On Further Review

“Simply having a wonderful Christmas time” 
     ~Paul McCartney

It’s the holidays: the most wonderful time of the year! Time off – from work. Time to – do the things we really love to do. We all have our favorites, don’t we? Hang out with the family or go out on the town. Stay at home and fire up the grill – or the oven. Engage in some retail therapy – from the comfort of the couch, if you don’t like fighting the crowds at the mall. 
So many choices and too little time. I wouldn’t mind a few more weeks like these.
Yes, I know some of us still work over the holidays. I did, and still do. Full disclosure: back in the day, I, for one, actually liked going in to work over the holidays. Work felt different. I blame the decorations.
With the big bosses gone for the holidays, most offices vacant, my phone seldom rang and rarely were there problems to be dealt with. Freed from those distractions, the amount of real work that could be accomplished was nothing short of amazing. There was even time for a friendly chat, over a cup of Christmas cheer. Decaffeinated, of course. 
Not that I am even remotely suggesting a commute back to your place of employment. These holidays are meant for enjoyment.
While you’re enjoying your holidays, you would do well to take a momentary time out to reflect on what really are the most important things in your life. I suspect very few are actually things and this time of year what matters most is always so clear.  As for work, that’s what you do to make your living. Manage to do that safely, you’re free to enjoy the holidays exactly the way you want them to be. 
It’s what we like to call the Case for Safety.

The Year End Review
With another year about to go into the books, it’s only natural to reflect: was it a good year – or not nearly so? There are a lot of factors that go into your review, most of them personal.  
At work, there’s a formal process to accomplish that task: the year-end performance review. You know the drill: a lot of factors go into that assessment, all about business. But the most important factor – did everyone go home, alive and well at the end of every day – in actuality is personal, not business.
If your answer is a resounding “Yes, they all did.” –  consider it a good year, no matter what else the business performance review might suggest. That’s just business.
The year-end offers another way to look back at the past year; a practical way to gain useful information from what happened, good and bad. I like to call it doing a “root cause of root causes.” It should be a part of every leader’s practice.
The Challenge of Time
As we’ve been explaining for the last two decades, when it comes to managing safety the toughest safety challenge every leader on the planet faces is time: finding the time to manage safety performance the way it needs to be managed. Were leaders to have an unlimited supply of time and able to focus exclusively on safety, the world of work would be a very safe place to be, simply because leaders care about safety and are good at fixing problems and leading their followers to work safely. 
But that’s not how it works in real life. There’s production, quality, schedule, customer relations, reliability, business process improvement, morale, teamwork, and cost that also needs to be managed, and there’s only so much time to go around. Hence the challenge. 
Not that I’m telling you anything you don’t already know. 
As the challenge of time plays out, it forces leaders to constantly make choices as to the allocation of their time: “Do I spend a half an hour looking at ‘that’ – or meeting with ‘them’?” Often, the that’s and the them’s wind up making that decision for the leader.
I am sure you are very familiar with the process, otherwise known as managing problems.
As a practical matter, a big part of the job of every supervisor and manager is dealing with problems, be they big ones or small. Were you to create what in Time Management circles is called an Activity Log – fancy schmancy for how you spend your time – you might be surprised as to just how often you are called upon to deal with problems in all their various types (equipment and people, just to name two) and in all their phases, starting with the phone call with the bad news, to rolling out the new procedure to make sure something like that doesn’t happen again, which are the beginning and end of the problem cycle.  
Can you imagine doing a root cause investigation into every single problem that comes your way?
I can. At least for every problem coming that has anything to do with safety. Full disclosure: I once suggested that something like that be done – for an entire company! It did not endear me to anyone. Who could blame them?
Admittedly, I was only half-serious, suggesting that to make a point: the difference between a scratch and a fatality is a matter of consequences, and those are often a simple matter of time and place. What actually caused the problem is really what matters, and that’s what should be of interest no matter how serious the consequences.
If that’s not obvious, an example might help. Drop a 25 foot tape measure. You might stoop over to pick it up off the floor, unless it fell from the 50th floor. Dropping it from that height will likely destroy the tape. If it hits someone, their life might well be destroyed. Don’t think it couldn’t happen.
Does that mean every time someone drops a tape measure it needs to be investigated?
Of course not. But the example points out the big flaw in most investigations, the consequences determine if the event gets investigated. Since serious consequences are relatively rare, only a small number of events are investigated. All the others are presumed not to matter.
Think about all the useful information that could be learned were more events investigated. But what leader has time for that?
Let The Data Speak
Expanding the breadth of your investigation process is always a good idea: more investigations mean more useful information. That’s something to consider when formulating your improvement plans for next year.
As for this year, sitting in that pile of formal investigations done this year is some highly useful intelligence – if you give the data the opportunity to speak.
An investigation presumes the event is unique, but often the incidents are part of a larger pattern of problems. In quality improvement terms, they’re “common causes.” When a production process is producing hundreds of defective parts every shift, common causes usually stand out. But where there are only a handful of injuries spread out over twelve months, common causes often escape detection. That’s where a “root cause of root causes” serves a useful purpose: looking at all the investigation reports as part of an integrated whole. 
An exercise of this kind is broader than noting, “We’re having a lot of hand injuries” and deeper than observing, “… because of line of fire.” Executing what we’ll call an  involves a deep dive into all of the information found in every investigation report. A fresh set of eyes is essential to the process. Picture a Six Sigma black belt, a reliability engineer and a root cause expert working with a safety professional and you can begin to see the possibilities. 
It’s hardly a new idea. Full disclosure: twenty-five years ago, I managed to convince the corporate lead for environmental performance to convene such a study, and served on the team. We spent a day slicing and dicing sixty or so root cause investigations into spills and releases; what we learned was nothing short of stunning. By addressing our findings, in one year the number of reportable events was reduced by 25%. 
As a side benefit, we saw just how poor the quality of our investigation reports were. That was despite a major investment into root cause investigation training, using trained facilitators to lead investigations, and following a well-established root cause analysis and reporting methodology. 
There wasn’t a thing wrong with the system or the training; but our collective execution of the process was “less than effective”, to use one of their terms of art. A lesson I learned: a system is not enough. Good investigations require the willingness to let the facts speak for themselves, and allowing the chips to fall where they may. Relatively few were willing to let that happen.
Bottom line: there’s nothing special about December 31, but the year-end does seem the perfect time to dig deeper into the information that is locked up in all those investigation reports. There’s no telling what they might tell you, if you let the data speak.
So, let it.
The Last Word
Best wishes for a happy and safe holiday season.
Paul Balmert
December 2022

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