Early Warning Signs that Systems are Impacting Safety
About 20 years ago I conducted a safety culture assessment for a large paper products company. They had been working hard on improving their safety performance and like many organizations, had plateaued. They wanted an assessment to see what more they could do to improve. My assessment revealed that they had done many things well, with one exception. With the best of intentions, they instituted a safety incentive program. It was a typical incentive of the time—a cash award for going a quarter without a recordable incident. To show how seriously they took safety, that cash award was significant. As I conducted interviews with frontline employees, it became clear that the incentive was suppressing reporting. One woman summed up the situation clearly: “If I get hurt and report it, everyone is going to lose the incentive money. I don’t care if I lose the money, but I don’t want to do that to my peers.”
When I gave my assessment report to the senior leadership team, I told them that their incentive was having the unintended effect of suppressing reporting. They didn’t believe me. They told me the incentive was working well; people loved it, and the incident rate dropped after they implemented it. They were adamant that if people were underreporting, they would know. They thanked me for my time and showed me the door.
Years later I saw one of the senior managers at a safety conference. He sought me out to tell me that I was right. He said they weren’t ready to hear it at the time, but in fact the incentive was causing underreporting. Regrettably, it took years for them to finally see it and do something about it. Years of wasting money, and more importantly, not gaining insight from the unreported incidents and therefore missing opportunities to improve.
It is an unfortunate fact that organizational systems don’t always have the intended effect. Incentive systems based on incident provide a classic example. The intention is to motivate safe behavior, but too often they motivate underreporting. Sometimes systems have the intended effect but have unintended side effects. For example, systems intended to improve efficiency might work to improve efficiency, but inadvertently encourage safety shortcuts. Similarly, systems intended to improve quality might do so, but if they are heavily dependent on quality monitoring by supervisors, the supervisors’ commitment to frequent safety interactions could suffer.
How can you know if an organizational system is having a negative impact on safety? Does it take hiring a consultant? Does it take years to finally see it? It doesn’t have to. Every organization has an early warning system— the behavior of frontline employees (what they do and what they say).
If your organization tracks behavior systematically (i.e., if you have BBS), those data can be used to monitor the impact of a new system. If previously consistent safe behaviors start to become inconsistent, the new system might be having a negative influence. If you don’t have systematic behavior tracking, engage your frontline supervisors. When supervisors spend time in the work area observing and interacting with the frontline regularly (as all supervisors should), they will notice changes in behavior that can be linked to system changes. Finally, if your organization has created a culture of psychological safety, you can ask frontline employees if a change to a system has any impact on safety. As long as they are comfortable speaking honestly, employees will tell you if a system change has increased their tendency to skip steps, rush through pre-task risk assessments, not report hazards, or do other potentially at-risk behaviors.
Some readers might be thinking that people often resist change, so if asked, they will say that a new system is problematic. Indeed, change is often hard and can lead to complaining. Here are some suggestions to minimize complaining and maximize helpful feedback. First, wait until people are past the early stage of the new or modified system. Change requires mental energy that can take away from other things until the new behaviors become fluent. Once the dust settles, ask for specifics if employees say a system is impacting safety. For example, if people say a new process takes time and encourages short cuts, ask what short cuts and under what conditions. If supervisors say the new system takes so much time they don’t have time for safety interactions, get specifics on what is taking the time and how they are allocating their time. When people are just complaining, they rarely have specifics. Getting specifics will also enable joint trouble shooting of solutions.
Returning to the paper company, what were the early warning signs they didn’t attend to? The supervisors that I spoke with noted that even though their incident rate was dropping, they still saw a lot of at-risk behavior during walk-arounds. Of course, we all know that at-risk behavior doesn’t automatically result in incidents, so in the short run this would not necessarily be a red flag. But over time those supervisors must have wondered why they continued to see at-risk behavior, but the incident rate was going down (and employees were getting their incentive payout). The key to early warning signals is that you have to be looking and questioning what you see. If you assume that the system is functioning as planned, then you won’t be looking for signs that it is not.
Organizations are closed systems so it is important to understand that changes to one system may well have an impact on another. Observation and questioning are essential. In addition to looking to see if the system is having the desired impact, also look for unexpected side effects on safety. The good news is there is no need to wait until incidents occur to identify a problem. Tap into frontline behavior for early warning signals. Observing and asking supervisors and frontline employees for their input will help avoid injuries, improve system effectiveness, and build better relationships.