As I have said many times, we MUST examine all Latent Organizational Failures before we even begin to look at the actions of the worker(s). Far too often, investigations will first (and usually only) look at the ACTIVE failures that led to the consequences. This is how so many accidents IMPROPERLY and UNFAIRLY get put on the back of the worker(s) involved. Even when those actions were recognizable “unsafe acts”, as investigators we MUST fully understand what drove those behaviors.
This leads me to what many will call “Unsafe Supervision”. This is NOT about transferring blame to the supervisor(s), but as I will demonstrate, the actions of supervisors or worse – the inaction of supervisors can cause a lot of problems that align to result in an accident. Here are the four (4) categories of “Unsafe Supervision” and how they play a role in our causal analysis.
Unsafe supervision has four subcategories:
- Inadequate Supervision,
- Planned Inappropriate Operations,
- Failed to Correct Problem, and
- Supervisory Violations
INADEQUATE SUPERVISION
Inadequate supervision covers factors where a supervisor or manager does not provide sufficient support to operators to enable them to perform their jobs. This may be manifested as
- insufficient supervisory or managerial oversight,
- inadequate training,
- poor supervisory example, or
- otherwise not preparing an operator to perform his/her job functions safely.
Other examples of inadequate supervision include
- inadequate tracking of operator qualifications and/or job performance,
not allowing a sufficient opportunity for rest, and - not providing up-to-date or current documentation and materials (i.e., bulletins, rule books, special instructions, etc.)
Inadequate supervision also can include not knowing or understanding relevant rules and how those rules are applied, or inconsistently applying these rules.
Inadequate supervision may occur in situations where supervisors and managers are overtasked, overworked, or undertrained/qualified, to the point where the supervisor loses awareness over what is going on in the area that he/she is responsible. An example of how this can happen is when there is a transfer of administrative tasks from administrative personnel to supervisors. Administrative tasks are often easier to measure than supervisory tasks, and therefore receive priority in accomplishment.
PLANNED INAPPROPRIATE OPERATIONS
Operations are conducted in spite of the fact that there is more than the customary risk in either the tempo or tasks associated with the operation. Planned inappropriate operations involve poor supervisory decisions that place operators at unnecessary risk. Examples include
- placing excessive and/or unusual workload on an operator or
- expecting an operator to complete a task in less than the customary amount of time.
FAILURE TO CORRECT PROBLEM
Failure to correct known problems refers to instances when deficiencies among individuals, equipment, training, or other safety-related areas are known to the supervisor, yet are allowed to continue unabated. These include failures by a supervisor or manager to correct observed or known unsafe behaviors, conditions, and hazards.
SUPERVISORY VIOLATIONS
Supervisory violations include occasions when a supervisor or manager consciously violates or disregards existing rules, regulations, and policies, or allows subordinates to do the same. Examples include encouraging operators to bend or ignore rules (cutting corners), failing to enforce the rules and regulations, and permitting unqualified operators to work. This results in a degradation of the purpose and importance of the rule and can lead to routine violations.