Accidents happen. Each one provides us with a unique opportunity to learn and take appropriate action to prevent recurrence. Andrew Sharman suggests that many organisations minimise the potential value they could gain from these incidents due to the way their culture responds to them. In this article he explores how a just culture and felt leadership in health and safety at work can help us get the balance just right.
Visiting a large construction site in London recently, I was surprised (though very grateful) when my host suddenly grabbed my elbow and yanked me quickly across the muddy terrain. A split-second later a large compressed insulation panel hit the ground just where I’d been standing. I’d just been the subject of a very near miss. Looking up, a roofing contractor waved apologetically and went back to his work, high above us. Catching my breath, I asked my guide what we should do about this event. With a shrug, he looked skyward and muttered “this sort of stuff happens all the time, probably more often that I know. If we wrote up a docket every time it did, I’d never leave my office.” Needless to say, the remainder of my site visit went very cautiously indeed!
Work at height – whether workers on a large construction site, an engineer working from a ladder insider a factory, or a technician working on an overhead power line – is regarded as perhaps one of the most significant potential hazards on many a risk assessment. Typically, a transactional approach to managing the risk is applied – creating permits, procedures and methods of work to control every action. So what had changed at this site that resulted in near misses from work at height activities being ignored?
Reports on several recent high profile industrial accidents have revealed that ‘toxic cultures’ have existed within the organisations involved. These toxic cultures undermine the positive value that great safety can bring by driving the reporting of bad news, honest mistakes and unfortunate accidents underground. In doing so, we miss important opportunities to learn from these events, and the cover up continues as near misses and unsafe acts become distorted from view. The situation is further exacerbated when the work area is remote or hard to reach – like when working at height, for example.
Clarity is key to developing a robust safety culture – as health and safety practitioners we know it’s important that all incidents are reported and that processes are in place for investigation and the implementation of suitable preventative actions. But if we truly want our employees to provide us with this information we need to create an environment where they feel able to step forward to offer thoughts and opinions objectively and freely – and for these to be received openly and respectfully by the organisation. Any processes we use to report accidents or to encourage feedback and suggestions from our employees must be easy to use, respect confidentiality – and be worthwhile. By contrast, a workplace where news of negative safety events such as accidents, injuries and near misses is met with disappointment and unease is not conducive to a developing this clarity – and in fact it drives things in the opposite direction – into the dark depths of forgotten anonymity, underground. The practice of reporting events is quickly minimised and provided only when forced or extracted, or when such an incident has been unavoidably witnessed by a superior. Near misses tend to be dismissed as accidents fortunately avoided through the sheer skill of experienced workers, and written off rather than followed up.
Reaching for zero
As part of their drive to share learnings from their accident investigation process, a new client of ours – a leading global player in the manufacturing industry – would distribute a newsflash to all sites summarising every incident that occurred. Not a bad idea you might think – surely this might help stop the same things happening over again… Not such a great idea if you were the injured person though, as your name and photograph would be featured in the opening sections of the report. As you might already be guessing, it wasn’t long before the company found themselves reaching their aspiration of zero reported accidents – though a corresponding spike in unexplained absences suggested to us that something wasn’t quite right.
Finding the balance
Organisations that place emphasis on identifying fault and apportioning blame will always encourage a culture of fear, which will sooner or later lead to under-reporting when it comes to safety issues. Yet at the opposite end of the spectrum, an organisation attempting to operate a totally blame-free work environment is likely to suffer willful neglect and violation frequently. Finding the balance should be our aim, and appropriate accountability is the route to success.
Balancing our desire to learn from mistakes with the need to take corrective action to reinforce the notion of accountability is the way forward. In safety terms, thanks principally to the work of the Australian Sidney Dekker, this has become known as a just culture, and can be defined as a culture in which individuals are not punished for actions taken by them that are commensurate with their experience and training. While it discourages apportioning blame, a just culture is not a ‘no-fault’ system. It doesn’t mean we have to operate under the auspices of ‘no blame’ but rather a sense of fair and appropriate accountability is incorporated into what we do. In a just culture there is an acceptance and understanding that human errors are often caused through system failures (as opposed to, but of course in addition to the potential for, personal failures) but where gross negligence, willful violations and destructive acts occur these are not tolerated.
