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My last book was all about workplace incident investigations. As I talked with people who read it and as I continued to facilitate serious incident investigations, and as I spoke often during training sessions about my belief that the conversations we have before an incident should be the same as the conversations we have after an incident, I became preoccupied with a thought: What if we could proactively give the vaccination against workplace incidents to leaders before we had an incident? What if we could tweak leaders’ thinking, behaviours and routines? What if we could front-end-load the remedies to drivers of workplace incidents? What if the leaders of workplaces had the skills, knowledge and expertise to make sure things went right, before having to worry about putting things in place after an incident? What could that look like?

I thought a lot about this and came to the conclusion that the various bits that impact safety in the workplace should have an underlying alignment. The ‘various bits’ I refer to here are the Individual, Leaders and Leadership, the Systems we use and the workplace Culture. This is the search for the Grand United Theory (GUT) that holds all of this together.

Physicists have long searched for a Grand Unified Theory that will tie together the fundamental forces that hold our world together. A Grand Unified Theory in the world of physics is all about bringing together the strong nuclear force, the weak nuclear force, and the electromagnetic forces together under the one roof. The corollary with safety is trhe brining together of the four areas of interest to us in this book. Namely the individual, the leader, the system and workplace culture. A question I seek to answer here is ‘In the world of safety, what is the simple, basic, underlying stuff that we simply need to get right?’

Since Routledge published my book Simplicity in Safety Investigations in 2017, I have researched in detail well over a hundred books and papers by safety thinkers of the past, the present and a few that point to the future, in order to extract from them information and data that helped me solidify my ideas and thoughts on the GUTs of Safety. I have also had lots of conversations with safety professionals and leaders in the various countries in which I work.

My Grand Unified Theory of safety is best described by a set of individual characteristics, distinctions, attributes or traits that can permeate through the workforce at all levels. It talks to each viewpoint of; the individual, leaders and leadership, the systems we use and the culture of the workplace. It is evidenced by a state where, driven through strong relationships, everybody::

• Understands their ‘Why’,
• Chooses and displays their attitude,
• Adopts a growth mindset – including a learning mindset,
• Has a high level of understanding and curiosity concerning Work-As-Done, Work-As-Normal and Work-As-Written,
• Understands their own and others’ expectations,
• Listens generously,
• Understands the limitations and use of Situational Awareness,
• Plans tasks using tools such as the Efficiency-Thoroughness Trade-Off (ETTO), Risk Intelligence, and a suitable wariness for the effectiveness of controls,
• Controls risk,
• Applies a non-directive coaching style to interactions,
• Has a Resilient Performance approach to systems development,
• Is preoccupied with failure, and
• Adopts an authentic leadership approach when leading others.

Using the above as a framework for being, thinking and behaving, individuals and leaders at all levels in the organization will be internally driven to set up work, procedures, systems, behaviours, practices, processes and routines that align with these attributes. It is through their consistent and interrelated application that the workplace culture will manifest, great systems will be developed, leaders’ behaviours will emerge and individuals will thrive.

It is important to treat the GUTs of safety, not as a checklist of things to rote learn and do in a particular order. They are best treated as one would a complex system. It is the interrelationships, the integration, the merging, melding and intermingling of the thirteen attributes that will make them work best. And will continue to make sure we do the things that help us make things go right.

The GUTs of Safety will explore each of these attributes in detail, talk about barriers to their effective use along with remedies, discuss some leader’s practices and routines, how to measure effectiveness of the attributes and also a discussion about how to use the elements of the GUT as a framework for exploring and understanding workplace safety incidents.

Here is a bit of a summary of each of the elements of the GUTs of Safety:

Understands their ‘Why’:
The more we understand our ‘Why’, the more we are able to be ourselves, and the more we are able to be ourselves the more effective we become as human beings. Feeling, expressing, believing, expressing and engaging in our authentic selves, powers our effectiveness.

Chooses and displays our attitude:
Once we get our ‘Why’ – the reasons why we do what we do, we are in a better space to be able to choose how we react to the work that is required of us to undertake. We can choose our attitude – whether we pick a positive attitude, or whether we pick a negative attitude. The choice we make can result in a huge difference to how we perceive the task at hand and how others perceive us as we undertake the task.

Adopts a growth mindset – including a learning mindset:
When we have a growth mindset we understand that we can learn, change, adapt, improve and generally stay on the journey to being the best we can be. When we have a fixed mindset, we tend to feel limited, that we are at the level we can attain in the world, there is nothing else we need to learn, and that that is simply the way it is. We explore how we can help move people from a fixed mindset to a growth mindset.

