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What to do when things go wrong

There’s a traditional view that the fault lays with the person at the point of delivery i.e. the person who does the job. Yet to truly understand why an incident happened, your organisation must take a much wider view and treat the incident not as the end result but possibly a symptom or sign of something much deeper within the organisation that caused the problem.

Take a look at the diagram below as a starting point for adopting such an approach and the statements to reflect upon.

A maze with a worker at one side and a boss at the other. In the middle are ticking bombs which block the route

(Click for a larger image)

In the diagram (source) the maze is the job, task or practice. The worker on the left is under pressure to get the job done and the boss on the right is focused on production. The ticking time bombs along the way are the barriers put in the way of the worker to successfully complete the job. The worker has decisions to make to please the boss and risk his and others safety. These barriers (or harm waiting to happen) could be equipment, technology, organisational or staffing issues for example.

How to find out why the person did what they did

Taking the points made above in the diagram, organisations have to engage with their employees – this is best done by a structured conversation by asking questions and listening, actively listening and not waiting to speak:

  • Listening for clues in the conversation
    • “Well I do it this way”
    • “Usually I do it this way”
    • “If everything is running OK I do it this way”
    • “If I have time I do it this way”
    • “Well the procedure says do it this way”
  • Testing systems where appropriate
  • Focussing on what are the key safe behaviours
  • Question why what was done was done, not what should have been done
  • Seeking solutions
  • Giving praise and reinforcement for good practice
  • Building trust, transparency and openness

Having taken this much more holistic approach your organisation can then decide whether or not the unsafe act or incident act fulfilled one of the criteria below (source: Four types of unsafe behaviours – Marx 2001):

  1. Human error: is when there is general agreement that the individual should have done other than what they did
  2. Negligent conduct: is conduct that falls below the standard required as normal – negligence is the failure to recognise a risk that should have been recognised
  3. Reckless conduct: to be reckless, the risk has to be one that would have been obvious to a reasonable person – recklessness is a conscious disregard of an obvious risk
  4. Intentional ‘wilful’ violations: when a person knew or foresaw the result of the action, but went ahead and did it anyway

Perhaps in one and two above training is an option and in three and four something more formal?

The best use of all this information is to feed the lessons learned in to some kind of organisational learning system, like our Engage software which helps staff record and track behaviour safe and unsafe, as well as share knowledge quickly and effectively across the organisation. But any way you can to keep tabs on your ongoing behaviour trends to feed organisational improvement is a step in the right direction.

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