With an increasing awareness of the importance of safety, we are seeing a growing trend of zero accident goals. Inherently, this is a laudable moral goal and if we truly value people in organizations, then our intentions should indeed point to a goal of not harming people during operational work. Protecting people is a good thing, but one of the problems with “zero goals” is the lack of acknowledgement about how complexity makes it impossible to predict and prevent all risk in an organization.
Acceptable Risk and Safety Margins
Two of the principles of US Marine Corps Risk Management are to “Accept No Unnecessary Risk” and to “Make Risk Decisions at the Right Level.” Although predicting all risk is impossible, risk-based approaches are preferable to chasing “zero goals” based on lagging indicators because they explicitly acknowledge the existence of risk during planning and operational execution.
Zero harm is a worthy moral goal. However, while “zero goal” approaches don’t necessarily mean risk isn’t examined, it’s easy for zero accident initiatives to get sidetracked by focusing too much on reducing the apparent causes of specific injuries/incidents that occurred in the past. This may lead to a reduced ability to imagine new ways risks could emerge. Additionally, overemphasizing “zero goals” could lead to a reduction in learning from small failures. Risk-based approaches force leaders to identify the organization’s risk appetite and level of risk tolerance and provide a framework for allowing those in key leadership positions to make risk decisions. Once risk decisions are made, the remaining risk is often referred to as residual risk and oftentimes that residual risk allows for a space of positive action oriented towards achieving successful outcomes.
When we add the complexity of numerous interconnected parts in an organization, such as work methods, schedules, supply chains and project funding constraints, the ability to detect the changing face of risk within safety margins can become even more difficult. As Shane Parrish explains, predicting system behavior in complex adaptive systems can be very difficult. This is why it is extremely important to have a questioning attitude about how risk may occur, to espouse the notion of adaptive capacity and to create organizational capacity to manage the unexpected. Adaptive capacity may be thought of like a glass of water: as we build resources into our organizations and outfit our operational teams with the right equipment, planning systems, communication systems, and the leadership attitudes and behaviors to support these tools, our glass begins to fill. As our glass fills, our organizations grow the adaptive capacity necessary to proactively create safety.
Tools for Managing Safety at the Margins
Many industries have known for a long time that while humans can have a tendency to be unreliable under many circumstances, they have the capacity to do things that simple components and machines are unable to do. While the human is often the weakest part of the system, it is the only one that can actively create safety in complex systems.
An example of humans creating safety in complex systems comes via the aviation industry, where workers built and implemented Crew Resource Management (CRM) systems to help create adaptability and resilience in crews. CRM has found an increasingly important role especially in military aviation, helping aircrew manage safe operational performance despite the high-threat/high-risk nature of their work. CRM has also found its way into other industries, such as the oil and gas, rail, and maritime industries. CRM affects safety by emphasizing the need for adaptability, decision-making, and questioning among crews as they work together to understand risk as it unfolds and to make decisions for safety and mission success. While the human may still be the weakest part of the system, risk-based approaches that use human creativity and imagination may go a long way towards raising both risk awareness and organizational adaptability to unexpected risks.
Here are some suggestions to help with actively creating safety within complex organizations:
- Equip, train, and plan. One of the hallmarks of effective teamwork is a system that views training, equipment, and planning as essential elements of excellent performance. By equipping teams with the right resources, training for initial and advanced competence, and implementing a robust planning system, leaders can create the foundations necessary to building sustainable safety and operational performance success.
- Develop adaptability as an individual skillset and adaptive capacity within organizational planning and management systems. When organizations are unable to adapt quickly, they miss opportunities to discover and adequately deal with risk. In other words, organizations miss the opportunity to fail gracefully. From a practical standpoint this may mean implementing systems, communication tools, information channels, the mindset required to facilitate adaptability when events force plans to change, and a process to review how and why these changes occurred.
- Create a risk “hotline” employees can call when time-sensitive risk decisions must be made. In fast-changing environments, leaders may consider developing a “hotline” communication system that facilitates the flow of information and that helps line crews determine who can help them make risk decisions.
- Consider debriefing a normal part of the workday. Just like putting tools away, driving back to the facility, or clocking out, there are certain things crews, teams and workers do after every shift. Debriefing should be integrated into the normal flow of work so that a good debrief is conducted after every shift to identify success and failure points from an operations and safety perspective. To take full advantage of this time, give your workers tools to use while debriefing so they can figure out what went well and where they can improve. This will allow your organization to make debriefing a habit.
Striving for “zero” is indeed a moral goal. However, in complex systems risk can be hard to predict and chasing zero may be more difficult than we realize. Organizations may not be perfect, and they may not be able to prevent all accidents, but with the right attitudes, behaviors, systems and tools to adapt and learn how to minimize damage, fail gracefully, protect people and operations, recover proactively, and learn for the future.