“Houston, we have a problem”
~Jack Swigert
Here’s a report of a recent industrial tragedy in the Houston area, of the kind I’m sure the experts would be eager to offer their expertise:
A sixty year-old truck driver… was killed at about 8:30am this morning when he fell beneath the wheels of his dump truck. According to Liberty County Sheriff’s Lead Investigator Deputy Brad Taylor, he was a contract driver and was attempting to enter a security gate at the Trinity Materials Company located at 28125 Hwy. 146 North in order to get a load of sand.
Although there appears to have been no eye witnesses to the accident, Deputy Taylor said that sources told him that it is common practice for incoming drivers to open the door of their truck and stand on the running board or outside gas tank and “swipe” their entry card past the card reader as it is difficult to reach the card reader while sitting in their truck seats.
It appears that the driver was standing on the side tank of his truck with the truck still in gear and slowly moving when he was knocked off the side of the truck by a nearby post and fell under the wheels of the truck where he sustained fatal injuries.
For a report of only three paragraphs, there appears to be a nearly unlimited supply of “causal factors” to be sliced, diced, and used to prove a point. For example, hardware experts will cite poor design: a driver shouldn’t have to reach that far out of a truck to badge in at the gate. Software experts will point out superior technology can be found on the market to completely eliminate that practice. For the rules guys, a classic case of “Rule known but not enforced.” By management, of course. Behavioralists will take note of the financial incentives reinforcing at-risk behavior: contract truck drivers are paid by the load, not by the hour. Maybe the whole problem is as simple as the failure to recognize that a truck in motion is a hazard.
Take your pick: define the problem anyway you choose. For each problem, there just so happens to be a perfect solution. Isn’t that the point of the exercise? Something went wrong; given that it wasn’t good, let’s make darn sure that doesn’t happen again. Change the hardware; the software; the incentives; enforce the rules; train the people. And be sure to put out a note with the “lessons learned.”
I see that all the time.
When it comes to identifying the factors involved in an incident, what I rarely see cited is the problem the lead investigator saw: a “common practice.” In a word, that’s culture. In this case, the safety culture. Which is exactly what Deputy Taylor observed and reported.
What’s the solution for that problem?
Common Practice
If there is any possible good that can come from this tragedy – which there needs to be – give credit to this good Sheriff’s Deputy for pointing the rest of us in the right direction: this is a classic example of a culture problem.
Professor of Psychology James Reason is one of the behavioral experts in safety culture. Reason once noted, “a safety culture is something to be striven for, but never achieved.” Nothing could be further from the truth.
If nothing else, Reason provided hard evidence to remind us that the experts are not infallible.
As to why he was so wrong, it’s immediately and intuitively obvious from the simplest definition – explanation, really – of culture. Culture is “common practice.”
Perhaps Dr. Reason needs a proper introduction to Deputy Taylor, who had this one figured out perfectly….more than likely within the first fifteen minutes of being inside the plant gate. Culture is simply what most people do, most of the time. In this case, standing on the running board or on the gas tank of the dump truck to badge in.
By the very definition of the term, every organization has a safety culture.
There is also a production culture, an innovation culture, an execution culture, a change culture. For any business goal or interest anyone has – management always does – there is always an existing culture to be found. (Unless it happens to be Day One of a new start-up venture. But it won’t take long for there to be one there, too, and once it exists, it’s like concrete.)
As to what any culture is, take Yogi Berra’s advice: “You can observe a lot – just by watching.”
For example, at this “materials plant” the safety culture started right at the front gate. It does at every plant in the world as well. Watch incoming drivers, with their doors open, trucks moving, swiping badges. Follow those trucks down to the loading rack, you’ll get another look at the safety culture. Observe the Loadmaster back in the product storage area, you’ll get another.
I’d be willing to bet that a smart leader like you could figure out the safety culture at this operation in a morning’s time. Of course, if you only visited the field part of the operation, you’d be missing out on management’s culture: there’s one of those, too. Sit in the boss’s office for an hour, eavesdrop on the conversations, look over a shoulder to read what’s in the emails, it wouldn’t take long to get that picture.
Come observe on a Tuesday morning, you’d even get to sit in on the 9:00 am Production Meeting.
Don’t worry about showing up on time: nobody does, least of all the boss. There’s always some crisis going on….or a new directive from HQ to be implemented. Once in a while, they actually are.
I’m not trying to be sarcastic: just honest. Honest about culture: it is pervasive, and it is what it is. Seldom is the problem knowing what the culture is; the problem is changing the culture into what the leader wants it to be.
Meaning a culture problem is really a change problem: how does a leader change a culture? From what it is – into exactly what the leader wants it to be? That’s what that “striven for” part of Reason’s comment on culture is really all about: a culture of safety is what’s not very common.
On that point, Reason was absolutely correct.
Tell Me “How?”
Reading this, you’re probably thinking, “Tell me something I don’t know.” Before jumping to that conclusion, tell me something I don’t know: If every leader knows there is always an existing culture, why do so few leaders talk about “breaking down the old culture” as the first step in the process of “creating a new culture”?
As a leader, you don’t strive for a culture so much as you are stuck with that culture. If you’ve ever tried changing the culture, you know how tough that is. A good friend – and great leader – recently described the process as being like “turning the Queen Elizabeth Two around – on the Hudson River.”
Most of the time, the focus of the dismantling of an existing culture isn’t aimed at safety. It’s taking out the entire culture: the business is sold, and the new owners come in and start changing everything.
Starting with the managers.
They could care less about what those “common practices” used to be: “What part of the word stop do you not understand? Either you stop your truck at the gate, get out, and swipe your badge. Or you and your truck will never enter our site again. Got it?”
Take it from someone who’s been there, seen that: that approach, which is more than a tad bit heavy handed, can work. But it’s not for the faint of heart.
And doing it takes energy. A lot of energy.
Which helps explain why it’s the road less travelled: what leader has the time and energy for that? What kind of leader is going to invest that much energy in one small problem at the entry gate? It’s like hammering ants. Besides, the perpetrators in this case are contractors.
Actually they are customers. And the customer is always right – even if they wind up being dead right.
It’s Who – Not How
Hate to disappoint, but you will have to wait until the publication of the next book to get the full story about successful culture change in operations like yours. But there is a preface to be found in Alive And Well At The End Of The Day in the chapter, “Creating the Culture You Want.” For now, that will have to suffice….as I’m running out of words and space….and time.
But I will leave you with one final thought on the matter of culture change as it relates to managing safety performance. In every case that I am personally familiar with where great safety performance was achieved, the safety culture was radically changed. Operations that became great at safety became entirely different places to work.
I don’t think it is possible to dramatically improve safety performance without doing radical surgery on the culture as well. The culture change is really the change: the injury rates simply attest to the change.
Finally, in every case I know of, where there was just such a big change in performance and culture, there was one single leader – with a name, rank and employee number – driving that change. I can rattle off a list of their names, but admittedly my sample size is small. As to what they shared in common, it was as if the change in safety performance and culture was their personal crusade.
If you have a first-hand anecdotal evidence to disprove that observation, by all means send it my way. Maybe it’s possible to make this kind of change by a system, process or committee.
But, I’m betting if you send me anything, it will be another name to add to my list.
Paul Balmert
May 2018
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