Make a rule, police the rule, punish the rulebreakers. That’s how many “traditional” safety programs work.  Another popular method over the years has focused on employee behavior. State the behavior, observe the behavior, modify incorrect behaviors. It’s not a lot different than the rules; this method just calls the rules “behaviors.”  Start a “Zero Harm” program?  Actually, that’s harmful to your employees.

The stubborn adherence to these methods has resulted in injury rates across all manufacturing to stay relatively flat for the past several years. This includes foundries, which overall have twice as many injuries per 100 employees than general manufacturing. Small foundries—those with 11-49 employees, have nearly twice the number of injuries as foundries overall, and medium foundries (50-249) report about 1 1/3 as many as the overall number. How do we reverse this trend? More rules and stricter enforcement? Zero – “Just Believe?”

They just aren’t helping, so what are foundries to do?

New Assumptions, New Principles

Let’s start with two assumptions: (1.) People want to do a good job, and (2.) nobody gets hurt on purpose. For some, these assumptions are not new. For others, who may have always looked at people as the problem, it’s a completely different way of thinking. Now let’s throw in five principles—developed by Todd Conklin, one of the “gurus” of Human and Organizational Performance (HOP)—and examine the benefits of embracing them: (1) Error is normal, (2) blame fixes nothing, (3) context matters, (4) learning is vital, and (5) how we react matters.

Error Is Normal

Human beings are fallible. We all make mistakes. We all suffer the proverbial “brain cramp” and screw something up. It even happens when we’ve done the same thing well for weeks or months. Start to think in terms of what happens when we make an error. How does our system recover from the error safely? Change your thinking from what happens if an error occurs to when an error occurs. Think about tasks in which the employee’s only protection is that they do the job perfectly every single time.

Odds are, sooner or later they won’t.  Admitting that error is normal is the first step in moving from fixing the employee to fixing the process.

Blame Fixes Nothing

As humans, we naturally want to know who is to blame. Who messed up? Was it Joe’s fault?  Off with his head! Problem solved! If only it were that simple. To improve, we must understand why fallible Joe got hurt when he made the inevitable error. What safeguards would have protected Joe if they were in place? What conditions drove the error? Ron Gannt, another leading thinker in HOP, says this: “Rather than framing the problem as ‘people are not following the procedures/rules,’ try framing it as ‘people do not see the procedures/rules as helpful to getting their work done.’” It’s a subtle change but it might broaden your perspective a bit and lead to a wider, more productive set of potential improvements.

Context Drives Behavior

When an employee makes an error, it’s very easy for those investigating to point out what should have been done. “Should haves” are moot since they did not happen. Context describes why the employee did what they did, and the “why” is as important as the “what” or the “who.”  What were the signals, gauge readings, experience, etc., that were in play prior to the error?  Get further upstream from where the injury occurred and do some hard looking at how it happened, rather than who or what. It’s very likely that if the injured knew they were going to get hurt, they wouldn’t have done what they did. If the action made sense to them at the time, it is going to make sense to someone else in the future and there will be a repeat incident.

Learning Is Vital

Conklin says we can blame and shame or learn and improve, but we can’t do both. Without learning, our organizations slowly wither and die. More importantly, people continue to get hurt and equipment continues to get damaged. There is always going to be a gap between work as imagined by engineers and owners and work as done by those at the sharp end of the stick.  

Humans make hundreds of decisions every shift to keep things running. We need humans to be flexible and adjust to changing conditions. Our people are vital to keeping operations running smoothly. So, learn how the work really gets done. Stop doing incident investigations and do some learning. Instead of starting with “what happened?” start with “tell me the story of your day.” Sit down with your team and talk about procedures and rules that don’t work, as well as the ones that do.

We can also learn when everything is “normal.”  If work is done safely 99% of the time, why is that? How? If we can learn that from our teams, we can duplicate the good stuff.  One of the biggest factors in whether we can learn is how we react to bad news.

