We've been studying up on Safety Differently, Safety 2, New Safety, and Human and Organizational Performance (HOP) lately, and in particular have recently been looking at books by Dr. Todd Conklin about Human and Organizational Performance (HOP).
In two earlier articles, we took a look at some key lessons from Conklin's book Pre-Accident Investigations and his book about learning teams. And in this article, we're going to look at some key lessons from his book Workplace Fatalities: Failure to Predict (buy a copy at the link you just passed).
We hope you enjoy this look at an important, influential, and somewhat controversial thinker in safety, and we tip our hat to the good work Dr. Conklin is doing. And by the way, we've included a video recording of Dr. Conklin's appearance in the plenary session of the ASSE Safety 2017 conference near the bottom of this article for you.
And lastly, before you begin this article, if you're interested in the work of Dr. Conklin, you'll no-doubt enjoy the guide to the "new view" of safety, including HOP, HPI, Safety Differently, Safety-II, Resilience Engineering, and more that we've got for you below. It has contributions from many of the world's leading safety experts, including Todd Conklin. Download it and give it a read (100+ pages!).
We encourage you to buy the book, sit down, and read the book from cover to cover.
However, we'll list a couple of the key points here to raise your interest.
Sounds obvious, but it's an important starting point.
Most workers don't die on the job. Most organizations never have a work-related fatality. Most work days at most companies end with all the workers still alive.
Here's how Conklin puts it:
Fatalities are not normal. Mostly people do not die while working at your facility. Mostly workers will spend their entire working career not getting seriously injured or killed. Don't think about a fatality as a failure of your organization's safety and reliability program. A fatality is an outlier event. Your organization does safe and stable work most of the time. This statement is just a fact. (See p. 32)
As you'll see if you read the book and continue reading this article, much of what Conklin will say is based on this fundamental observation that fatalities at work aren't normal. For example, if a fatality isn't normal, then "normal" safety efforts may not be the right approach for reducing them.
At one point in his book, Conklin even refers to the book The Black Swan: The Impact of the Highly Improbable by Nicholas Taleb in this context.
When someone is killed at work, there's a tendency to assume our processes are flawless and the fatality must have occurred as a result of worker error.
As Conklin puts it:
We tend to want to over-simplify the problem of such horrific events in order to reinforce the same old answers. Clearly, if a person is involved in a serious event, they must have done something really wrong; they missed whatever indicators were present and allowed this bad thing to happen. This person failed to prevent the bad thing from happening. Therefore the person is the problem--the person is negligent. Right? Wrong! We continually fall in this trap...we have meetings and we tell our workers and managers to prevent accidents more efficiently and start doing it now! (see pp. 12-13)
You can see why this is a simple and tempting explanation, but it's not likely to be accurate and it's not likely to be something we can protect from, either.
While reading this short section, keep in mind what we said earlier about fatalities not being normal at work--that they're outliers.
Traditional safety efforts, such as reducing slip, trip, and fall hazards, have helped to drive occupational injury rates down but they have nor reduced the number of severe injuries, illnesses, and fatalities.
Faced with those facts, a safety manager may be inclined to double down and apply those same traditional safety methods even harder, but that's somewhat similar to the old quote from Albert Einstein that "The definition of insanity is doing the same thing over and over again, but expecting different results."
As Conklin puts it:
I know one thing for sure: Doing what we have been doing--harder and better--will not solve the problem of fatalities at work. In fact, I would propose the idea of doing more of the same-old-same-responses might just be the problem. Continuing to think about and act on fatalities and serious events using our traditional thinking almost guarantees more people will die or get seriously injured. If we keep doing what we have always done, we're always going to get what we have right now. What we have right now is not working...
...We are beginning to understand our current safety systems are necessary and have served us fairly well for industrial safety issues, but are not sufficient in preventing catastrophic outcomes. (See p. 11)
Furthermore, not only is it ineffective to double-down on traditional safety to try to reduce fatalities, but it's inherently dangerous because we're applying resources like time, money, and effort that could be used more productively and effectively.