In simple terms, a just culture is about being objective, rational and fair rather than jumping to conclusions drawn from our first steps of investigation or observations. If we are thorough in our accident investigation processes and truly strive to identify what went wrong, we may find that the majority of unsafe acts and behaviours that have occurred are due to unintentional error rather than deliberate wrong-doing. Thorough and systematic evaluation of events is key and investigations into where things have gone awry should include determining whether the actions were as intended; whether an individual knowingly violated policies, procedures or rules; and if so, whether there is a history of such violations. Remember there is a clear distinction between human error and violation. An easy way to note the difference is that in order for there to be a violation there must first be a rule and secondly an intention to break it. If there’s no rule, there can’t be a violation.
In fact, when we look at those events that we consider to be violations, we may often find that such willful incorrect actions have been quite literally catalysed in the worker’s mind due to organisational pressure – whether real, implied or imagined – or perhaps an internal self-influence of simply wanting to do the right thing; like meeting the day’s shift production targets, for example. Where the mistake was inadvertent or occurred in a system that was not supportive of safety (such as a period of extended, mandatory overtime leading to fatigue) an appropriate response in a just culture would include coaching and education.
Of course, malicious or purposefully harmful behaviour must not be tolerated and individuals should be held responsible for their actions within the context of the circumstances in which they occurred. Even where the act is found to be predominantly willful and malicious it’s worth trying to understand – as objectively as possible – what caused that mindset. Is there something that the organisation did that contributed to it? And could other employees have the same perspective?
Building the benefit
Just culture embraces the notion that people are indeed fallible and will from time to time get it wrong. Building a work environment where individuals feel free to support and improve workplace safety by offering up ideas, by sharing openly when they spot weaknesses and failures in the system, and by stepping forward when errors occur creates benefits on many levels, here’s just a few that spring quickly to mind:
- Increases transparency
- Builds trust
- Enhances worker commitment and motivation
- Contributes to learning and continuous improvement
- Empowers workers
- Increases openness of reporting of issues and weaknesses
- Improves objectivity in analysis and decision-making
- Brings balance and accountability
- Promotes safe behaviours
- Reduces the frequency of unsafe acts
Encouraging and sustaining a just culture in your workplace allows people to concentrate on doing their best work rather than worrying about watching their backs and trying to eliminate every chance of a mistake for fear of repercussion.
A just culture places safety as a core value, part of the organisational DNA, and an intrinsic ‘way we do things around here’. It engenders employee engagement and builds trust.
The traditional view of culture change is that it is deemed to be effective only when everyone is involved, from the boardroom to the shop-floor. Every leader, every manager, every supervisor, every frontline worker.
Of course a coordinated approach is best, but frankly it’s nonsense to suggest that only a totally inclusive approach can be impactful. I would not argue against the notion that 100% engagement of the entire workforce would be beneficial in many respects, but I don’t believe that it has to be an ‘all or nothing’ approach to influencing safety behaviours.
In his magnificent and highly provocative book Viral Change, psychiatrist Leandro Herrero explains that culture change works one person at a time. Herrero tells us that change is most effective when it spreads like a virus. Step by step, gradually infecting everyone – just like catching the common cold from that guy sneezing next to you on the bus this morning. When we realise that effective change comes from this individualised action, not only does developing a positive safety culture feel more achievable, it actually becomes more practical to manage too.
‘Felt leadership’ operates in exactly this sort of viral change process. It’s not necessarily a new style or theory of leadership; instead we might consider it the distillation of the some of the more impactful elements from a range of schools of thought on leadership. It’s essentially about ‘walking the talk’, demonstrating that commitment to safety is as strong as it’s claimed to be. In my view, it’s the foundation for building trust and supportive relationships at all levels within the organisation. Done well, felt leadership moves an organisation from a focus on compliance to a deeper, more cultural approach, based on shared commitment – the results can be impressive.