Has a high level of understanding and curiosity concerning Work-As-Done, Work-As- Normal and Work-As-Written:
As a leader, we tend to have opinions about how work is done in our patch. We often write down rules, procedures, standard ways of working, ‘safe systems of work’ et cetera and then we believe that this is how the work is then being undertaken. In the real world, however, the way that work actually gets done (WAD) does not always match how we think it is being done (WAW). Sometimes an individual does something that is different to what everyone else is doing and sometimes the way the work is normally done by many in the group (WAN) does not match how the written method or procedure has it being done. Leaders need to be curious about all three.

Understands their own and others’ expectations:
We all have expectations – of ourselves and of others. We all need to have a shared view of how expectations can be formed, shared, understood and translated into behaviours and conversations. As an example in the book, I share my thoughts on expectations regarding the creation, use of, and management of procedures – following accurate procedures thoughtfully works for me.

Listens generously:
Listening is the most important skill a leader can possess – it is an art and a skill that can be learned and practiced. Generous listening is all about paying attention to, being curious about, and otherwise focusing on the person being listened to, rather than having the focus on what the person doing to the listening wants to hear.

Understands the limitations and use of Situational Awareness:
We, as human beings, are not capable of keeping an eye on everything that is going on around us – it is simply not possible. Deciding what to keep an eye on and how to keep an eye on it are key to using situational awareness here. Aligning mental models before, during and after an activity is super-important.

Plans tasks using tools such as the Efficiency-Thoroughness Trade-Off (ETTO), Risk intelligence, and a suitable wariness for the effectiveness of controls:
One activity that links together the ideas of the ETTO, Risk Intelligence, and Chronic Unease, is one that we all do all the time and is essential to getting things done in the workplace – that is the practice of planning. Planning is one of the foundation elements of getting the creation of safe work right. We have to strike a trade-off between being efficient and being thorough in all things, including our planning.

Controls risk:
Controlling risk is a balance of people trying to keep in mind; why they doing what they’re doing; what the level of situation awareness is; what their level of risk awareness is; what their mental models are; what they put into their planning activities; what the risk control measures they choose (hierarchy of control for example); their expectations regarding failures; preserving options; being mindful; and of course what tools and equipment, procedures and systems they need to use.

Applies a non-directive coaching style to interactions:
Coaching, and using a coaching style in management, is such a wonderful way of making a profound and positive difference in helping people bring out the best in themselves.

Has a Resilient Performance approach to systems development:
One effective way of building sound and useable systems is to apply the lens of resilience over the creation of the system as you create it. I want to convey resilience in its positive light, so have tweaked the definitions a bit, hopefully without losing any of the impact: Resilience Engineering is all about: Knowing what to do when things start moving away from going right; Knowing what to look for or being able to monitor things that need to be in place to ensure things go right; Knowing what has happened and being able to learn from the experience; And Knowing what to expect or being able to anticipate developments into the future.

Is preoccupied with failure:
When things are going well, leaders should worry. When things are going not so well, leaders should worry. Leaders need not be obsessed by what could go wrong, they just need to be preoccupied with it…

Adopts an authentic leadership approach when leading others:
True effective, caring, powerful and sturdy leadership is all about people being themselves only more so. Leadership is about setting context, direction, purpose and the ‘Why’ of work. Leadership is all about being authentic, about leaders being themselves, with their stories, their backgrounds, their foibles and their failures. Intent-based authentic leadership and a strong motivation to help their peers and teams to be the best they can be is most assuredly the way to go.

Like most things we do in our lives, both in our work and outside of our work, we need to clearly understand why we do what we do. Those who know why they do what they do function at a higher level than those who simply know what they do and how they do it. Those who know why they do what they do get to live their passions. Those who know why they do what they do don’t consider their work ‘work’, it is their lives. This is just as true for an element of work such as a workplace incident investigation as it is for bigger questions like career and the effort we put into being authentic in our leadership. Those who know why they are investigating a workplace incident get the point that the process of doing the investigation is a learning experience each and every time and is also an opportunity to show authenticity as a leader. Those that just want to find out who did what and what controls to put in place to make sure that person doesn’t do it again tend to see investigations as something that must be endured, a chore, and something to be gotton through with as little pain as possible. It will be just another box to tick. This is a missed opportunity as this is the way NOT to learn from an incident.

