for whoever is not against us is for us*
When you take a step back and look at
most of our safety management systems it might appear that we
are building systems to protect us from employees who want us to
be unsafe. Yet after 30 years of investigating accidents
and evaluating risk in the aviation sector I am yet to meet
employees like that. We all know the handful we have seen
involved in some of the more recent tragic suicide cases but
that isn't the norm and hence not the total focus of our safety
systems. The truth is that our task is to protect the
wider world from the mistaken actions of employees that just
didn’t know what the right decision was at that moment in time
when it all went wrong. They didn't set out to have an
accident or incident, most usually it is what they know (or
don’t know) and what they assume that leads us to the
catastrophe. Therefore our drive should be to help them to
know what they need to know and then not to assume what isn’t
the case!
Most of us will know safety management systems that let people tell us what is wrong (incident reporting) and then we, the management, the safety ‘organisation’, will take that report and process it until we can tell the system how they should do it better (new procedures or training). It is a loop and it seems we so often fail to make it more of the mirror it really needs to be. In most cases they don’t need new procedures, more people telling them how it should be done, they need to know the things they didn’t at the time it went wrong, they and everybody else who might meet it. They need to know how it, and they, fail, they need to know how the barriers in the system work and what is (and might not be) available in the situations they find themselves. They really are on our side and perhaps we should start to treat them a bit more like we know that.
Information truly is the heart of
safety improvement and knowledge is the ultimate key to good
risk management decision making.
The question is how do we effectively communicate and to whom ?
*Jesus in Mark 9:40