What Is a Safety System?
No matter how much traditional safety “stuff” you do, it doesn’t necessarily mean you have a functional safety system. Without such a system, however, safety results are largely dependent on luck and good intentions. This is not a strategy for safety success.
Webster tells us that a system is “a regularly interacting or interdependent group of items forming a unified whole.” Like any effective system, safety systems must include goals and objectives with plans (P), for how every level of the organization will contribute to those goals and objectives by doing (D) specific activities. To provide for accountability and to ensure those planned activities actually happen and that they are effective, they must also be measured and evaluated - commonly known as check (C) in Deming parlance. These three steps are vital for any organization that hopes for continuous improvement by acting (A) on what they learn in their ongoing system evaluations. Systems are not static, however, but are constantly transforming themselves as they learn and continually improve. Most commonly such systems are known as PDCA systems.
PDCA Safety System
Since most organizations want to stay in business, they have long recognized the importance of nurturing a PDCA system for their business imperatives. Inexplicably, however, many of these same organizations fail to manage safety in the same manner.
Check: The Missing Link
Time and again the author has witnessed organizations start on a safety management system only to bog down in the details without completing the process. Most commonly they lack an effective “check” step. The check step goes by many different names but is absolutely essential for any functioning system. Dr. W. Edwards Deming, often credited as the father of the plan, do, check, act cycle, actually preferred “study” to check but eventually yielded to the wishes of his Japanese customers. Six sigma programs use terms like “measure, analyze and improve.” The ANSI standard for health and safety management systems (ANSI/AIHA Z10-2012) calls for an “evaluation and corrective action” step and the DOE uses the term “feedback and improvement” for the same process. Whatever you call it, a check step is vital for establishing accountability, as well as for acquiring the feedback necessary to fix and continuously improve the entire system.
Unfortunately some organizations appear reluctant to self assess safety in a meaningful manner. As a result even companies that establish excellent safety goals and objectives, complete with comprehensive (and often expensive) implementation schemes, fail in their efforts. They fail because they lack a process to measure and analyze their progress. Safety assessment is left to the safety staff, if it is done at all. Managers may know their accident rates but have little understanding of how well (or poorly) they are doing in regard to their organizational safety goals and objectives. Therefore they don’t know what to fix, improve, do away with or celebrate – leaving only hope that needed corrective actions and process improvements are implemented. I’ve seen this “don’t ask don’t tell” safety approach so often I’ve actually given it a name - the Plan, Do, Hope, Pray (PDHP) process.
Why the Missing Link?
There are, no doubt, many reasons for the PDHP approach seen in so many organizations, but safety personnel are often part of the problem. Commonly the safety staff hands off a set of traditional lagging indicators to a passive management. These metrics are then accepted by management as all the evidence needed to support the staff's conclusion ("just tell us if it's safe"). It sadly surprising how many managers/supervisors don’t know what is really going on in the field and are content to read reports, issue memos, give speeches, and then hope their operations are performing safely.
There Is a Better Way
In the author’s many years of organizational assessment, the best (i.e., safest) organizations employed a variety of leading and lagging indicators but often went beyond the numbers to include management discussions (not safety staff sermons) on what managers are seeing in the field and specifically what they are doing to ensure improvement based on those observations. Managers (again, not the safety staff) were also expected to discuss any accidents, incidents, near misses and negative trends as well as the status of associated corrective actions. These discussions stressed concrete actions to improve the safety system and help ensure continuous improvement.
The Importance of Observations
You can only go so far with performance indicators. Even the best crafted leading and lagging indicators are no substitute for actually getting out, observing work and interacting with the workers. Every organization must have a real time way to inform itself of how well, and safely, its operations, especially high consequence operations, are conducted. In high reliability organizations such as commercial nuclear power this is known as operational awareness. An effective safety system check step is not possible without it and you can’t get it from behind a desk. Unfortunately many organizations don't seem to understand the importance of operational awareness, not only to safety, but to their very existence.
There are three types of safety observation in common usage:
- Traditional OSHA-type inspections that focus mainly on conditions
- Behavioral-based observations that are typically performed by employee peers and focus on a set of pre-determined “critical behaviors.”
- Observations of work and work processes – commonly known as management walkarounds but sometimes performed by safety staff, safety committee members and others. (See Safety Management by Walking Around Part 1, Part 2, and Part 3 in earlier SafetyCary articles).
The three types of field observations are not mutually exclusive and all three can add safety value as well as provide useful input to the safety review implied in the safety system check step. The remainder of this article, however, will address #3, observation of work and work processes. The author has found this type of observation the most valuable both in identifying root cause safety issues and in gaining assurance that process safety and safety critical operations are appropriately addressed.
Why Observe Work?
Managers have an obligation to understand how safely the work they are responsible for is performed. Lack of such an understanding has been a recurrent and principle factor in recent tragedies from the Columbia and Challenger disasters to the Deepwater Horizon. A genuine understanding of safety performance cannot be delegated or achieved solely from accident statistics. Nor can this understanding be gained through traditional compliance inspections that focus on conditions or some predetermined subset of behaviors. A deeper understanding of the work, and the systems and processes that support it (or not), is needed and should be the principle goal of work-focused walkarounds. Conditions and behaviors (see observation types 1&2 above) are not ignored but the emphasis is on observing work. The goal is to understand how the work is actually performed and then to partner with the employees to gain additional understanding of the work, its hazards and the adequacy of the controls – including the use, misuse or nonuse of procedures, training, equipment, environmental factors etc. Well structured walkaround programs emphasize the importance of partnering and actively listening to those performing the work. Worker engagement is prompted with questions such as, “What is the worst thing that could happen on this job?” This cooperative and “fault free” approach helps ensure employee cooperation in finding safer and better ways to perform the work. Effective walkarounds are thus performed with employees – not to them (a tip of the hat to Alan Quilley for this turn of phrase).
How important is operational awareness? Consider the Deepwater Horizon where 11 employees were killed and tens of thousands of barrels of oil spilled into the Gulf of Mexico for 87 days. 
Just seven hours prior to the Deepwater Horizon explosion, top managers from both BP and Transocean were on the drilling platform walking around. They were focused, however, on conditions such as fall protection devices, housekeeping and trip hazards, and a specific employee behavior, glove use. Missing from their walkaround was any serious attempt to find out how the very critical well capping work was progressing, thus tragically missing an opportunity to deal with the many safety issues that were affecting the capping effort. Subsequent investigation by the Chemical Safety Board found BP overly focused on common personal injuries and behavior – to the detriment of process safety as well as more serious safety issues. This finding was very similar to an earlier finding at BP’s Texas City refinery where an explosion killed 15 in 2005.
Summary
There are no silver bullets in safety, but a systematic PDCA approach is essential to success. And you don’t have a working safety system without a vigorous check step. Observations, especially observations of work, put reality into your check step data. Without this reality-based safety review you can hope your work and critical processes are safe, but you’ll never really know – at least not until it’s too late.
* Image courtesy of Deepwaterhorizon News, Video and Gossip - Gawker
