Leading and Learning Through Safety
Leading and Learning Through Safety
Episode 156: Learning for the Future
In this week’s "Leading and Learning Through Safety" podcast, Dr. Mark French emphasizes the importance of capturing and understanding data to support risk reduction procedures, stating that good safety practices are indicative of good leadership. He highlights the need for organizations to learn from past incidents to prevent future occurrences.
Dr. French references a recent Chemical Safety Board (CSB) report on a 2022 refinery explosion that resulted in fatalities. The report revealed that the organization failed to learn from previous mistakes, did not capture the reasons behind incidents, and lacked systemic changes to prevent recurrence. This failure to learn poses significant risks.
To illustrate the importance of documentation, Dr. French provides a hypothetical example where an organization, after an injury, revises policies and implements protections. However, new management might later remove these measures, reintroducing risk due to a lack of understanding of their importance. Thus, documenting the rationale behind safety procedures is crucial for continuity and safety.
He stresses that the absence of injuries indicates effective safety measures, not redundancy. Organizations must maintain and improve safety standards through continuous proactive risk management.
Dr. French advocates for thorough root cause analysis (RCA) and corrective action processes beyond quick methods like the "Five Whys" for complex, high-risk scenarios. Capturing the "why" behind safety policies involves documenting historical contexts and reasons, ensuring future leaders understand and preserve safety improvements.
He concludes by emphasizing the cultural importance of safety and continuous learning, inviting listeners to the upcoming Kentucky Safety Conference. The episode underscores the need for effective documentation and proactive safety management for strong organizational leadership.
This week on the leading and learning through safety podcast, we're talking about capturing data so that we know why we have the procedures for risk reduction that we have that and more this week.
Announcer:Welcome to the leading and learning through safety podcast. Your host is Dr. Mark French marks passion is helping organizations motivate their teams. This podcast is focused on bringing out the best in leadership through creating strong values, learning opportunities, teamwork, and safety. Nothing is more important than protecting your people. Safety creates an environment for empathy, innovation, and empowerment. Together, we'll discover meaning and purpose through shaping our safety culture. Thanks for joining us this episode. And now here is Dr. Mark French.
Mark French:Welcome to the leading and learning through safety podcast. Hi, I am your host, Dr. Mark French. And I am so happy that you have joined me this week as we continue to talk about leadership and safety. How do we merge those things together? More importantly, why I feel safety is absolutely the first step of good leadership. Show me good safety. I'll show you good leadership, show me bad safety. And we'll learn on how to be better leaders from that. So this week, I want to continue the discussion the Chemical Safety Board. So last week on the podcast, we talked about a report that Chemical Safety Board released just a few weeks ago about a 2022 refinery explosion that killed two people. Part of the key finding was that the organization did not learn from their mistakes. They did not capture the reasons why things were happening the way they were happening, and they didn't learn from those items. And that's critical for any organizations no matter what size, no matter the risk level, there's risk there that we should learn from. How do we do that? That's the key is how do we systemically make sure that we learn from what we're doing? How do we capture that data? So I'll give you an example. A organization has a significant injury or maybe even if it was a potential SAF or potential significant incident or fatality, someone falls. And there's they realize that just the basic policy or the Basic Law, Policy was not enough, there was a specific circumstance that led to it. There should be definitely more protections of some form that are in place. So they put it to capture that they put it in a policy, they write it into a policy train everyone on the policy going forward, everyone coming in to do that work, learns that policy. So there's a good edge let's, let's assume there's a great education, part of that policy. That the it's been captured, it's been working, and they don't have any more incidents. Now, this is a common story. This is I'm giving you a hypothetical. But what I'm telling you is I have seen this happen. And I have been there in almost made mistakes of that type. And fortunately had opportunity to ask some good questions. And so you suddenly have this policy that seems that it has additional steps. And of course, what do we think about safety? Sometimes that's just a waste. We're doing all this extra? What are we getting from it? It's just a cost scary thoughts? And I'm sure if you've spent any time in the safety world or in the leadership world, you've probably heard those discussions. Hopefully you stopped those discussions, but was so true. So we have this great policy that is reducing risk that actually almost happened or did happen, and we have it in place to prevent it. Let's skip ahead five years. Let's say some management's been