Over time, many organisations have found that their safety cultures have been considerably enhanced through the application of felt leadership and studies have shown that good safety leadership can positively influence the safety behaviours of workers by up to 86%, and reduce incidents and accidents by around 35%. But the benefits don’t stop there as it’s known that improving safety culture and performance delivers sustainable, shared value to other areas of the business too, such as quality, delivery speeds and operational efficiencies.
The corporate ‘bottom line’ is also positively impacted – as organisations with good safety performance also appear to have better economic performance. Is there a connection between the two? The answer is undeniably ‘yes’, as reduced incident rates and improved working conditions boost employee morale, enhance engagement and generate positive influence over productivity and therefore profitability.
For leadership in safety to be ‘felt’ by those around us, leaders must hold an absolute personal commitment to the organisation’s value on safety. In our own research, three safety values in particular were found to recur again and again. It’s worthwhile to take a look at these now:
- All workplace injuries and ill-health are preventable
- Everyone has the right to go home safely at the end of every day
- Safety is a line responsibility that is owned, led and driven by the entire team of leaders within the organisation
These values act as the blueprint for felt leadership. Acknowledging that safety is a core business value, and integral to the very existence of the organisation, is crucial for setting the scene, and when demonstrated through the actions of leaders can have a profound effect on employees. Pause for a moment and consider how these values might be reflected in your organisation.
Principles of felt leadership
How can we utilise the concept of felt leadership at work? Over the last few years as our consulting business has partnered with many organisations around the world we’ve come to learn that taking a principled approach to safety not only provides a strong framework but also yields great results. Through our work we’ve identified five principles of felt leadership that can add significant value to any safety management system:
- Inspire people with a clear vision of what success looks like
- Lead by setting a great example
- Empower people to think and act in safety
- Use meaningful praise wherever possible
- Take the time to coach rather than tell
Look at that list of leadership principles one more time. Now consider who in your organisation would undertake these actions. I passionately believe that these principles are for everyone: felt leadership in safety is not the exclusive domain of senior executives. While commitment must start from the top, all levels in the organisational hierarchy can spread the safety change – just like the common cold virus spreading on the bus. The five principles shared above are as relevant and useful to the new team member as they are to the CEO, so whatever your role in your organization, you can certainly use the viral approach to leading forward. Which of the five principles above do you feel that you have strength in? And could there be some in which you might want to gain some further development?
Can you feel it?
How can we demonstrate that we’re truly committed to safety? Here are some specific actions that can help your own personal leadership in safety to be felt by those around you:
- Work to anticipate – rather than react to – risks
- Proactively discuss hazards with employees and within peer groups
- Respond quickly when unsafe conditions are discovered in the workplace
- Inspect the workplace frequently and intelligently
- Ensure effective corrective actions from accident investigations, audits or surveys are prioritised, attended to, and completed
- Objectively investigate incidents and accidents, take a ‘helicopter view’ and resist the urge to apportion blame
- Understand the needs and aspirations of workers with regard to safety
- Find a way to involve everyone – risk assessments, investigations, project teams or even just asking people for their thoughts all count!
Felt leadership is an approach that can be used by anyone, regardless of their role, seniority or place in the organisational hierarchy. It works because it builds strong safety cultures through the inter-relationships between leaders and followers. As we’ve discussed in this article, it’s action-focused – and even the smallest actions count towards making a difference. When felt leadership is demonstrated within an organisation in the area of safety, a cultural transformation can occur. More importantly, that transformation becomes sustainable as it becomes part of the fabric of the company and the work environment.
Great safety leaders ultimately challenge those around them to make a personal commitment to be the best they can be while making safety easy and fun, and releasing people’s energy, skills and ideas to create safety in the workplace. Remember that safety excellence is a journey, not a destination. Along the route you’ll get the level of safety performance that you as a leader personally demonstrate that you want so don’t forget that attitudes, behaviours, actions, and inactions will all be viewed as illustrations of our personal level of commitment with respect to safety in the workplace. What we say, speak and write as leaders – no matter where we are in the organisational hierarchy – must be visibly reflected in what we do. Lead on and get the balance just right!