Here's how Conklin puts that:
This artificial supply (prevent bad things from happening-harder) seems wrong, really wrong. All this false information being represented as new thinking makes me worried. Good people in good organizations are going to try these old ideas-amplified and feel like their organization is going to be safer. The organization will not be safer or more stable. The organization will not prevent fatalities and serious injuries any better than before; however, the organization will think they are actively preventing deaths and catastrophic events. Worse still, organizations that do fail will spend lots of money and resources just to be told they should have been better at preventing the fatalities or serious event from happening.
It's not that traditional safety is ineffective. Its' really effective for a lot of things, and safety managers should keep those efforts up.
It's just that they're not effective at reducing these occupational fatalities, and we need to do something new to address those.
Or, as Conklin puts it:
We are starting to learn that doing the same things we have always done does not take us to any new operational results....We know that notably safe companies and organizations, places with amazing safety programs and near-zero reportable numbers, still kill people. We have examples of excellent safety programs; yet, these programs continue to have fatalities at an unfortunately stable rate. Thus, we are being forced to think and manage our operations and systems differently in order to get new and better outcomes. (See p. 11)
Conklin argues that fatalities are largely unpredictable results that exist within uncertainty, and that since we can't predict fatalities or completely control uncertainty. As a result, he thinks we have to create systems that are resilient enough that we can experience unpredictable, uncertain events and ensure they won't lead to a fatality.
Here's how he puts it:
Are we asking the right questions about fatalities and series events?
Could it be all the work we do to prevent accidents weakens our ability to respond to accident outcomes, fatalities, and serious events? Could it be over time our investigation processes and legal liability processes have caused us to limit our questions almost exclusively to only learn how we "failed to prevent a serious event" as opposed to how we "failed to control the serious outcome?" Could it be that e are confusing our prevention efforts with prediction efforts? Instead of wondering how the horrible outcome was possible, we have drifted to mostly asking how we failed to prevent the horrible outcome. we don't know how events happen. We only know what we failed to do to stop the event.
We are only getting partial information about fatalities and serious events in to our leadership offices and boardrooms. We have completely discounted the story of what happened in place of loudly telling the story of what didn't happen. Does all our emphasis on prevention set us up to be horribly surprised by the failure? Is the reason we can manage ankle sprains effectively and still kill workers because our entire thinking is around how we should prevent events from happening? (See p. 16)
We have systems at work.
They generally work well and create stable work conditions with few injuries and illnesses.
But remember, we've said that fatalities aren't normal--they're outliers. And that our focus on traditional safety efforts not only doesn't reduce fatalities, it may increase them.
So that same system that does so much good also allows the fatalities to occur.
As Conklin puts it:
The crazy thing is that the system that "caused" the anomaly is also the system that creates the stability. I can't seemingly say this enough....This attribute, stable to outlier, is so vital in understanding fatalities and serious events. The fact that the same system that creates success has the potential to prevent fatalities and catastrophic outcomes. Yikes! By all rights that should freak us out--however, mathematicians have known this for a long, long time. Anomalies are neither normal not abnormal--they are rare events.
Given all we've said above, Conklin argues that it's incumbent upon safety managers to design systems that will not result in tragedies when they fail.
Failures within the system can't be entirely predicted or avoided. But horrible consequences, including severe injuries and fatalities, can be avoided.
Here's how Conklin puts it:
Here's what we know. We can't predict everything. We can't prevent everything. We can only hope to create systems that help us minimize the consequences. We must control the outcome. You don't manage the uncertain...you manage the certain. We don't manage accidents because accidents are uncertain. We can only manage the capacity we have in our organization to have accidents that fail gracefully. Capacity to recover is certain, and this capacity is real.
As we promised earlier, here's the recorded video of the plenary session at the ASSE Safety 2017 conference which features Dr. Conklin and others discussing the merits of HOP, behavior-based safety (BBS), and more.
In addition to Dr. Conklin and his book, you may find some of the other sources listed below helpful on the topic of reducing workplace fatalities, too:
And, because Dr. Conklin's specialty of Human and Organizational Performance is so closely related to the school of thought called Safety Differently (I'd argue they're the same thing), we'll include these articles focusing on Safety Differently as presented in a series of interview with Ron Gantt:
Let us know if you have some thoughts of your own about how to prevent occupational fatalities.
Hope you enjoyed this article. Don't forget to rush out to buy a copy of the book and give it a thorough read.