MANAGING SAFETY PERFORMANCE NEWS

Regarding Knowledge

“Knowing something – and understanding it – are not the same thing.” 
 
     ~Charles Kettering
 

In matters of safety, there is no getting around the simple fact that there are only two ways to learn: the easy way and the hard way. 

You can go to class, sit up and pay attention, ask questions, do your homework, study the material, memorize what you must remember, take the test, pass the test. That is how learning works. It takes work, a lot of it. 

If you put in the time and effort, you will learn. You hope what you learn was worth the investment. Sometimes it is. Sometimes you have to wait to know. 

It may not seem that way, but that is actually the easy way to learn.

The alternative is to learn from personal experience. You know: just do it, and see what happens. Firsthand experience guarantees you will learn, and what you learn will be valuable to you. This is your real-life experience.

Learning by doing can seem like the easy way. It can be the easy way – until an experience turns into the equivalent of a lab experiment blowing up in your face. But your real life isn’t a lab experiment: the cost of knowledge gained by personal experience can border on catastrophic. You may spend the rest of your life paying for the lesson.

You might be thinking, “I’m a busy leader. What’s the point in telling me something everyone knows?”

What do we really know about knowledge?

The First Line of Defense

As we head off to the point of this edition of the News, let’s start with a question about your knowledge of safety: What is the most basic and fundamental principle of working safely? What is the one thing that matters most to working safely?

I would like to think that every leader would have the answer on the tip of their tongue. It should be one of those “Everybody knows…” kind of moments.

Think it’s caring? If you think caring is the most fundamental principle in safety, you need to read Paul O’Neill’s account of the turnaround of safety performance at Alcoa. When he showed up as the newly appointed CEO, he found that everyone cared to the point of shedding tears over accidents, but did nothing to actually change things for the better. “Caring is not enough. Caring is not nearly enough” O’Neill said, and then set about to change safety habits.

Is it the elimination of hazards? A worthy goal, but no matter how hard you try, there will always be hazards. Hazards are the things that can harm people: the only way to eliminate all of them is to get rid of all the people working around them, yourself included.

Is it procedures to manage hazards?  There will never be a procedure for every hazard. For the ones you have, if they’re not being followed, they’re nothing more than pieces of paper.  

So what actually does matter most to safety? The answer is stunningly simple: knowledge! Knowing what the hazards are, and what the procedures are to keep from being harmed by the hazards. Knowledge is the first line of defense in safety. 

Putting the first principle of safety into practice goes like this: work should be assigned only to those with the knowledge to work safely. No one should ever do something they do not know how to do safely. This is true no matter who they are or what they do.

Yes, that would seem to be something everyone knows.

Another Industrial Tragedy

Prompting this examination of knowledge about knowledge was the recent news that a five year-old industrial accident case had been settled – in a courtroom. In 2017, four people were killed and two others seriously injured when the contents of a tank they were working on unexpectedly released. One of the two injured later died. 

Found to be the root of the problem was the procedure to safely perform what was clearly a very hazardous task. There was an energy control procedure and it had recently been reviewed and updated. But those working on the job knew hardly anything about that. In the immediate aftermath of the event, eight of the nine people interviewed said they never saw the procedure. Finding it required searching the company’s intranet; there were no copies on site. Presumably that explained why the procedure wasn’t followed, and the event caused.

You would like to think the lack of knowledge as to the proper procedure to follow to safely perform the work would have stopped the work from being assigned, in this case, to a contractor. You would also like to think the absence of knowledge as to the procedure would have stopped the contractor from undertaking the work.

But it did not. Killed were employees working for both owner and contractor. A brutally tough way to learn that knowledge is the first line of defense in safety. Now they know; what about the rest of us?

The Learning Process

Whenever I read about someone else’s lesson in failure, I can’t help but think about those two ways to learn. Experiencing failure is the hardest way to learn: you cross your fingers and hope it doesn’t turn out to be a disaster. 

Failure is also the backwards way to learn. First you take the test. When you fail, you go back, do your homework, start asking questions, and finally realize it is time to sit up and pay attention to what you needed to know about the subject in the first place. 

In life, we all learn a lot of things the hard way. But it’s in our best interest to learn as many things as we can the easy way, every chance we get. When you become a leader, the need becomes more pressing: you have followers who depend on your knowledge, and your failures can put them in harm’s way.

Learning from the mistakes and failures of others is the easy way to learn. But there is a process to be followed to accomplish that which requires the investment of time and energy. Skip the process, it’s likely that there won’t be true learning: what must be understood is the huge difference between thinking, “I knew that” and properly understanding the “what, how and why of that.” 

The learning process to accomplish that starts with finding out somebody’s failure. Information of this type comes from various sources and routes: you hear about what happened on other shifts, different departments, other parts of your company. The reports can be by word of mouth and unofficial; there may be a formal report that can be read. 

Speaking of reading, found on the internet is a nearly unlimited supply of events on which to draw useful knowledge. As you probably know, we’ve been sharing stories of misfortune for two decades in the NEWS and FLASH. This month’s story on what the lack of knowledge can cost is the latest in a long string of stories dating back more than two decades.  We started by pointing the finger at us (me, mainly) sharing some of the biggest mistakes made when it was our turn to lead and manage. 

As to how exactly a good leader like you might actually learn from all of this information about the failures of others, it is to do more than just read them. A lot more than just read, which is where the learning process frequently fails. You read a lot of news stories, most of which come and go in a moment. You retain little to nothing, probably for a good reason as there is little value in a lot of what we read these days. It’s just background noise, like having the tv on while you’re surfing the web.

To extract the knowledge, you really do have to dig into the case. Asking questions to yourself is a great idea. Just don’t let your questions be ones like, “What were those people thinking?” or “Why didn’t they just ……..?” That sounds a lot more like criticism; what you are after is knowledge – and understanding. 

Comparisons are also a good way to learn, as long as they don’t follow the form, “Something like that could never happen here because we…..” Better to compare by asking yourself, “What really was the mistake they made?” and “How could something like that happen here?” and “What can I do to make sure that it does not?”

As to testing, in some cases that is exactly what you should do: test your own processes. Were I to have read about this case back when people in my department were issuing work permits to contractors, I’d have sat in a few of these hazard explanation sessions, and evaluated just how effectively we, the owner, were communicating hazards and procedures, and just how well the contractors understood what we were telling them. 

As To Why?

By understanding other people’s failures, you might very well avoid making the same mistake.  

The alternative is to cross your fingers and hope you don’t wind up like the CEO in this edition’s case. When he and his followers failed their test on knowledge, he wrote, “We have accepted full responsibility and we hold ourselves accountable”.

Accountable for five fatalities simply because those doing the work did not understand the hazards or the procedure to keep them safe.

Paul Balmert
May 2022

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