We have a choice when we investigate a workplace incident – we can choose to learn or we can choose to blame. It is very difficult to do both. In order to learn from an incident, we need to have a growth mindset and be very curious about what elements conspired to create the incident: We need to seek to understand what part our leadership played; what aspects of our culture contributed; what systems, processes, environments et cetera played a part; we need to land on how all the interrelatedness of these elements set up a situation where things did not quite go as we planned them. To set up to do this, we need to do a few things:

1. Spend time as an individual and as a leadership team (if you are part of one) exploring the ‘Why?’ of incident investigations
2. Be curious, have a growth mindset, be keen to learn from the incident
3. Establish an investigation team that has a good level of diversity (of thinking):Independent leader, Independent investigation process facilitator, Subject matter experts, and Real people (Front line workers who really know how the work is normally done, not only how we think it is done)
4. Give them the time and resources to do the investigation justice
5. Use an established method such as Work-As-Written, Work-As-Normal, Work-As-Done based 5- Whys, or something more complicated if needed
6. Trust the team to come up with the answers and encourage open and transparent discussions of incident drivers.

I want to share some of the drivers for these team member choices.

Independent leader: The reason we have independence in the investigation leader is that you cannot have the fox looking after the hen house – you cannot mark your own homework. In order to get into the nitty gritty of a localised system, culture or leadership element that contributed to the incident, you need to have an appropriate level of independence in the leader. A manager from another department is usually sufficient for this role.

Independent investigation process facilitator: The job of the facilitator is the toughest in the team. They come armed with a proven process that when followed using a facilitation style, will maximise value-adding participation by the team members and getting to the nub of the issue. My advice is to develop a small number of facilitators and ensure they are supported, given feedback on their work and developed over time. They will help facilitate learning. They will also be able to tweak the investigation process to suit the incident. Most investigation methods are based on models and the facilitators need to understand them and then use them to help us get where we want to get to and not to get all pedantic on process. Avoid too much Newtonian cause and effect stuff for example. Let the process flow and keep it simple. The facilitator will help with all of this.

Subject matter experts: Getting a couple of people at the top of their field really helps the investigation team understand the technical aspects of the specific work involved in the workplace incident. This greatly increases the team’s understanding of how the job needs to be done in a certain way and why.

Real people: Front line workers, whether nurses, doctors, engineers, maintainers, pilots, mechanics or operators, know how the real world works. Managers and most leaders do not. We think we do, but the way work is done (Work-As-Done) does not always equal the way we think it is done or the way our systems and process say it is done (Work-As-Written, or Work-As-Intended)

So, after we have the investigation team is all sorted, it is worth stopping and re-considering the team’s mindset. Does it have a growth mindset, where it is ready to learn, expand and grow? Or does it have a fixed mindset, focussed on what is broken and fixing it. The other mindset to consider is one of whether the team has a finite or an infinite mindset. By this, I mean whether we want to win the short-term game of preventing occurrence, or whether we want to play the longer-term game of taking advantage of the incident to help us learn what we can do to further build our approaches to getting it right into the longer-term future. This is the classic choice between the finite game and an infinite game scenario Simon Sinek talks about his new book The Infinite Game which came out in 2019 and is published by Penguin Business – well worth a read by the way.

So, in summary, think about how you think about investigations; think about why investigations are critical to learning. Think about setting up the balance and diversity of thinking in the investigation team for success, and then maintain your curiosity and authentic leadership support for the process, aim to learn not to blame, strive to recognise the need to understand how we normally get it right (Work-As-Normal) in order to understand how we got it wrong (Work-As-Done) and generally use an unfortunate incident as an opportunity to display your authentic and caring leadership characteristics.

Further reading: Simon Sinek, Eric Hollnagel, Sidney Dekker, Ian Long

There is no difference between a great leader and a great safety leader.

I believe that through strong relationships driven by authentic leadership; setting clear expectations; applying a coaching style; developing a learning culture in their team – especially learning from when we get it right; listening generously; being appropriately wary of the effectiveness of risk controls; and having a high level of curiosity as to how work is actually done rather than how we think it is being done, we will achieve greatness in safety and greatness in leadership generally.

Let’s have a look at some of these:

Building Relationships

The attention we pay as a leader to the relationship we have with our team can make or break the rest of the work we do in the leadership space. Getting relationship, and hence trust right gives us permission to engage, coach, mentor, guide, teach, encourage, inspire and otherwise help our team members be the best they can be. Getting relationship wrong can make us and our team unhappy, resentful, untrusting, discouraged, uninspired, and dysfunctional as a team with all the consequences of that situation, including adverse safety outcomes.

Leadership style
The best and most effective leadership style – by a long way – is authentic leadership; leaders leading from who they are. They know who they are and why they do what they do. They act according to their values and principles, care for their people, have good relationships with peers and followers, are real, come across as genuine, have a growth mindset, admit their mistakes, recognise that leadership is an improvisational art, know that leadership is not about power, persuasion and personality, and truly believe it is all about helping others be the best they can be.

