Are safety reporting systems creating heroes and villains?

Can you relate with the two communication styles in the picture below? If not, do not waste your time reading this article. If you do, and you are wondering what’s wrong with it, let’s continue.

Over the years, a specific pattern of organisational communication has caught my attention - our tendency to explain away unexpected outcomes into simplified stories of blame and fame. The problem exists in all repositories and databases of communication, but I chose to draw from incidents, near misses, non-compliances, and hazard observations. It is one way of understanding how we as humans make sense of situations when we are faced with an unexpected situation or when our expectations are violated.

Why should you care?

Think about it. When every unexpected outcome paints a picture of exceptional performance or negligent behaviour, you are unknowingly creating heroes and villains and becoming detached from operational realities. If you are trending the data, chances are you maybe scaling up villains and tracking down heroes in your databases.

Scaling up villains means even more procedures, rules, checklists, training, and re-training, miscommunication, breakdown of communication, and frustrated employees. But then of course you have a library of mental health programs, don’t you?

Furthermore, since you have not engaged with the problem, you may realise that the same errors and breakdowns will keep coming back. That is ‘learning disability’ and it is a common problem in many organisations when the same stuff keeps hitting us back and we have no idea how to save our reputation and business.

Learning disability is often the result of too much experience but too little curiosity. And it lends itself into two further problems – 1) our inability to question, imagine and understand the patterns behind errors and breakdowns and 2) viewing every problem through a single-minded focus on compliance with predetermined rules, and our past work experience. You may have heard this famous expression from an old investigator, auditor, or a business leader, “10 years ago when I used to serve on ships, I have seen precisely the same problem”? This is a typical problem in the maritime and Oil and Gas world. It is the irony of prior knowledge and understanding that it comes in the way of improving our understanding and inadvertently leads to simplified stories of heroes and villains.

But with recurring patterns and problems comes another challenge. Your people won’t always be in the right place at the right time. Gradually, heroes will turn into villains and your ability to control unwanted, unexpected situations will start to diminish each day. But that is the price we must pay for choosing laziness over thoroughness.

So, what should I do?

Stop playing this game of hero-villain analysis and begin with asking better questions from people doing the work. You may find something new that could lead to meaningful change. Consider an example. A leak on a fuel line was detected and immediately repaired on the scene by your safety engineer Alice. A typical response I have noticed is “Well done, Alice”. That is a mindless response and more importantly, if it happens too often, it is the sign of a toxic workplace where people don’t want to engage with problems.

Consider another example where a worker raises concerns about a certain equipment during a planned site visit and the typical response is to ‘remind’ the worker to be more careful and follow the procedures. The conversation will usually end there. Mind you, in many organisations we have also learnt to blame machinery and equipment – that is faceless bureaucracy, and it serves well to hide problems. Back to the example, the typical response is ‘we don’t have time to go into everything’. Interestingly though, we have time to transfer all the ‘data’ manually into excel sheets and paint colourful trends to impress our bosses, regulators, and clients. This is not a question of time, it is time for thinking, reflection, listening, the desire to collect meaningful information and the ability to analyse this information to create meaningful change.

Even from these two simple examples of how errors are detected and reported, two different patterns emerge and lead to significantly different understandings about how you are managing risk and safety in your organisation – either your success is dependent on luck, or your controls are working as they should.

You may continue to create heroes and villains and introduce mindless bureaucracy of paperwork, or you may wish to listen and appreciate perspectives of people who do the work (and even more if they don’t match with yours). Beware though, in most accidents and human failures, you will never get to the full truth, but each time you ask open questions, you will learn something new. That would improve your understanding and ultimately, your chances of succeeding in an uncertain world. It would also help you connect with your people and make you a better leader.

A word of caution here. As you gain a better appreciation of your problems, you may realise that you don’t have control over all the variables. For instance, there is nothing much you can do about a substandard product when you are tied up into a contract with a supplier for the next five years. But at least you will make an informed decision about renewing your contract with the supplier or delve deeper to find out how that ‘substandard’ product interacts with your wider eco-system, where the interdependencies may exist, and then focus on strengthening those dependencies.

That’s better than creating heroes and villains every time you face an incident, near miss, technical failure or an unexpected outcome and living in the dark.

What do you think?

Nippin Anand is the Founder of Novellus Solutions. He is a master mariner with a PhD in Social Science and Anthropology. He has a passion for researching accident investigations, incident reporting systems and safety management.