turned over. Safety has been turned over and new people are at the helm. running the organization. They look at this policy and overtime they realize that we're not getting anybody hurt doing this process. Why do we have all these silly extra steps, because one, they weren't there when the bad thing happened, that they needed to put into place so they don't remember it. And they see it as extra work that doesn't need to be needed. And so they start to think about removing it, because we haven't had any issues. So let's just remove it, the absence of injury does not indicate an opportunity for improvement, the absence of injury confirms, in a very reactive way, that you have a good policy or that you're doing it right. You don't go backwards. The goal is not to backup your to continue to increase risk until you get someone hurt. And they go, Oh, we went too far. The goal is to continually look at proactive, preventative, good risk management, so that no one gets hurt. And you're actually building more and more space, and more and more systems. So we guarantee even more so that we don't hurt someone. The absence of injury is not the indication that we're wasting time. Again, the absence of injury means we're doing the fundamentals correctly. It may not mean we're even getting much further ahead, it means that either a we could be just lucky to it means maybe we have a good process. It that frustrates me and I've seen it. And I remember a time we were talking about a very policy that had a lot of redundancies a lot of time. And I was just being kind of because it was a safety policy, and I was fairly new. Just why do we have to do it? Why do we have to do it? And I kept asking around, there had to be a reason that it was so calm, like there were so many redundancies, there were so many extra steps of engineering and process that it did seem like it was very just it took a long time to do it. So I kept asking questions, why. And finally, someone pointed me into the direction of someone who knew. And they pulled up an old root cause investigation report where someone had been seriously injured. And they had to put all that in place to guarantee it never happened again. We could have removed that. And we could have brought that entire risk, we could have repeated that entire risk again, because we had not systemically captured it in a policy and then also had the backup documentation if you knew where to look, backup documentation that was supported. To support why we did what we did to protect that person. Just like my example of we had a follow we had to put extra steps in place, we have to capture the why we're adding extra steps, or why we put into place the safety system or the safety process or the engineering change to protect people because we almost had it happen or we did have it happen. In this report. One of the biggest call outs one of the problems that they cite is that they did not learn from their previous incidents, they had operators tried to respond to way too many alarms 3700 alarms and a 12 hour shift. They had so much that was not going right in to work on this system. And in they had done it before the organization had killed people before the organization had had near misses before the organization had done all of it before and didn't learn from it. And they continued it. How do we capture these things in a policy if you had good record management and maybe you have a great quality system that helps you keep good records, putting in your policies references, like this policy. Part number five is here because of root cause investigation. 2022 A. And so you see that we have this extra policy, there's extra work that has to be into place, and you can reference back into your documentation to say we learned this the hard way. We're doing it because we learned this the hard way. That is why we have it. If we don't keep the why we will lose that we will take a step backwards. It will reintroduce risk, sometimes unknowingly, but in this case, it felt like according to this report, it felt like it was knowingly like we just chose not to learn from it it like we are we make some changes, but we'll just choose not to learn. Oh, let's continue that. Let's talk a little bit more about learning. How do we learn? And how do we capture that learning? On the second half of the leading and learning through safety podcast,
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Mark French:DSD, a consulting, learn you lead others, the Myers Briggs Type Indicator is an amazing tool. The problem is that it can be easily misinterpreted. Dr. Mark French is MBTI certified and ready to help you discover your inner strengths. The MBTI assessment can help with team building stress management, communication, conflict management, and so much more. Individual and group sessions are available to help you discover what makes you great. For more information, visit us on the web at T SDA consulting.com. And welcome back to the second half of the leading and learning through safety podcast. So as part of an organization, we learn from our incidents, or we learn from our near misses or potential si F's potential, significant incident or fatalities, how do we learn? How do we capture that learning? This goes into where we would call your root cause and corrective actions. How did you problem solve? You see there's an issue? How do you solve it? And how do you capture that information. In the first half, I referenced having a policy system that would actually put a reference section to say, part five of policy, whatever