Setting expectations
Setting expectations is a critical activity that never stops. It is based in relationship and conversation. Expectations need to be shared otherwise they are simply wishes. For example, we need to have conversations around our expectations on ‘procedures’, what we want with respect to any ‘drift’ people experience and we need to have conversations about our expectations related to ‘Just Culture’. The last is important so that we have absolute clarity around our behaviour when something does not go to plan.

I feel that procedures are very interesting tools of the trade. On one hand they play a critical role in the creation of safe work. On the other hand they are the bane of our existence. There are too many of them; they can’t always be followed; they can’t easily handle unexpected interruptions; they can’t guarantee safety; they’re usually not accurate; they’re sometimes simply dumb; and they are often written by people who do not actually do the work.

I love the idea of ‘freedom within a framework’ that Sidney Dekker talks about. It roughly means that we provide workers with guidelines and context about a task but do not tell them exactly how to achieve it. They need to get together and think about it, come up with a plan and then execute it. They have control over the nitty-gritty and this helps them think, make decisions, and act in alignment with the intent.

The most important expectation is that all procedures are accurate, both from the perspective of the business and, critically importantly, from the perspective of those who need to use them in their work – the end-users.

I support a simple process that can easily be applied when you are asked to approve or sign off on a new or modified procedure and that can help us have accurate procedures: Get a couple of people together as you review (or approve) a procedure and collectively answer a few simple questions along the lines of:
1. What is the value to safety of this procedure?
2. What is the value to the end user of this procedure or change?
3. Will it help us in the journey to ‘always getting it right’?
4. How does this change add or reduce complexity here?

One of the biggest issues we all face is drift – both within procedures and within processes. We need to be cognizant of the fact that work undergoes a slow and steady disconnection from the procedures that are intended to describe how the work is to be done. This drift, or sometimes called practical drift is happening and continues to happen. We need to help our people understand this and encourage them to keep an eye out for it– this is harder than it looks. Keeping an eye on how work is actually being done on a day-to-day basis and comparing it to the ‘work-as-written’ helps here.

We also need to acknowledge that sometimes things do not always go according to plan. People make mistakes, mis-plan their work, take well-intentioned shortcuts, do work that does not have the desired outcome et cetera. When this happens we must try to learn from it. I hope we have learned from the past in this space. Many of us used to apply a “Just Culture” process. We have now learned that you cannot apply a culture – you can only do things that may promote or impede its creation. So we should now be applying various activities and have various conversations to ensure we minimise blame and maximise learning. With the aspiration of achieving a culture that is just.

Overall, we need to constantly, consistently and comprehensively share with our teams that there is a difference in making sure things going right, and attempting to stop things going wrong. We want things to go right.

A coaching style
Adopting a coaching style, preferably a non-directive coaching approach is critical and an important skill all leaders should possess. It needs to be taught, supported, nurtured, and practiced over a long period of time.

Coaches, and leaders managing using a coaching style, need to know that the answers to problems lie within the capacity and expertise of the player, not themselves. This is aligned to the idea of intent-based leadership that Marquet so masterfully discusses.Doing the thinking for players is simply a waste of time – getting them to think by asking great questions and listening to the answers is the way to go.

Creating a learning culture within the team
Teaching is not learning. Learning occurs in the mind of the person doing the learning. This is why a person at the front of a room reading a PowerPoint presentation for two days in an induction has nothing to do with learning. We should all know this by now …

We need to seek to learn during every conversation, activity, induction, workshop, incident, and in-the-field interaction.

What I think is a good example of embedding learning into daily activity is talked about in my last blog. I hope you have all read it. It is called Learning from Normal Work. If not, take a break now and read it. OK. You are back? Let’s keep going.

In order to focus on learning we can also talk about the fact that human performance is variable and that unexpected events come from both good decisions and bad decisions. This means that we do not simply focus on bad decisions when investigating incidents. Human performance variability in neither positive nor negative, it just is. We need to try to learn just as much from low-level incidents as from major incidents. It is even better that we learn from normal work, when things normally go right.

Overall, in an effort to encourage learning, we need to remind people to speak up. More importantly, to support this, we need to spend a lot of time making sure, we, the leaders, listen. Listening is the most important skill a leader can have. And to listen generously is to listen with intent, to listen to understand, to listen to learn, and not to listen to interrupt and tell people how it is. This is not always easy and definitely needs practice.

Being wary of control effectiveness

When things are going well, we should worry. When things are going not so well, we should worry. We should not be obsessed by what could go wrong, just preoccupied with it … This preoccupation with failure is sometimes called chronic unease.

I first read about chronic unease in James Reason books and loved the idea – as long as it is not taken to extremes, which some leaders have done in the past. It is all about a healthy scepticism about whether stuff is going to be OK or not. I have heard the phrase ‘wariness of risk controls’ and ‘vigilance’ popping up quite often in references about chronic unease.

