MANAGING SAFETY PERFORMANCE NEWS

Another Close Call

“That was not a boat accident” 

     ~Matt Hooper – Jaws

Picture, if you will, six sports reporters seated around the semicircular desk of a television studio, live on camera. It is showtime. Suddenly, and without warning, a wall of big screen TV’s collapses, falling onto one of them. The reporter sitting in harm’s way suffered only bruises. 

Lucky guy. Don’t take my word for it: view the video yourself. This was all caught on camera:  

 

Officially, a minor injury. It could easily have been a lost workday case, occurring, of all places, in the newsroom of a TV studio. Imagine that. Are you shocked something like that could happen? And happen right in the middle of a live TV show?

If we’re being honest here, I’m not. Arrive at my age and station in life, you’ll have seen just about everything to see. Although I will be the first to admit, thanks to the uber presence of video cameras, a lot less gets left to the imagination and a lot more gets caught on cam. 

Still, that something with potential consequences as serious as this happened in what was roughly the equivalent of a conference or training room at your site should give you pause to reflect. You do have big screen TV monitors hanging on the walls or suspended from the ceiling, don’t you? Maybe other things like display cases mounted on the walls and moveable white boards sitting around the perimeter?  You don’t suppose something like one of those might come crashing down and hit somebody?

Now that you think about it, you’re thinking sure, that’s possible. Do you think anyone working in that studio thought about those possibilities? It’s now obvious they should have. But that’s how these things work in real life: we learn from experience. Based on this learning experience, can we once and for all lay to rest the notion that some places are safe spaces?

Next time, before plunking down in your favorite chair in one of those spaces, you might want to consider doing a Job Hazard Analysis. It might just keep you out of harm’s way.

Just a thought.

 

But Wait: There’s More!

Things that can hurt us are found everywhere. That simple truth points out the folly in taking what I like to call a static approach to hazard recognition: assuming hazards are found within a narrowly defined set limited to specific tasks someone deemed hazardous. Hazard recognition is required constantly: our exposure to hazards is created dynamically by everything we do and everywhere we go. 

Thinking otherwise sets us up for unexpected harm. 

No, we can’t reasonably be expected to check how well a video screen is fastened to the wall behind our chair in every conference room we sit. (Although, the next time I’m sitting in front of one, I will check; in these matters, I do not consider myself a lucky guy.)  On the other hand, if the monitor is supported by a movable stand and there is work being done on the other side of the stand, yes, we most certainly should be on the lookout for the possibility that someone might knock the stand over.

Those principles and practices noted, there is so much more to this story than just a wakeup call about hazard recognition. 

Suppose the set had fallen and missed hitting anyone? Would the cause of that miss have been any different than the actual hit caught on camera? Of course not. 

Suppose the set had failed after the show ended, with the crew gone home for the day. The whole thing would have amounted to nothing. OK, maybe not nothing: it might have been classified as a near-miss, near-hit, close call, incident, or what is called in some places a “good catch.”  Even though it missed hitting anyone. 

Call it by whatever name you will, something happened, and it wasn’t good.  That is, unless “It never happened.”  Think that could ever happen?

This just in to the newsroom: it happens. 

Not that the boss would know that it did, which is the point of it, isn’t it? Instead of a report, there’d be a requisition for a replacement set for the boss’s signature. If you ever find your signature required in circumstances like these, better to ask questions than to provide your John Hancock. 

But you know that.

As to what to call unplanned and unwanted events like these, the trusty five decade old Webster’s Dictionary sitting in the bookcase within easy reach of my desk would suggest “accident.” 

Yes, I know all about that word. I’ve been in the room when experts have gone off on their “There’s no such thing as an accident!” diatribe, literally screaming at idiots like me. “What’s wrong with you people?” 

On more than one occasion I’ve been tempted to explain: given the fact that what happened was both unplanned and unwanted, it does meet the definition of that word that you find so objectionable.

But what’s the point of arguing with someone who’s mind is made up? Better to focus effort where it might actually make a difference: someone who’s reasonable and willing to consider these matters logically. Someone like you. In the interest of sending everyone home alive and well at the end of the day, let me do just that. 

First things first: stop trifling over words. Something happened, and it wasn’t good. Call it an event, because that’s what it was. 

You know the event happened. You know something caused it to happen. That is, unless it happened to be an Act of God; but those are few and far between. You know you need to do something to keep it from happening again.

Do you know whether you need to understand why it happened?

Sure you do.

Cause, Effect And Solution

This is all so simple. No upside to making things more complicated than they already are. An event is an effect. It was caused in some way. Should you not want the event to happen again, a solution is required. In most cases, understanding cause is necessary for a solution.

It is that simple. Unfortunately, simple and easy do not mean the same thing. If they did, managing events would be easy. In practice, managing events proves brutally tough for three reasons that thankfully are easy for a leader like you to understand. 

In the first place, you actually have to know that something happened. Funny thing about unplanned and unwanted events that happen: most people are disinclined to tell on themselves. If everyone worked in a TV studio and the cameras were always on, that wouldn’t be a problem. You’d just roll the video. But most of us don’t work for a living on camera.

Hence the first of your problems: if you don’t know what happened, how are you going to fix what happened?

Suppose you did know about everything. Picture, if you will, every single one of those close calls, near-misses, near hits, and good catches – now known as events – dutifully and fully reported. How many of them would there be? You’ll have to tell me.  

If you don’t have the foggiest, that’s telling you something.

Thus, the second problem: if you were to know every single thing that went wrong, fair to say you’d have more work to do. Perhaps a lot more work.

Back in the day when I was the Corporate Champion of Root Cause Analysis, for a global outfit, I had a conversation on that very point. Happened with a line leader, and happened to not exactly be a friendly conversation. “So, Paul, are you telling me that I have to do a root cause investigation for every single near-miss that happens in my area of responsibility?” 

“No, sir. You only have to investigate the ones you don’t want to happen again. No need to waste any of your valuable time looking into events you’re fine with repeating.”

Suffice to say, that leader did not go away happy. You can begin to see why some leaders might take the path of least resistance, and just sign the requisition.  

The third problem: coming up with a solution that actually solves the problem. Solving being operationally defined as, “having a decent chance of preventing the event from happening again.” As you know well, fixing things is easy; fixing people is not.

“Sharing the lessons learned” seldom fixes anything. 

About These Events: What now?

I know: all of this is painfully obvious. You know you’re better off hearing about the unplanned and undesirable events that go on in your operation. You know you need to understand what went wrong when it did. You know a solution is required, or you’ll just wind up facing the same event again.

I know your next question: How do I start solving that tough challenge?

My best advice is this: decide for yourself if you even want to start. Invoke what I call the Principle of Honest Dialog – when it comes to safety, leaders and followers owe it to each other to be honest – and have an Honest Dialog with yourself. What’s really going on? What’s the downside of continuing with “business as usual”? What’s the upside of taking every unwanted and unplanned event seriously?

The first person you have to convince in this matter is yourself. Once you become convinced, the path forward will become clear. Then it’s simply a matter of starting down that path.

One final word of advice: it doesn’t matter what you call those events.

Paul Balmert
March 2021

 

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