Features, HR, Safety

Moments that matter: debating significance of incidents

Head of organisational reliability at Brady Heywood Jodi Goodall highlights the value of changing how we approach workplace incidents.

Head of organisational reliability at Brady Heywood Jodi Goodall highlights the value of changing how we approach workplace incidents.

The event will receive a more detailed investigation, the findings will be presented across the business, sometimes wider, and the CEO and board need to be informed.

The next day, there is fierce debate about the importance of the event among members of the leadership team.

They have very different views on the risk. On one hand, the plant manager believes this is a success story. In their eyes, the team foresaw that the load might slip, and put a drop zone in place.

They argue the control (the drop zone) worked as intended. After all, the machine cover did land inside the drop zone, and no one was hurt. They see the event as low risk.

In contrast, another lead team member argues that the event could have killed someone given a slightly different scenario.

They point out that they attended the shutdown meeting this morning and had a discussion with the team. They are concerned about the machine cover landing so close to the edge of the barricaded drop zone, which is adjacent to a pedestrian walkway.

Additionally, there are differing views between the workers about why the load slipped with the way it was rigged up.

This is a common debate at all leadership levels.

Both perspectives seem valid and reasonable. But your response to this debate is a moment that matters in shaping your culture, by demonstrating that what you value most is learning from failure.

This event had potential to be fatal – the workers could see that. It is a valuable free lesson. There are two key questions to explore with the team in the moment.

Firstly, is the potential (what could have happened) outcome of the event being considered, or just the actual outcome of the event?

When there hasn’t been injury or damage, it is easy and often comforting to think of an event as less important because the controls worked.

Unfortunately, “easy” and “comfortable” are two places where learning rarely occurs.

In the case of the lifting incident discussed above, the work team did the imagining for the manager. In their eyes, the cover could have landed on the walkway and hit a person walking by – it didn’t, but it is reasonable that it could have.

Secondly, are we comfortable to reach the last line of defence when the stakes are so high (a worker could be killed)?

If there are no more layers of redundancy left for further risk controls, this is a dangerous place to be.

This could be viewed as either a success: “Our controls worked, and we didn’t have a fatality”; or as a chance to learn and improve existing measures: “We don’t want to be at our last line of defence. What can we learn from this?”

There are often other influences swaying the level of importance given to an incident. How much extra workload an investigation will cause, if the person perceives it could negatively affect their career, or the response of their leader can all be major factors.

Having many more high-potential events without harm (significant near misses) means more opportunities to learn and prevent a fatality.

This is in direct conflict with what feels natural, so it’s best to seize the moment and seek out the high-potential events.

These are significant moments for an organisation – moments to listen, to demonstrate an organisation’s commitment to learning, and to act.

Brady Heywood provides expert advice to boards and senior business leaders on how their organisations can move towards higher reliability. Organisational reliability helps companies consistently achieve predictable and safe operational performance and avoid catastrophic failure.

Visit bradyheywood.com.au to find out more.

This feature first appeared in the June issue of Quarry.

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