In keeping with the concept of wariness of risk control / chronic unease, one of the ways we can ensure we maintain a preoccupation with failure is that we can take on a systems perspective that tells us we must look beyond the individual behaviour, mistake or ‘error’ and understand the underlying structures, culture, leadership and system interrelationships that create the required conditions for a failure to emerge.

We need to encourage people to have sufficient unease such that they approach each day as if something will go wrong, and then plan for it.

Mindset
Whether we have a growth mindset – believing we can all learn, get better and grow, or whether we have a fixed mindset – where things are simply how they are and that is it, will greatly impact our thoughts and hence our words and actions.

A growth or fixed mindset can also manifest in the way we, as leaders, search out for and listen to expertise. If we have a fixed mindset and believe that we know all we need to know and do not defer to expertise as and where it resides, then trouble ensues.

Even how we ask our people to do things and how we ask questions reflects our mindset. For example, questions like ‘What are we doing that annoys you?’ ‘What can we do to learn from you?’ show a growth mindset in the leader asking the questions.

Resilience Engineering

As I hope you are already aware, resilience engineering has four potentials of interest to us, and these we need to encourage, measure and talk about. These are the potentials to; Respond, Monitor, Learn and Anticipate:

Respond: Knowing what to do when trouble goes down, or is about to go down.
Monitor: Knowing what to look for or being able to monitor things that could go wrong.
Learn: Knowing what has happened and being able to learn from the experience, and
Anticipate: Knowing what to expect or being able to anticipate developments into the future.

We should think about Resilience as we do our in-the-field leadership conversations, checking out how resilient our procedures and systems are, and checking whether the teams doing the work have; thought about what could go wrong; are keeping an eye on what is going on as issues develop; and have plans to bounce back from the face of adversity back into safe production without the event impacting. We need to identify resilient performance and celebrate it, understand it, and learn from it. i.e. establish how much of Work-As-Normal represents resilient performance on a day-to-day basis?

I actually like a bit of a tweak on resilience. The intent is not to change what the resilience potentials mean but to focus them on ‘getting it right’:

Respond: Knowing what to do when things start moving away from going right.
Monitor: Knowing what to look for or being able to monitor things that need to be in place to ensure things go right.
Learn: Knowing what has happened and being able to learn from the experience, and
Anticipate: Knowing what to expect or being able to anticipate developments into the future.

Conclusion
It has been said (by Edgar Schein and others), culture and leadership are two sides of the same coin. We sometimes forget that as leaders we create the culture we see in the bits of the organizations that we play in, and that what we think, say and do can make a huge difference… positively, or negatively to the safety of our people.

To reiterate, I truly believe that the few things a leader must do every day in order to most powerfully assist in the creation of safety and production are associated with building strong relationships driven by authentic leadership, applying a coaching style, listening generously, being appropriately wary of the effectiveness of controls, and having a high level of curiosity around what is driving any differences between Work-As-Done, Work-As-Normal and Work-As-Written, all balanced with a growth mindset.

Authors you should read (That the above thoughts were drawn from – and not in any particular order): David L. Marquet; Erik Hollnagel; Simon Sinek; Jim Wetherbee; Carol Dwyck; Sidney Dekker; Scott Snook; Diana Vaughan; James Reason; Karl Weick and Kathleen Sutcliffe; Rob Goff and Gareth Jones; Steven Shorrock and Claire Williams; David Woods; John Maxwell; Bill George; Sharon Parks; Amy Cuddy; Joe MacInnis; Art Kleiner, Jeffrey Schwartz and Josie Thomson; Ron Westrum; Andrew Hopkins; Daniel Kahneman; Art Kleiner, Jeffrey Schwartz, and Josie Thompson; Corinne Bieder and Mathilde Bourrier; Adam Higginbotham; John Whitmore; Myles Downey; Max Landsberg; Ronald Heifetz; Sharon Parks; Carol Wilson; David Rock; Kerry Patterson, Joseph Grenny, Ron McMillan and Al Swizler; Ian Long; J.G. Mahler; Todd Conklin; Steven Poole; Tom Nichols; Peter Senge; Chesley B Sullenberger III; Art Kleiner, Jeffrey Schwartz, and Josie Thompson.

If you are after specific books by these authors, just drop me a line.

Enjoy

Ian

Q. What do you get when you cross a field leadership conversation with a micro investigation / mini learning team activity?

A: A Learning from Normal Work (LNM) activity

A lot of us do things called variously; Field Leadership, Felt Leadership, In-The-Field Leadership, Visible Safety Leadership et cetera. The idea is to engage with our workers as they do their work. The purposes vary a bit but are generally about helping people create safe work and be the safest they can be.

