Risk, Vampires, and the Politics of Perestroika

Okay, it's Halloween and so I'm going to try and write a spooky story about risk and disciplinary action in the work place.  Gather the kids, light some candles, and get your hot chocolate and marshmallows...

It was a dark and stormy night, and all the vampires were just getting to work.  As they gathered around the blood cooler drinking their cups of red 'go-juice', the conversation was dominated by the subject of a chilling event that happened a few nights prior.  Apparently, Vlad (not his real name) sprained his ankle while jumping down off a flat bed truck trailer.  He had climbed up onto the trailer to replace a tarp that had been ripped sometime during previous usage.  He threw the ripped tarp onto the ground below.  Then, instead of climbing carefully down the permanent access ladder at the back of the truck, he sat down on the edge and gently pushed himself off.  He landed on the discarded tarp, which slipped under his foot.  He then twisted his ankle.  Ouch!  The witch doctor concluded he had a badly sprained ankle, which forced the safety manager to reset the lost-time accident counter to zero.

During the interview, Vlad offered the following:

"Well, that turned out to be a stupid mistake.  I did this work as a human for five years as a contractor in Moldova before my abrupt introduction to the realm of the undead.  You think vampires are thick in Transylvania?  Well, after Gorbachev took the lid off the Eastern Block, they fanned out all over the place.  Just like Bald Eagles - you used to go your whole life without seeing them... now they're competing for road kill with the crows.  Hmmm, speaking of road kill, is it lunch time yet?  Anyway, now I've been doing the same kind of work - albeit on the night shift - for the past fifteen years.  But my undead bones must be getting weak.  I've never been hurt before.  I thought that I was being careful by sitting down first before jumping off the trailer.  If only I hadn't landed on that tarp, I wouldn't have slipped and we wouldn't be here."

Management wasn't buying it.  They knew that Vlad had been trained recently in best safety practices because they pulled the training roster.  Right there, between Keith Richards and Joan Rivers (two longtime members of the undead) was Vlad's scrawled signature.  He should have known that that his actions of jumping off the trailer weren't acceptable.

The rules were very clear.  If an employee violates a safety procedure, they are to be bolted into their coffin for two days with a sunlamp and a bag of beef jerky.  That's what the conversation at the blood cooler was all about.  Sure, Vlad may have violated a rule.  But did he really deserve to be punished in such a way?  The punishment wasn't perceived as just by the other vampires onsite because Vlad had a reputation for being safe.  He had never been hurt before.  And, everyone took shortcuts from time to time.  The supervisors seemed to be more interested in meeting their demonic production targets than making sure that every little safety rule was followed.  If Vlad hadn't been hurt, no one would have cared.

Now I know what you're thinking.  If you've got enough vampires to work the night shift, and you're worried about a sprained ankle, your priorities could use some fine-tuning.  Agreed, but since I'm already invested in the metaphor now we've got to stick it out...

Recently, Cory Boisoneau and I attended the National Safety Congress conference in Orlando, Florida.  I had the opportunity (thanks to Hilda Koskiewicz of NSC) to host a professional development session titled "Does Disciplinary Action Increase the Risk of Human Error?".  This was a panel discussion where I gave a presentation and then we opened up a dialogue with the panel members and the audience about the topic.  I was very fortunate to have Beth Lay, Manager of Risk Management and Loss Control and Mark Thomasson, Six Sigma Master Black Belt, both of Siemens Energy, as panel members.  Also, thanks to the attendees who contributed great stuff to the conversation.

My take on this, as you can see from my previous blog on this subject, as well as my recent article in the October 2009 issue of Occupational Health and Safety, is that systemic risk can be found in conditional causes of events and non-systemic risk can be found in the action causes of events.  Most investigations focus on action causes, and therefore only on the non-systemic risk elements in an event.  However, as we stress in our root cause analysis courses, the best solutions are often found in controlling conditional causes.  This is because controlling conditions reduces the systemic risk of recurrence to which all employees are subject... not just the single actions of any one employee.

Disciplinary action is intended to control action causes of an event.  It attempts to control worker's choices by providing a disincentive to acting outside the established rules.  However, my experience has shown me that disciplinary action is often ineffective in reducing risk.  This experience is apparently mirrored by many others.  In James Reason's latest book
"The Human Contribution: Unsafe Acts, Accidents, and Heroic Recoveries" page 74 discusses the concept of blame (the act of attributing to which occurs immediately before handing down disciplinary action) in the context of what he calls "the fundamental attribution error", which occurs when we assume that an error is caused by some character flaw, rather than the fact that they made choices based upon past experiences along with information available at the time of the incident.  In other words, the conditions at the time of the event were eminently important to the decisions made by the blamed (and subsequently disciplined) individual.

Disciplinary action often not only fails to reduce risk of future recurrence, it also can actually increase the risk of future errors.  When discipline is applied programmatically (as in Vlad's case above - the supervisors were 'forced' into discipline by their own rules) regardless of conditions at the time of the incident, the action will be perceived as unjust by both the person experiencing it and that person's peers.  This is a nightmare (remember, it's Halloween) scenario for an investigator of future incidents because when the time comes to understand the causes, no one's talking.  No one saw anything.  No one knows what happened.  That's spooky stuff.

This was the point I attempted to make in my presentation.  But I learned that I needed to account better for times when punitive disciplinary action actually does help to reduce risk... primarily when dealing with cardinal rule violations, such as horseplay, drinking, drugs, etc.  Beth Lay of Siemens shared a great decision tree based on the work of James Reason that they created in order to help recognize the difference between an error that resides primarily with the employee or with management systems.  I am convinced that this is the right way to go.  An organization needs guidance to know how to act, and in the future we at Apollo will work to develop our own guidelines to help decide when disciplinary action will be effective without actually adding to systemic risk.

A great article on this subject by Kevin Sharpe of Science and Spirit Magazine can be found here for those interested in reading more.

Have a happy Halloween!  Be safe!  Or be boring like me...I think I'll spend this year on the couch watching baseball.

Brian Hughes

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