Safety Risks: Unwanted Outcomes, Questions to Ask

The following article first appeared in ASSP’s Professional Safety publication. It is reposted here with permission from the author. 

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A few years ago while touring a manufacturing plant, we spotted a red floor area adjacent to a walkway where the words, “No Storage” were stenciled. 

The words were difficult to see because there were so many boxes of parts stored on top of them.  

Everyone in the plant, workers, supervisors, and managers who walked by that area every day seemed to be okay with this obvious nonconformity.

Situations and practices that are obviously wrong, that an organization no longer sees or respects as a problem, are indicators of much greater issues in an operation or organization.  

Merely fixing them when they are found closes the door to understanding the real reasons for organizational dysfunction.  

This article provides a method to identify the common systemic and cultural factors that influence the operational reality of an organization.

Beyond the Observation

Many organizations have an expectation that senior management will periodically visit the frontline to walk and talk their value for safety, as well as other imperatives.  

These visits are often formalized into purposeful events such as inspections, conversations, behavioral observations, GEMBA walks, etc., with their frequency or quantity tracked as a metric or performance objective.  

What should senior leaders be learning from these events?

Even though these visits are valuable in elevating the connection with worker and workplace reality, quite often we find that the leaders are not taking the time to understand what is behind their observations. 

Quite often we find that the leaders are not taking the time to understand what is behind their observations. 

Typically, they are recording their observations and handing them off to someone else to fix, without identifying the underlying reasons.

To be clear, it is the responsibility of operations management and support staff within the plant to recognize and maintain control over safety risk.  

It is the responsibility of senior management to strategically align the organization’s imperatives. If the senior management team does not make business decisions balancing benefit and risk, excessive risk is created within the operation.  

The resulting imbalance and excessive risk often originates from strategic activities such as business development, sales, bidding, procurement, hiring, engineering/design, etc., which ultimately have negative implications on the operations.

Decision-Making 

Although the signs and symptoms of these decisions can be seen and heard in very obvious ways, most are not recognized or tracked to their origins.  

Therefore, when a senior leader walks through a plant or field site and readily sees safety issues or nonconformities, such as unsafe conditions and practices, it is much more valuable for them to focus on their reasons rather than gathering and fixing problems.  

Ultimately, they must realize that the reasons often originate in decisions within their realm of responsibility.

Leaders must realize that the reasons often originate in decisions within their realm of responsibility.

Benefits and risks in every organization are created by decision-making.  

Decision-making at the senior leadership level creates the environment and sets the tone where operational decisions are made.

The common thread of how benefit and risk are balanced and the negative implications of imbalanced decisions can be tracked using the Culture to Unwanted Outcomes Relationship model.

Culture, Unwanted Outcomes

The model below shows the relationship between the factors that influence senior management decisions (organizational and operational factors) and the creation of excessive risk which leads to unwanted outcomes. 

One of the easiest ways to see this relationship in play in any organization, is to trace the relationship backwards from excessive risk.  

This risk can be readily identified in the field and facilities where work is being performed.  

Therefore, unsafe (excessive risk situations and practices) such as those identified through management visits are a great place to start on the trail.

The starting point should be obvious issues that are readily recognizable and commonly understood as wrong. 

Such as a clearly marked walkway with a pallet blocking the route, a plant-wide PPE requirement that is not being followed, and the use of damaged/defective equipment.

Diagnostic Questions

To facilitate this walk-back, we have created three diagnostic questions that should be answered (not asked) whenever an obvious unsafe or nonconforming situation, condition or practice is identified.  

For each of the questions the observer needs to understand why the operation or area is not recognizing, acting on and correcting something that is obviously wrong. 

The red floor area storage nonconformity example will be used to frame each of the questions. 

As background information, the area was painted red and labeled to assure sufficient access was provided to critical emergency controls.

Question One: If you recognize something as an obvious problem (excessive risk, nonconformity, etc.), why don’t others see it that way?

The Expectation: This question requires that the observer discern why the issue they are witnessing does not seem to be recognized or respected by those working within the area or process.

The Process: Ask area workers or supervision how they would assess safety in their area. Ask them if they see any issues. If they don’t see what you see, point out the red area storage situation and ask them if it is acceptable. If they agree it is a problem, go to question two. 