Also a lot of us do investigations when things go wrong. There are many ways of doing this and the one I want to talk about a bit later on is called Learning Teams. If you want really get your head around learning teams talk with, read, or listen to Todd Conklin.

Not many of us do investigations when nothing has gone wrong. And not many of us use a positive leadership interaction in the field as the basis for an investigation. This is exactly what I am proposing here today … Let me explain:

The other day I was helping a bunch of people get better at workplace safety incident investigations. We were talking about leadership roles within investigations and the fact that leadership conversations before an incident should be the same as leadership conversations after an incident – attempting to understand differences between how the work is being done and how we think it is being done. It got me thinking.

I have spoken previously about the importance of the need to understand how work is normally done being an essential component of doing an investigation, Extending this idea into our normal day-to-day activities as a leader is where I want to focus the conversation today.

Before we do that, especially for those of you who do not have any kind of Field Leadership process, it is worth going over what a Field Leadership activity might look like.

Overall, a Field Leadership Program is all about getting our leaders out into the field and undertaking verifications, observations and engaging activities for the purposes of identifying whether the way we think the work is being done matches the way it is actually being done. This occurs at a number of levels and the primary driver is the creation and improvement of “safe work”, rather than the finding and correcting of “unsafe work” and “un-safe conditions”. One such process is called a PTO (Planned Task Observation):

Planned Task Observations:
The why – To identify and understand any differences between the way the work is intended to be done (as per the procedure / process) and the way it is actually done in the field so that we can learn and share when our people have identified better ways to do the work and, over time, align the Work-as-Done with the Work-As-Intended through procedure improvement, sharing of learning and behavioural changes if required.

How – A procedure is reviewed prior to the observation. It is then taken into the field and a conversation started with a crew, exploring how they are actually doing a task. Many topics may be covered during the conversation in order to get a sense of the level of understanding of the crew as to the control of risks et cetera and whether they do, or do not align with the requirements of the procedure. Examples of the sorts of topic covered in PTOs could include:
- Assumptions by the crew about how the work is being conducted as compared to how we think it is in the procedure.
- Level of understanding of the responsibilities and activities of the team members for the task.
- What they think will go right. Or go wrong.
- What they think about the procedures.
- Whether they have plans for what to do if it all turns south.
- If any drift has occurred over time in the practice or the procedure.
- What could, or has, happen(ed) that may influence their ability to follow the procedure.
- What they have to keep an eye in the environment of the task.
- What level of Situational Awareness is needed, and on what, specifically.
- What is in the line-of-fire that can bite them.
- What is going on in relation to critical controls that they should be considering, especially if there are some in the procedure of interest.
- Discussion about any anomalies in the workplace that do not appear to have been there before. – Anything that stands out as different.
- Do they have a plan if something does go wrong?
- What if…?
- How they built their mental model of the task prior to starting it. (hazard, risk control, SIMOPs et cetera)
- What usually goes right here, but may not today.
- What will happen to them and the team if they do not control the risks.

NOTE: The intent of these topics is to raise the level of conversation, through which it can be established whether the procedure has been followed, and more importantly why, and /or why not. Of course, this is just a quick brain dump of engagement conversation topics possibilities. The intent is that these are not a set of questions but rather a conversation.

When we do a PTO and discover a part of a task that is being undertaken in a way that differs from what is outlined in the procedure or work instruction, we would conventionally do one of two things: One is to tell the worker to change their behaviour and the other is to change the procedure to match the way the work is being done. I suggest that there is a third way that will better help to create safe work going forward. It is to undertake a micro-investigation – a mini-learning team – based on what we have observed and only make changes after that.

Let’s work through an example. You have decided to explore some scaffold construction work and have grabbed the scaffold procedure and had a look through it prior to going into the field. You have decided to focus on the controls scaffolders are using as they erect scaffold. You plan to look out for foot plates, harness use, particularly attachment points and how the scaffolders ensure no unauthorised people access the scaffolding during construction. You trot off into the field armed with the scaffolding procedure and start chatting with a work team building some scaffold. You notice that they have a piece of danger tape across the entrance but you recall that the procedure requires a drop bar to be installed rather than danger tape and so you start asking the scaffolders about this. They say that they quite often use danger tape as it is easier to duck under when they are going in and out of the scaffold as they are building it. Rather than making a big fuss about it and telling them to put a drop bar in, you decide to visit some other scaffolding erection going on to see what Work-As-Normal is – how others secure their scaffold entrances during construction. Over the next day or so, you visit five scaffold construction crews at work on the shutdown. Three out of the five had used danger tape, one had used a drop bar and one simply had the scaffold tag removed from it’s holder as the control to prevent unwanted personnel from entering the scaffold.

