Re: A Safety Case LO2336

jack@his.com
Sat, 05 Aug 95 10:57:05

Replying to LO2333 --

Rick, you begin this post with a quote from yourself regarding "near
misses". At the end you ask, "What can we do in our organizations to
improve the flow of feedback about unsafe or just ineffective things so
our systems can be improved?"

One important thing is to stop speaking of "near misses." This language
reinforces the idea (and attendant behavior) that close calls are "safe".
Let's face it, a miss is as good as a mile, and accidents are a toggle -
yes or no, accident or not, injury or not, etc. No "near" anythings.
What we call a "near miss" is a near hit.

How we unlearn safety is by surviving close calls. The closer you can
shave your behavior without incident, the more likely you are to repeat
it. Over time, performance in hazardous activity becomes increasingly
"careless" because safe emergence from unsafe practices has "taught" us
that those practices are safe.

The NASA form is an excellent beginning... but what needs to happen is
that safety standards (or other performance standards) need to be
precisely defined and, as in the case of the NASA form, individuals and
groups need to be "encouraged" to report their own behavior. The outcome
- a safe (or more effective) work environment - must be identified with
the source in order to maintain a self-amplifying loop. In this case, we
do not want "balance" (which is to say, an "acceptable" level of unsafe
practice) and we do not want to measure success by counting accidents,
since an accident-free environment is merely an outcome, not the goal.

I know there are readers of this list who will say, "if the practice does
not lead to accidents, what meaning is there to labeling it an 'unsafe
practice'?" I do not have a "logical" answer to this question.
Everything we do in life embraces hazards. Those things we label as
"unsafe" touch not only on accident data, but on some of our values. I
don't know why I call one action "unsafe" and don't another. But I know
it when I do it.

As in all things, you can shed the practice when you reach the goal, which
in this case is, "Always act safely."

--
Jack Hirschfeld         Just what makes that little old ant think he can move
jack@his.com            a rubber tree plant?