Many of us are aware of the “Miracle on the Hudson” in which Captain Chesley ‘Sully’ Sullenberger landed U.S. Airways Flight 1549 safely on the Hudson River after his plane was struck by a flock of geese that disabled both engines shortly after take-off. All 155 people on board survived. The ensuing incident investigation found Captain Sullenberger made the correct decision to deviate from the available “normal” engine-loss procedure, which was designed for cruising altitude and not for immediately after take-off. Captain Sullenberger understood the intent and limitation of the available procedure and was aware of the risks, which enabled him to make an informed and ultimately, the correct decision.
Operational discipline is not “strict adherence to procedure.” It is not practically possible to develop procedures for all situations that an operator may encounter. Therefore, as Captain Sullenberger demonstrated, operational discipline is also about being aware of the risks and understanding which procedure to apply to mitigate those risks.
Preventing ‘Blind Compliance’
An organization with a high degree of operational discipline exhibits several characteristics, including leaders who lead by example; practices that are consistent with procedures; and employees who are highly engaged, have shared values, and are risk-aware and sensitive. At DuPont, we define operational discipline as, “The deeply rooted dedication and commitment by every member of an organization to carry out each task the right way, every time.”
To reduce incidents and achieve operational discipline, organizations must ensure that employees know and are sensitive to the possible risks in the workplace, while also having procedures and processes in place to mitigate them. When a procedure does exist, operators need to know its limitations and be ready assess its effectiveness relative to the existing risks. This will help them make the correct decision, even if it means they need to improve the procedure.
Absence of risk awareness causes procedures and processes to become items to comply with blindly. Culturally, when the lack of risk awareness is not addressed, it promotes a compliance mindset that results in complacency. In situations where judgment is required, consequences may be fatal, with luck as the primary layer of protection.
Safety vs. Risks
The first step in increasing the level of risk awareness is to shift the organizational mindset away from safety and towards risks. The differences are subtle but important. Safety is binary—something is either safe or unsafe. Personnel often interpret being safe as the absence of incident. When an incident does happen, it often comes as a surprise, prompting the organization look at deficiencies in current controls. Safety is reactive and seen as the responsibility of the organization’s safety group (or maintenance or technical group), while everyone else should just do their job and follow procedures.
The idea of risks, on the other hand, is more continuous—higher vs. lower risk. It is proactive and discourages complacency. That is, regardless of the current safety performance, risks are still present and they need to be continually reduced and managed. In order to achieve the desired safety performance, everyone needs to be aware of the risks in their day-to-day operations and be sensitive to them. Risk awareness is not another program, but a mindset that everyone must own individually.
Increasing the Level of Risk Awareness
Transforming the culture of an organization to be more risk aware requires engaging the people who do the work. Frontline personnel have the most knowledge about the operational risks they face on a daily basis. They know which procedures work and which ones are typically not followed. At one point, they were new to a specific operation and had a heightened sense of risk awareness. But over time, they may have become complacent, and while they are aware of the risks, they no longer consider them. Engaging with frontline operators to articulate and re-internalize operational risks will transform their mindset from safety to risk and enable them to recognize daily risks more readily.
For example, in a high-hazard environment, a process hazard analysis (PHA) is conducted on a regular basis with the involvement of operators and mechanics as best practice. However, PHA is a single event. While PHA is important and effective, discussions about hazards and risks should not only occur during PHA or other events in time, such as pre-shift meetings. Instead, discussions about risks should occur more continuously in an informal, organic manner without any requirements imposed by leadership. The intent is not to replace the rigor of PHA, but to complement it and normalize risk discussions to empower frontline personnel to discuss it openly and continuously.
The goal is for frontline personnel to envision themselves as a critical layer of protection. Though not perfect, each one of them owns pieces of the company’s operational risks and internalizes the roles they play in ensuring the integrity of controls, which makes for a more vigilant organization.
Once this mindset is in place, workers will no longer follow procedures blindly. In fact, it will be common for them to identify hidden hazards and modify existing procedures accordingly. They will not only highlight risks, but also take ownership to fix them. They will hold company leaders accountable to provide the necessary support to address risks that have surfaced, and leaders will be asked to be more transparent and to communicate their plans relating to the identified risks more effectively.
Encouraging frontline operators to focus on daily risks instead of simply safety will enable them to make informed decisions, be more proactive, and reduce complacency.
Alfonsius Ariawan is global solutions architect and Lawrence Short is senior manager with DuPont Sustainable Solutions. DuPont Sustainable Solutions, a business unit of DowDuPont Specialty Products division, is a leading provider of world-class operations consulting services to help organizations transform and optimize their processes, technologies, and capabilities.