Safety 2014: Just Culture YouTube

Safety 2014: Just Culture

Dr. Sidney Dekker is quick to tell you he does safety. He just does safety…differently.

Dr. Sidney Dekker offered a provocative keynote address at Safety 2014. A university professor, a professional pilot (737s) and a noted author and speaker, had a few people get up and walk out of his presentation. But many more stayed to listen as Dekker turned many widely accepted safety practices on their heads.

Dekker started his talk with a quick discussion of the hundreds and thousands of workers killed each year in the late 19th and early 20th centuries. “Get to 2014,” he pointed out, “and those numbers [workplace injuries and fatalities] are really, really low.”  

He mentioned a large construction project in Australia 80 years ago, when 120 people died building 120 kilometers of tunnels and dams. That project was considered successful because for that time, it had a low fatality rate. Skip ahead to 2013 when the same company was building a tunnel and a single worker died. That project, said Dekker, “was a failure.”

The reason it was considered a failure is that companies now have “zero injuries” as a goal. But, Dekker added, “there’s a difference between the commitment and the goal.”

Numbers Lie

He spoke of a worker named Maria who worked at a petrochemical plant that had a big sign out front boasting of 290+ days without a lost time injury. While at work one day, Maria was dowsed in product. She needed to leave work to see a doctor.

A coworker took her to the doctor and while there, Maria got a call that her school-age daughter was sick and needed to be picked up. So, when Maria and her coworker left the doctor’s office, they picked up her daughter. 

Maria’s doctor said that she should not work for a few days, which caused consternation for the safety director, who knew this meant his beautiful sign would reset to zero days worked without a lost time accident.

When the safety director talked to the human resources director (“evil people” was how Dekker referred to the HR function at a company), the HR director suggested offering Maria a “post-dated compassionate leave,” because she had to stay home to care for her sick child. This meant that Maria technically was not out on sick leave, and therefore the sign didn’t have to change.

Several days later, Dekker noted, the sign read “300 days” without a lost-time accident. “That,” said Dekker, “is selling out safety,” and all so the safety manager didn’t have to explain to his boss why the sign was reset to zero days.

“A safety culture is a culture that allows the boss to hear bad news,” said Dekker. “And this [example] is the erosion of a safety culture in the drive for zero.”

Little Change in Stats

“The more we seem to do, the less change we see,” said Dekker. Calling it a “syntonic curve” and a “dying strategy,” he added, “Doing more of the same will get us more of the same.”

Anyone who subscribes to a “hearts and minds” philosophy about safety is doing the same thing that philosophers and scientists have talked about since the fourth century, said Dekker. “We’re doing something we’ve been doing for 1600 years!” he noted.

Using an example from his own occupational experience, Dekker noted that in the 737s he flies, there’s a regulation/rule that states the plane cannot take off until the flaps have been lowered. However, there’s no warning device to indicate wheather or not the flaps have been lowered. So, Dekker  explained, pilots use a Styrofoam cup and place it over the knob for the flaps.

“We finished the design with a 10 cent cup on a $55 million jet,” said Dekker. They see the cup and realize they haven’t lowered the flaps. “I think you’ve got a lot of workers every day who finish designs in order to get the job done and get it done safely.”

Idiots Need Not Apply

Dekker discounted what he called “the idiot theory,” which subscribes to the theory that a few workers are “responsible” for the greatest percentage of incidents.

A popular theory, several people in the audience grumbled when he said that firing or reassigning employees who are “accident prone” will not make a difference in the long run. That theory only works if “every single worker has to expect the same amount of accidents,” said Dekker. However, he added, “It’s all about context.”

Office workers don’t experience the same hazards as workers in forestry or heavy manufacturing. A construction supervisor doesn’t necessarily experience the same hazards as his direct reports. In other words, a worker might not be “accident-prone.” The worker might be placed in more hazardous situations than co-workers.

“Nobody comes to work to do a bad job,” said Dekker. “When something goes wrong, we have to ask why it made sense to them to do it that way. Because if it made sense to them to do it that way, it will make sense to others to do it that way.”

Normal Work Often Is the Culprit

What Dekker calls “normal work” often is what results in injuries and fatalities for employees. The single worker killed working on the Australian tunnel in 2013 ran a piece of heavy equipment. It was old and cantankerous and he’d have to crawl underneath it and reach up into it to get it to start. He probably had done it dozens or even hundreds of times – it was part of the “normal” scope of his every day work – and then one day, the machine started up and decapitated him.

All of those times he had reached up into the machine never were reported as near misses or “incidents,” but that’s what they were, said Dekker.

“Murphy’s Law is wrong,” he said. “Everything that can go wrong usually goes right. The enemy of safety is success.”

In order to reach a culture that doesn’t mask injuries as something else or that relies on luck – probably more than safety directors and corporate leaders could ever imagine – to stay safe, Dekker suggested companies keep discussion alive with employees and seek out fresh ideas. Watch for those instances where employees are “finishing a design” in order to do their work.

True culture change comes from great leadership, he concluded, and a culture that supports autonomy to bring up safety challenges and even stop work when necessary, a mastery of the job tasks and safe work strategies and purpose, to ensure everyone makes it home safety and sound.

“In the United States, I saw a hard hat. It said, ‘We build America.’ That’s autonomy, mastery and purpose,” Dekker said.

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