The following morning you hold the scaffold crews back after the morning pre-start meeting for thirty minutes and run a mini learning team activity. The intent is to explore and understand the variability amongst the crews as to how they secure scaffold entrances during construction. The format is a conversation with participation, hopefully, by all present to explore their level of understanding of what the normal practice is and more importantly why it is what it is. It turns out during the conversation that you are the only business that they do work for that requires drop bars and all other companies only require danger tape or just leaving the scaffold tag out of its holder as a control to prevent unwanted people from accessing the scaffold as it is being built. They are simply not used to installing a drop bar – they forget to do it.

You then move the conversation into what they think can be done about it and what good practice would look like. The unanimous voice is a request for you to change the procedure as danger tape is, in their opinion, just as effective a control as a drop bar is. You understand their wish for simplicity and alignment with other companies and agree with their request. You walk away from the conversation agreeing to change the procedure and allow tape to be used in lieu of a drop bar. A half hour conversation has resulted in a more accurate procedure, effective buy-in by those who control the risks (the scaffolders) and less of a gap between Work-As-Done and Work-As-Intended. Everybody is happy.

Even when you are simply being out and about engaging with the workforce, you can employ a similar approach. Next time you find a discrepancy between Work-As-Done and Work-As-Intended, rather than extolling the virtues of following procedures, strive to understand why the work is being done the way it is being done.

Leadership behaviour – The few things that can make a huge difference to safety… positively, or negatively:

One of the most significant leadership factors that appear during workplace “accident” investigations is a lack of clarity (or perhaps a lack of understanding) amongst leaders of the size of the shadow their behaviour casts. What is often underestimated is the impact the leader’s thoughts, words and subsequent actions can have on their team’s behaviour, their team’s approach to safety and the beliefs their team members have of them as a leader.

I am not aiming to share my complete thoughts on leadership with you, but rather to talk through those few leadership ideas, behaviours and actions that can make the biggest difference in creating ‘safety’ – getting it right, and in workplace incidents – getting it wrong.

My goal in this blog is to encourage you to think a bit differently about how you go about your day-to-day leadership activities.

The topics I cover are in an order that I believe is important and are in some ways hierarchical in nature. They are certainly not an exhaustive collection of actions and I openly acknowledge there are many other topics and behaviours that also are capable of making a difference out there in the real world.

It is all about ‘Relationship’

I suppose that in talking about ‘relationship’, I am not off to a good start if this blog is supposed to be all about behaviours and actions, but the overarching topic of ‘relationship’ is way too important not to start with. The attention you pay, as a leader to the state of ‘relationship’ you have with your team can make or break all the rest of the work you do in the leadership space. Building trust is done in many ways by the positive enactment of, inter alia, the other behaviours and actions I discuss here. Getting ‘relationship’ right gives you permission to engage, coach, mentor, guide, teach, encourage, inspire and otherwise help your team members be the best they can be. Getting ‘relationship’ wrong can make you and your team unhappy, resentful, untrusting – basically not a functioning team – with all the consequences of that situation, including adverse safety outcomes. I will not talk in detail about ‘relationship’ related behaviours and actions here as I feel the rest of the blog is ALL about that.

Leadership style
• Coaching Style, Field Leadership, Just Culture.

I have clumped ‘Coaching Style’, ‘Field Leadership’, and ‘Just Culture’ under the general topic of ‘Leadership Style’ as they are all intimately related.

I believe the most powerfully impacting leadership style you can adopt through your thoughts, words and actions is one of authenticity – of you being you. In order to make the biggest difference in safety you must be you, and more. Adopting some autocratic or copycat style of leadership that is not authentic is a waste of time and your team will; a) see straight through it as you behaving differently from your values sticks out like dog’s ears, and b) become confused at the inconsistencies that will inevitably leak through the façade that is not you.

Consistency in your behaviours is key here, Your people need to see that your leadership style does not flap around like the tail of a fish stranded on a sand bank, but is steady. Your leadership and behaviour will not always be perfect and correct of course, and exposing your weaknesses is OK as long as you are being you.

Learning all about intent-based leadership (David L. Marquet – Turn The Ship Around), seeing if it aligns with who you are, and then practicing it may also make a huge difference to the impact of your leadership and hence the behaviour and actions of those around you. This aligns with a coaching style of leadership. Asking rather than telling, giving context rather than directions, being curious rather than questioning, having conversations rather than monologues, and seeking out (and listening generously to) expertise are all actions that can truly transform your leadership and how you are seen by your teams.

