We have all heard the story of the three little pigs and their construction decisions impacting their futures. It is a sad fable that needs to be told often and even to adults who do not understand “latent failures”! But in this article, I want to have you think about three (3) mountains an organization MUST climb to change how safety is managed in the workplace fundamentally. I can not say it better than Reason said it in his 1990 book “Human Error”…
- Failure is inevitable in complex human systems; it is part of the human condition.
- We can NOT change the human condition, but we CAN CHANGE the conditions in which humans work.
- Moving from a person approach to a system approach to failure helps move a culture from blame to one of LEARNING.
These are huge mountains to scale. They are often steep and tall with no easy path. But if management can embrace these three (3) simple human error principles long enough to scale all three mountains, the pay-off is immense, and the payback far exceeds anyone’s expectations. But the journey is hard and long, and in today’s workplaces within the USA, management turn-over almost all but dooms facilities to fail in their journey. This journey can not begin until senior leadership truly believes these three (3) statements. The organization is not ready with any level of doubt in most management-level minds.
Unfortunately, the workers usually pay the price for this lack of transformation, from the continuation of the blame for accidents and the injuries received from the accidents. And even more unfortunate, the catalyst to move management to accept these three (3) principles is usually a traumatic incident, and sometimes even those incidents are not enough to shift management’s way of think about safety and human error. I have found that frustration by the majority of senior management is a strong motivator. Maybe that frustration impacts a senior manager’s pay or advancement. Whatever it takes, the organization’s leadership has to embrace those three (3) simple human error management principles to achieve world-class safety.