OVER BLACK WE HEAR THE DULL SOUNDS OF INDUSTRY; A MUFFLED MASS OF MACHINES, GEARS, STEAM. FADE IN ON:
A SIGN. Twelve feet across. Painted decades earlier, grime-covered black, white and red. It reads in large 40’s era, hand-painted type, “SAFETY IS OUR PRIMARY CONCERN!” Then:
“DAYS SINCE LAST ACCIDENT” and below that, NUMBERS, painted on hanging metal cards. Four possible digits can hang here, but there are currently three: “784.”
SLOWLY PUSH IN on this sign as a MAN APPEARS, rising on a forklift, in a greasy, monochromatic work jumpsuit. Removes the “4” from its hooks. Then removes the “8.” Then the “7.”
Finally, he hangs up a number. “1.”
The man LOWERS out of frame as we creep even closer to the
hanging single digit, wondering about the accident… and how
bad it was and the FACTORY SOUNDS GROW DEAFENING — AND AS IT BUILDS TO A CRESCENDO, WE CUT TO SILENT BLACKNESS.
(SUPER 8, Written by J.J. Abrams, FINAL SHOOTING SCRIPT, December 16, 2010)
It is 1979. Elizabeth Lamb, the wife of Deputy Sheriff Jack Lamb of Lillian, Ohio, and mother of 14-year-old Joe, is killed in a steel mill accident. The emotive opening to the science fiction film Super8 grimly resets the accident-free counter on the factory’s motivational sign. Apparently, J.J. Abrams had the idea to start a film with the factory’s “Accident-Free” sign long before he came up with the rest of the idea of the film. When I saw this, two issues came to mind.
We have an image problem
The image is profoundly dispiriting. Perhaps we have the idea that such signs might remind people, even motivate them, to ‘be safe’. I know of no evidence that they work. Deming knew this. He stated 14 points for managers in Quality, Productivity, and Competitive Position and revised them over time (also in ‘Out of the Crisis’). Deming urged managers to eliminate slogans as well as management by numbers and numerical goals. Deming’s point 10 was as follows:
Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.
We not only waste time and resources with such exhortations, but focus attention away from where it should be: the system.
We have a paradigm problem
The sign presents almost perfectly a more fundamental paradox that we have in safety. How can safety be the primary concern of any organisation? The primary goal of the Lillian Steel Factory cannot be to avoid or prevent accidents, which the sign implicitly suggests as its definition of safety. The primary goal of the Lillian Steel Factory has to be to serve the customer – to meet customer needs – as well as those of other stakeholders. If the primary goal was to avoid accidents, then the most effective solution would be to stop making steel. Safety, then, when defined (only) as avoiding accidents and unacceptable risk, will always be at odds with the real primary concern of organisation: to serve the customer.
We have a solution
And it is simple, at least in principle. First, get rid of slogans that tell people to be safe, be careful, do a good job, etc. Second, stop defining safety solely in terms of accident avoidance. That doesn’t reflect the purpose of the organisation and is more of an anti-goal than a goal.
Instead, seek to understand systems conditions, such as demand and pressure and the resources and constraints, in the context of the system as a whole, mindful of the purpose(s) of the system. Involve the field experts in all stages of understanding and improving the system. Understand the trade offs they must make, and how they adapt and vary their performance to meet variable demands in light of variable conditions. But see things from their point of view, their local rationality. Understand that nobody goes to work to have an accident; they set out to do their best and achieve a good outcome. Just culture is still important. Get a better idea of the flow of work from end to end, including the interactions between different elements of the sociotechnical system. Understand that system behaviour and outcomes in complex systems are emergent; they cannot be reduced to the behaviour of the human or technical components and are often not as expected, imagined or designed. And last but not least, understand that success are failure are equivalent; they come from the same source: ordinary work.
Safety really is our primary goal
If safety is actually viewed as ensuring things go right (which includes avoiding that things go wrong), then safety really is our primary goal. By ensuring things go right, especially in day-to-day work, we achieve the purpose of the system, by definition.
EUROCONTROL (2013). From Safety-I to Safety-II (A White Paper). Brussels.
EUROCONTROL (2014). Systems Thinking for Safety: Ten Principles (A White Paper). Brussels.
Hollnagel, E. (2014). Safety-I & Safety-II. The Past and Future of Safety Management. Ashgate.
Organisations and the ghosts of failures past, present and yet to come
Thank you Steve. Most interesting. Best regards, Yves
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