I don’t often have the luxury of time to watch television or see movies, but over the Christmas holidays I actually sat with my children and watched a Spider Man movie. Now I’m not totally ignorant about Spider Man – from watching cartoons when I was younger I still remember the theme song from the cartoons on television – you know the song – “Spider Man, Spider Man – does whatever a Spider can…”. I know that after being bitten by a radioactive spider, high school student Peter Parker gained the speed, strength and powers of a spider. I know that Spider Man can cling to most surfaces, has superhuman strength and the combination of his acrobatic leaps and web-slinging enables him to travel rapidly from place to place. But as I watched the movie, I soon learnt that there was something I hadn’t recalled from my childhood.
During the movie, I made a comment to my boys about how would Spider Man know the Green Goblin was about to attack him. My two boys, James and Jacob, simultaneously gave me “the look” in response to my question – you know that look that your kids give you that conveys the answer is soooo obvious and you are so not cool for asking? Well, after they rolled their eyes they said “Geez Mum, he knows something is about to happen because of his Spidey Sense!”. Spidey Sense ? I must have missed that bit from the cartoons I watched in the ‘70’s. So knowing I was risking more looks and eye rolling I asked them to elaborate.
James and Jacob explained to me that Spider Man has a super power referred as “spidey sense” – an extraordinary ability to sense imminent danger. A kind of ‘sixth sense’ if you like. The power apparently originates as a tingling feeling at the base of Spider Man’s skull – alerting him to the fact that there is danger nearby. When Spider Man says “my spidey senses are tingling” he’s got a feeling that trouble is coming or there’s a threat like the Green Goblin in close proximity.
So now that I was better educated on all things Spider Man, I watched the rest of the movie and it got me thinking about safety and how we sometimes have “spidey sense” about work places / sites. That little tingling, intuition or early warning detection system when we see subtle little clues that all is not well, that hazards are not controlled and the worry that one day it could all go wrong. The indicators can be subtle, intermittent and perceived as nothing to really worry about. However, you don’t have to be a Super Hero to realise that these indicators and uneasy feelings should be a sign that we really need to stop and assess how vulnerable we are.
An organisation with a mature safety culture doesn’t wait for an incident to occur to identify contributing factors and improvement opportunities. A mature organisation is never complacent, doesn’t accept low incident rates as a given that all is well and proactively seeks to identify areas of deficiencies and vulnerabilities. This state of mindfulness has been described by safety experts such as Professor James Reason and Professor Patrick Hudson as “chronic unease”. Mindful organisations exhibiting chronic unease maintain a high level of vigilance and are aware that despite normal functioning, danger can lurk below the surface at any time. Just like Spider Man who has “spidey sense” if the Green Goblin is nearby, mindful organisations are able to detect warnings especially from weak signals and they respond strongly to them. They detect variability and respond to it appropriately.
While mindfulness is a critical part of a mature safety culture, even organisations just starting out on safety improvement journeys can very simply make an assessment if there are “red flags” to be concerned about. These indicators of unsafe conditions should be treated as an early warning detection system that hazards are lurking, that vulnerabilities exist and one day they could escalate. The proactive use of the Organisational Factors in ICAM can be a good start in assessing how well an organisation has sound foundation policies and protocols in place to protect against vulnerabilities.
So what should we be looking for ? From a systems perspective, based on a selection from the ICAM Organisational Factors and other resources, I spent some time recently compiling a non-exhaustive sample list of headings and indicators that should be making anyone’s “spidey sense” tingle like an electric shock if they tick more than a few boxes.
EQUIPMENT / PLANT
- Incomplete equipment / plant registers
- Absence of original manufacturer’s equipment manuals / references
- Poor state of existing equipment
- Poor stock or ordering system
- Equipment not fit for purpose
- Unapproved modifications
MAINTENANCE
- Poor planning, controlling, execution and recording of maintenance
- Shortage of specialised maintenance personnel
- Equipment / plant frequently taken out of planned services due to operational pressures
- No system to ensure plant taken out of service slots goes back in
- Frequent unplanned maintenance (due defective / malfunctioning equipment)
- Breakdown before life expectancy
ORGANISATION
- Poorly defined departments or sections
- Unclear accountabilities, responsibility or delegation
- Excessive bureaucracy
- Individuals covering multiple roles
COMMUNICATION
- Lack of clear lines of communication
- No standard communication format
- Missing or excessive information
- Record keeping poor – information / records missing
INCOMPATIBLE GOALS
- Conflict between safe work and operations / production
- Imbalance between safety requirements and budget allocations
- Unrealistic work schedules / deadlines
PROCEDURES
- Ambiguous, outdated (legacy) procedures
- Operational / technical errors in procedures
- Difficult access for users / lack of knowledge of procedures
- Lack of procedures for some tasks
- Conflicting procedures
- No set review interval / mechanism
- Lack of compliance monitoring
DESIGN
- No standardisation of equipment or usage
- No adapting to human needs and limitations
- Poor designer – user communication
- Poor indication of system status provided by design (eg. on / off etc.)
TRAINING / ASSESSMENT
- Training not directed to all job / skill requirements
- Poor Training Needs Analysis (TNA’s)
- Poor training records
- Poor training outcomes
- A lack of skilled trainers
- Inadequate learning plans, assessment strategies and guides.