I have included ‘Field Leadership’ here as it represents the manifestation of your leadership in the field – where people meet the workplace hazards and where they control risk. Leadership in the field through conversation is where the rubber hits the road and where people actually see and hear you as a leader. Too much telling and not enough curiosity and listening in your actions will undo any other words you may utter in meetings, pre-start meetings or in emails.

If you see field leadership activities as simply something that must be done to keep the boss happy and KPIs achieved I believe you are doomed as a leader. If you treat field leadership activities as great opportunities to make a difference, to really impact the likelihood of getting work right (safety), then, provided you are authentic about it and not formulaic in your approach, then all is good. . I have often seen during investigations field leadership activities being done prior to an incident but not being effective in correcting a known normalization of deviation, set of non-compliances to process, or correcting known inaccurate procedures.

The same applies to ‘just culture’. It is very important that any just culture process you apply is done so consistently. This is more important than anything else about the process, including the consequences. It has been said many times by some for the greatest current safety thinkers “you can either learn or blame – you cannot do both”. And there is not a much more destructive leadership behaviour than blaming.

In a nutshell, be authentically you, only more so.

Wariness of Risk Controls
• Chronic Unease, Feral Vigilance, Expectations regarding procedural compliance, Curiosity in WAD, WAN and WAI, Normalization of Deviance / Drift, Acceptance of the level of quality of procedures.

I first read about chronic unease in James Reason books and loved the idea – as long as it is not taken to extremes, which some leaders have done in the past. It is all about a healthy scepticism about whether stuff is going to be OK or not. I have heard the phrase ‘wariness about risk’ and ‘vigilance’ popping up quite often in references about chronic unease and I recall a discussion in one of Reason’s books about ‘feral vigilance’ used by Western Mining Corporation (now BHP) which also points to a constant look-out for what could go wrong implied by chronic unease. So, what does the behaviour or action of a leader look like if they possess chronic unease and how can it impact safety?

Leaders who show chronic unease ask questions in order to encourage their team to question the way they work. They ask questions in order to encourage their team to question the accuracy of the procedures they are expected to use. They ask questions in order to encourage their team to challenge any normalization of deviance and drift. They ask questions in order to understand for themselves what is driving any differences between Work-As-Done, Work-As-Normal and Work-As-Intended (Prescribed).

This questioning approach will drive openness and ‘safety’. Doing the opposite, intentionally or unintentionally, will drive the opposite. i.e., if you demand procedural compliance, you may drive violations. If you are not always questioning and exploring any gaps between Work-As-Done and Work-As-Intended, Work-As-Normal will drift away from Work-As-Intended and increase the likelihood of an incident. If you are more interested in the fact that a Task-Based-Risk-Assessment has been completed, than being extremely curious as to its quality, don’t be surprised when somebody gets hurt or killed because a critical step was missed or risk not controlled.

Mindset
• Growth or Fixed?

Last, but certainly not least, we need to talk about how a leader’s mindset can impact safety in their team. Whether you have a growth mindset – believing we can all learn, get better and grow, or whether you have a fixed mindset – where things are simply how they are and that is it, will greatly impact your thoughts and hence your words and actions. I have seen during workplace incident investigations, the impact of a fixed mindset. It can manifest as leaders not providing the right human resources (people) for risk assessments, training and field leadership activities et cetera. The right resources doing what they need to do for these activities has a direct impact on the likelihood of getting it right (safety) or wrong. The growth or fixed mindset can also manifest in the way leaders search out for and listen to expertise. If they have a fixed mindset and believe that they know all they need to know and do not defer to expertise as and where it resides, then trouble ensues.

In summary, just like the fact that your shadow late on a clear summer’s afternoon is much larger than you are, so too your leadership shadow is much larger than you are. The way you think, speak and act plays a direct role in the way your people think, speak and act. Your behaviour therefore directly influences the safety of your people. If you do not display authentic leadership, apply a coaching style, listen generously, have a nice level of chronic unease, and have a curiosity to what is driving any differences between Work-As-Done, Work-As-Normal and Work-As-Intended, all balanced with a growth mindset, your actions may well be directly and adversely impacting the health and well-being of your people, even if that is not your intention.

As it has been said (by Edgar Schein and others) culture and leadership are two sides of the same coin. We sometimes forget that as leaders we create the culture we see in the bits of the organizations that we play in, and that what we think, say and do can make a huge difference… positively, or negatively to the safety of our people.

To reiterate the points, I truly believe that the few things a leader must do every day in order to most powerfully assist in the creation of safety is through strong relationships driven by authentic leadership, applying a coaching style, listening generously, being appropriately wary of the effectiveness of controls, and having a high level of curiosity to what is driving any differences between Work-As-Done, Work-As-Normal and Work-As-Intended, all balanced with a growth mindset.