If they do not see it as a problem, try to find out why by asking questions like: Is it in conformance with the plant expectations/rules? If it is not acceptable with the expectations, is it generally okay (an allowable deviation)? How do you determine if something is unsafe? 

If they don’t see what you see, point out the red area storage situation and ask them if it is acceptable.

The Expected Result: Questions like these should reveal the workers perspective of responsibility for their area, safety role, training/knowledge, decision-making line between safe-enough and unsafe, and level operational discipline. Visit other areas and ask similar questions to determine the systemic nature of your findings.

Realize that all of these factors have organizational implications that are much greater that the discrete safety issue or nonconformity that you identified.

For example, if workers are not complying with simple and obvious safety rules, what other expectations are they choosing to disregard? The reasons for your findings should be tracked back and systemically addressed. 

Question Two: If they’ve seen it, why haven’t they fixed it?

The Expectation: This question requires that the observer discern why this same issue, which is locally recognized as a problem, is not being acted upon immediately to reduce the risk or planned to be solved or prevented.

The Process: Ask area workers or supervision who clearly recognize the issue, why it hasn’t been fixed or controlled? If the issue has been recognized and fixed in the past, go to question number. 

If not, ask questions such as: Who is responsible for safety in this area? How do you prioritize risk and determine what gets addressed? What is the reason for this issue? Are issues like this common? What challenges do you have maintaining a safe work area?

Ask area workers or supervision who clearly recognize the issue, why it hasn’t been fixed or controlled?

The Expected Result: The information from these questions should reach way beyond the safety of this work area. The elements of an effective safety management system should be suspect based on the results of questions one and two. 

Weak system elements may include safety roles and responsibilities, performance measures, risk assessment, risk ranking and control, training, inspections, resources dedicated to safety, etc.  

Organizational and operational factors such as area roles/responsibilities, accountability, process planning, production changes, staffing, maintenance, capacity of supervision, etc., will often be in play.

Again, realize that all of these factors have organizational implications in production, quality, ethics, worker engagement, etc. 

The reasons for your findings should be tracked back and systemically addressed. 

Question Three: If they recognize the significance of the issue and they have fixed it in the past, why is it back?

The Expectation: This question requires that the observer discern why this same issue, which is locally recognized and has been remedied in the past, has returned. The questions should center on the ability of the operation to effectively solve the reasons for its problems and sustain control over the work environment.

The Process: Ask area workers or supervision who are familiar with the issue, why the solution to the problem is not working. Ask questions such as: Did they fix the reason or just band-aid the problem?  Is the recurrence of fixed issues typical – are there other examples?  Who knows about these issues and who is ultimately responsible? 

Ask area workers or supervision who are familiar with the issue, why the solution to the problem is not working.

Results: Most of the feedback that is received from this question will be centered on organizational and operational factors, not safety. Factors such as, operational roles/responsibilities, accountability, process planning, production changes, staffing, maintenance, capacity of supervision, etc., will most likely be in play. The goal is to find defective systems and processes, not people.

Again, realize that all these factors have organizational implications for production, quality, ethics, worker engagement, etc.

The reasons for your findings should be tracked back and systemically addressed. One of the solutions related to the repeated nature of the red area issue was to improve the planning and communication between sales and operations.

Application 

These questions and the diagnostic process outlined herein can be applied to all obvious issues in operations, not just safety.  

The approach can be used for all types of nonconformities, near misses as well as harmful events.  

The more often these techniques are applied and common reasons are discussed the better aligned an organization will be with risk prevention and cultural improvement.

The more often these techniques are applied and common reasons are discussed the better aligned an organization will be with risk prevention and cultural improvement.

Senior leaders who follow this approach while visiting their field and plant operations will soon realize that the data they receive may not be fully representative of the operational reality.  

They will also begin to recognize the implications of their, and their subordinate’s decisions on the operational dynamic.

Having coached senior leaders on these techniques for many years, we can attest to the change in leadership mindset and operational effectiveness that this approach creates. 

Copyright ASSE, Susca, P.T. 2018. It’s Always Bigger Than Safety, Professional Safety, 63(1), 40-42.

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About the author: Peter Susca is a principal at OpX Safety and has 35 years of environment, health and safety, business leadership, and process improvement expertise. He has served in various EHS technical and senior management positions in large multinational corporations.