helps lead to a reciprocal candidness that is a key ingredient to
near miss reporting and hazard abatement.
3. Be Fair.
At times, discipline, dismissal, and other difficult organizational
decisions in the workplace are required, but always strive to be fair. A lack of fairness leads to a loss of
respect, resistance, and limited communications that will not help to uncover
accident precursors, at any level.
Your Early Warning
System
Wherever fear exists, there’s always a lack of engagement,
energy, excitement, creativity, openness, and willingness to change.
Right now, you just might be thinking, “Sure, everything is
clearer after it happens. Hindsight is
always, 20-20. There’s a certain ‘after-the-fact-bias’
to all of this!”
In return, I must say – yes, there may be a particular “precursor bias,”
but you have a built-in early warning system, wherever you work. And fear just could be a major barrier to communicating, tracking, analyzing, managing and abating the hazards, conditions, and at-risk actions that
need to be resolved.
History is on your side – and it’s an awesome warning system.
Please take heed!
In return, I must say – yes, there may be a particular “precursor bias,”
but you have a built-in early warning system, wherever you work. And fear just could be a major barrier to communicating, tracking, analyzing, managing and abating the hazards, conditions, and at-risk actions that
need to be resolved.
History is on your side – and it’s an awesome warning system.
Please take heed!
About the Author. David Sarkus, MS, CSP is an author,
consultant, coach, and motivational speaker. He has written five books
and more than 50 empirically-based articles. David is Chief Motivational
Officer and President and Founder of David Sarkus International Inc. His talks
focus on teamwork, coaching, safety leadership, and safety culture change. His firm also conducts safety culture
assessments and interventions for some of the biggest and best run corporations
in the world. Please visit us at: www.davidsarkus.com.