was created due to root cause 1234, we did this root cause we found there was an issue. And we had to put this policy or this change in place because of it. Now, what I'm describing is by far, a best in class process, it is one that is robust and follows through there's training involved, there's references to tell you where to go to look, to understand why it was created, the way it was created, to capture the historic documentation to assure that those who come later understand why we did what we did now, or who in the past did what they did, and why they did it. Because we understand the why I've actually seen where a policy got changed retrospectively because no one had gone back and really read it. So in the first time I gave the example of we have a more complicated process because we had to, to fix to prevent risk. I have seen where we've went back and looked at that. And we did the research, and found that during some upgrades to the facility, that issue was actually engineered out, maybe we were using a different chemical, maybe we were just had a change to the system, maybe technology evolved to where we can engineer it out. We eliminated the hazard. So we didn't need the antiquated policy. So it can go the other way to where we learn. But the key is, is that we go back and understand the why in the report that came out from the Chemical Safety Board. Part of what they talk about is how they discovered the why. And they talk about that they were using a five why investigation? A five why investigation is basically they say if you ask five, why five times you'll get to the root cause a five Why is a very fast, very rudimentary. It's kind of the one that you use for like problem solving on the run. So you're out and you see a near miss happen. And let's say there's water on the floor and you see that someone could slip. You put a cone out. And you say don't don't walk here because it's wet. But the next logical thing is you ask why is there water on the floor in the first place? And you go, oh, there's a leaking pipe. Well, why is the pipe leaking? Oh, it's condensation because it's a cold pipe. And it's a hot day and high humidity so there's sweat on it, and it's dripping on the floor. Okay, well, why was it left in that condition? Oh, well, we pulled the insulation off to do some repairs a few weeks ago and forgot to put the insulation back on Route cause put the insulation back on clean up the spill. And we haven't fixed there found that there was a similar five why investigation at this site that they just did a five why and ultimately, you know what they came up with. We should have an alarm that warns us when the FILL TANK is getting too high. Now recall in the incident, there was too many alarms. Part of the problem was alarm overload 3700 alarms and a 12 hour shift. They found that the five Why was inadequate, they actually quote this five why investigations are described as part of their incident investigation procedure for that organization. But in the book, An Introduction to system safety engineering, the author explains this technique for incident analysis can lead to an investigation team omitting important systemic causes. The root cause is not an alarm or not the fix to a root cause. It should have been more than interaction to safety systems. The baseline introduction book cautioned us that when there is something this bad happening, you should not just use your fast method of problem solving, you should sit down and really do a good problem solving. There's a lot of really great systems that do in depth root cause corrective action. I am certified in a couple of them not to brag not to say that they're the best not to say that they are the ones that would always work 100% For every situation. But if when you're working with something that has significantly high risk, it should be more than just asking yourself why there should be a more detailed understanding of what is happening when there is a potential for serious injury or death. There should be more details, a more detailed incident more time, more investment in assuring that that risk is eliminated, and then capturing that learning. The more effort that is put into it from an organizational standpoint, the more likely more people will remember it. Oh, yeah, I'll remember we had that big potential incident that happened. And a lot of us had to get together and problem solve. And we came up with some really great ideas on how to fix it. Well, guess what that knowledge has captured what is captured within the organization because people remember the urgency. They remember the importance, they remember the way the investment happened from an organizational standpoint, to find the answer. It's a cultural, cultural shift. And that's what I really it's, it's the fact that we're finding the problem. We're finding the problems. We're fixing the problems. We're looking for the answers. But we have also created a cultural wave that said, wow, look at the way the organization handled that it was so big, so serious, that we got a whole lot of people involved in fixing it. It says a lot for your culture. It says a ton about your leadership. And it guarantees your commitment to safety. Thanks for joining me on this episode of the leading and learning to safety podcast. So happy that you joined me. Hey, if you're going to be in Kentucky in August, Kentucky safety conference is coming up. Gonna be a great time. Again, thanks for joining me, and until next time we chat. Stay safe.
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