How We React Matters

Actually, it matters a lot. None of us likes getting bad news, but often that bad news is something to learn from. Blowing up, yelling, or rolling our eyes when we hear bad news stifles communication. Blow your stack with an employee who is telling you about an error, and you can be sure you won’t hear about the next one. Embarrass an injured employee by standing them in front of a safety meeting and making them tell how they got hurt, and they’ll hide the next injury. Do these or others and you will miss receiving crucial information.

Instead, provide positive feedback for the report. This doesn’t mean tossing responsibility out the window, but how about responding to news like this: “That’s pretty serious, so thank you for telling me about it. Let’s see how we can keep it from happening again.”

Seek Competence, Not Compliance

At a home swimming pool, which works better: having a rule that says “do not drown” or teaching the kids or grandkids to swim well? Most would agree it’s much more effective to teach swimming. Do people who know how to swim still drown? Certainly, they do, but their odds of surviving a fall into water are much better than for someone who is following the “don’t drown” rule. Similarly, it’s more effective to train workers to visualize and manage risk than it is to develop hard and fast rules for everything. In our incident learning, we can then discuss how events developed in the context of what that person was seeing and thinking at the time. Sound familiar? Learning is vital, and context drives behavior.

People who are competent in their tasks will recognize and react to risks better than those following strict rules, and that’s better for business no matter whether we’re talking safety, quality, or productivity. The rigidity of “work to rules” typically slows things down and makes production harder to accomplish.  Rules should be guardrails for competent employees, not a tether holding them back.

Eliminate Safety Clutter

“Safety” can involve a lot of paperwork, but it doesn’t have to. Over time, many operations have created “safety clutter” as we add forms and checklists in response to an accident or a perceived liability. Take some time to review forms, checklists, and records to see if they are really fulfilling their purpose. Sometimes we forget what the original purpose was, and the forms become meaningless routines. Often, checklists are added because we’re trying to avoid liability. After all, if a person was hurt after they signed off that everything was safe, it can’t be management’s fault. The truth is, a “tick and flick” checklist process that doesn’t really complete the checks actually creates liability rather than avoiding it. A good attorney will tear you to pieces for not doing what you say you will do. It’s much better to train employees to a point of competence and educate them in the importance of the checks.

This is not to say that all checklists are bad. I want the pilot of the airplane I just boarded to use one. But things like pre-use checklists for ladders just aren’t valuable.

Focus on What Matters

Many in our industry have a relentless focus on injury rates. This focus can reduce those rates, but low rates don’t mean the plant is safe. Lack of accidents doesn’t indicate the presence of safety any more than not having had a heart attack means no heart disease. We focus on the minor and turn a blind eye to the STiKY—Stuff That Kills You. Some of this comes from the Heinrich Pyramid, which has been misinterpreted to mean reducing minor injuries will reduce fatalities. For this theory to work, one has to believe that sprained ankles lead to deaths.  In reality, they are not related. One injury does not predict the next. Instead of focusing on minor injuries, focus on the things with serious injury or fatality (SIF) potential. What tasks can result in a life-threatening injury? What are the defenses in place to prevent the worst when things go wrong? Are those defenses enough?

Earlier I asked you to think about tasks in which the only thing between the worker and a life-changing event is that they do the job perfectly every time and what happens when (not if) something fails. Put your focus on those tasks. It’s not that the little injuries aren’t important—they are. But when relentless focus on little things takes our eye off the STiKY, our people eventually lose.  

Why Different?

Foundries in general aren’t inherently dangerous places to work. They aren’t more dangerous than other manufacturing—the hazards are just different. So why does our industry hurt people at almost twice the rate of other manufacturing? All must answer this question on their own, but doing things “the way we’ve always done it” is a recipe for further damage to our industry and the people who work in it. Step out and try something different. Question everything, set your mind to improving, and change can happen.    MC