ORGANISATIONAL CULTURE
- Poor communication
- Evasiveness in responses
- Poor financial position
- Employees lack of information
- Diverse and conflicting values and beliefs of personnel within an organisation
- Unaddressed employee fears and anxieties
- Low levels of trust and stress
- Inconsistency between organisation’s values and actions
ORGANISATIONAL CLIMATE
- Disparaging remarks from employees
- Lack of mission for the organisation
- Poor team process
RISK MANAGEMENT
- Inadequate or poorly conducted risk management process
- Hazard identification process not systematic or covering all operations and equipment
- Level of risk analysis inappropriate for the degree of risk or phase of life cycle
- Inappropriate selection or poor implementation of risk control measures
- Outdated risk assessments
- Inability of personnel to explain risk assessments
- Lack of update / review process for risk assessments
- Inadequate monitoring of risk control effectiveness
- Incomplete, inadequate or out of date Risk Registers
MANAGEMENT OF CHANGE
- Inadequate or poorly conducted management of change processes
- Objectives and scope of change activity not clearly determined
- Inadequate risk vs benefit assessment of the impact of change
- Poor change implementation plan
- Poor communication of plan
- Inadequate monitoring of the effects of change to existing performance / safety levels
CONTRACTOR MANAGEMENT
- Inadequate or poorly conducted contract management process (eg. assurance, communication, reporting, review processes etc.)
- Poorly defined selection process (eg. cost vs performance / safety)
- No formal contractor evaluation procedure
- Contract not clearly defining HSE obligations, performance and reporting requirements
REGULATORY INFLUENCE
- Ambiguous understanding of regulations
- Lack of knowledge regarding regulatory requirements
- Poorly defined processes for documentary evidence
- Non-reporting of hazards due to fear of enforcement actions / penalties
- Inability to demonstrate compliance or satisfy legal requirements
ORGANISATIONAL LEARNING
- Incidents not being investigated systemically
- Lessons from incidents not communicated to the workforce
- Poor evaluation of corrective actions
- Inadequate incident reporting
- Lack of an incident databases that is intuitive for data integrity when entering information
- No trending of data (particularly more frequent low level incidents) to indicate key areas of vulnerabilities
VEHICLE MANGEMENT
- Lack of adequate, fit-for-purpose vehicles
- Lack of formalised trip management plans / safety verification (particularly in regards to rural areas / sole workers)
- Inadequate appreciation of vehicle management standards required (eg. sat phones, roll over protection etc.)
MANGEMENT SYSTEMS
- Lack of internal rules alignment with recognised Codes of Practice, Standards, Regulations etc.
- Lack of systems to encourage open reporting and communication
- Silo systems / databases that are not integrated (eg.various databases that do not “talk to each other” eg. incident management, quality management, environment management, maintenance management, risk management etc.)
RECORD-KEEPING
- Incomplete documentation
- Lack of documentation
- Difficulty in locating documentation
INADEQUATE RESOURCES
- Frequent workarounds
- Delays on repairs / servicing
- Excessive use of support staff
- Excessive / unplanned overtime
INADEQUATE TIME
- Procedures and routines are overlooked
- Requirement for excessive remedial work
- Lack of follow-up to check the quality of work completed
INAPPROPRIATE SCHEDULING
- Delays in the processing of tasks
- Personnel frequently operating beyond their rostered duty times
- Training opportunities are overlooked as personnel can’t be spared to attend training
INAPPROPRIATE WORK DEMANDS
- Personnel are required to undertake multiple roles within the organisation
- Personnel do not have the experience and/or skills necessary to undertake a particular role
- Fatigue management strategies are not taken into account in allocation of work
INADEQUATE LEVELS OF EXPERIENCE
- Promotion of personnel occurs rapidly within the organisation (without adequate skills / experience)
- Personnel are required to operate in areas that are in excess of their training and experience
HOUSE KEEPING
- Trip hazards (eg. dunnage laying around)
- Storage of items / spares not organised or categorised
So how did you go ? Did your “Spidey Sense” tingle a bit as you read through the indicators ? Proactively, the indicators listed are the type of issues that organisations should have under control, however, all too often are overlooked or considered unimportant in the face of operational / production pressures. Deficiencies in these areas will not automatically lead to an incident…however, they are an indicator an organisation is vulnerable. Deficient organisational factors may:
- produce adverse task / environmental conditions (or allow them to go unaddressed),
- promote or passively tolerate errors or violations or
- undermine or remove the system defences.
When this happens, these organisational deficiencies are not tolerated by the system any longer and an incident occurs. Too often I see organisations measuring their safety performance via paperwork and statistics. With this approach, safety is viewed almost as an abstract concept. Safety is so much more than ticking a box, filing a report, writing a procedure, conducting a toolbox or disseminating a risk assessment.
On my office wall, I have a copy of a quote from Sir Brian Appleton (Technical Advisor to the Cullen Inquiry – Piper Alpha) that I believe exemplifies the practical appreciation of safety.
“Safety is NOT an intellectual exercise. Safety is truly a matter of life and death, and is the sum and quality of all our individual contributions that determines whether our colleagues LIVE or DIE… on July 6th, 1988, 167 people died.”
Therefore, being proactive and assessing the efficacy of organisational factors – before an incident occurs – is of immense value in safety enhancement and incident prevention efforts. So, just like “spidey sense” has undoubtedly saved Spider Man many a time, don’t forget the value that chronic unease and mindfulness could have in protecting your organisation against adverse events such as: interruptions to normal operations, environmental incidents, equipment damage – or the worst possible scenario, injuries or fatalities.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
- Quality review of incident investigations using ICAM
- Trend analysis of organisational factors contributing to serious incidents
- Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Jo De Landre (Executive General Manager)
After 15 years with the Bureau of Air Safety Investigation (BASI), which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.
In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.
Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.
Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.
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