Why do we just NOT Learn:

Volume 6 Issue 2

TRANSFORMATIONALSAFETY.COM

APRIL 2010

We really should be scared!

oped to minimise
the risk of this
exact thing happening. As a
public company
it would be irresponsible
to
shareholders to
do anything else.

What a title for an

article abut Safety!
Believe
me,
I
thought long and
hard before deciding to write it this
way. Unfortunately
(or fortunately, depending upon your
point of view) my
frustrations
with
individual people,
and corporations,
demonstrating
toxic tolerance of
risk has caused me
more than a little
distress lately.
In a prior edition of Transforming Safety (Vol 5, No
3) I began an exploration
of Risk Tolerance and
its very direct association
with safety outcomes at
every level. The more I
am confronted with circumstances in safety, the
greater the involvement of
Risk Tolerance, as a fundamental
contributor
within the accident causation sequence.
I remember being told by

a very senior manager of

a global manufacturing
company, some years
ago now, that they had
purchased a competitors
company quite cheaply.
When I enquired why?
This was the response.
The entire Board was
killed in a plane crash
over Switzerland. Ouch!
Now many companies
have procedures and policies deliberately devel-

I was recently
doing some work
in Perth, Western
Australia.
Whilst there I
became aware of
a mining company that had
just experienced
one of the worst disasters that a company can
have. Whilst flying to a
potential mine site in the
African Congo an aircraft crashed into the
jungle. Every person on
board was killed. The
entire Board of the
Company gone in an
instant!
Now we know this sort
of thing has happened
before . That is why
(Continued on page 3)

Collective Mindfulness & its Effective Measurement.

Safety is traditionally
managed through an approach which we might
define as "command and
control". People are empowered to achieve targets, in most other areas
of business, using creativity and imagination.
When we set targets for
safety, we also tell people

how these should be

achieved. We give them
very "tight" procedures;
with very little room to
manoeuvre.
When taken to its limits,
the command and control
approach can often
amount to excessive
management control.
What also commonly hap-

Inside this issue:

pens is that the workforce actually challenges

that "control" by deviating, often in the smallest
of ways, from those procedures. Thus the excessive control then
constrains the completion of tasks. This form
of "challenge" also commonly ends up being
(Continued on page 2)

Special points of interest:

Why do we just NOT Learn

Collective Mindfulness & its Effective

Measurement

The SAFE-T-NET Integrated Behavioural

Safety Technologies

An entire Companies Board of Directors dies

in the one accident.

Risk assessment is just a journey toward the

lowest common denominator; read to see why.

TransformationalSafety.Com develops one of

the Worlds first Collective Mindfulness measurement tools. See why it is so important.

BEWARE of traditional BBS. Learn why it is

all so much more than this.

Collective Mindfulness & its Effective Measurement. (cont)

(Continued from page 1)

found within the causal chain of

some pretty significant accidents.
A traditional approach to safety then
tends to be top-down with managers
providing "advice" to their front-line
workers. The managers are in turn
guided by "Regulations". This approach is really not that helpful - remember Regulation is often determined as being the "lowest common
denominator" agreed to by a range
of politically motivated stake-holders.
The end result may well be
the production of a workforce that
can not think for itself. A workforce
such as this may make inappropriate
responses to novel hazardous situations - as they often are.
Consider this:- accident investigation
teams will often attend to the technical and procedural causes of accidents. (I pray we can one day move
past the "old" blame models). This
approach naturally leads those
teams to identify technical and procedural solutions. It is pretty easy to
see why this happens.
First, technical and procedural failings are easy to understand and
these types of solutions usually lie
with the area of competence of the
investigators.
Second, it is relatively straightforward to identify some corresponding
corrective action.
This approach gives the impression
that the problem has been fixed, but
the fix may turn out to not address
the deeper underlying causes. When
is the last time you included a human behaviour professional (safety
psychologist) on an investigation
team.
The root-causes of accidents though
often go back to "cultural" factors.
Management teams often feel impotent to fix these factors, or fail to recognise these factors, or believe that
the fixes are beyond the scope of
their responsibilities.
Attention will be given to these
deeper issues only if the environment and work culture actively considers the management of accident
hazards as part of day-to-day work
planning. Moreover, robust cultural
change will not be achieved through
any single process or initiative, but
can only occur through changing the
VOLUME 6 ISSUE 2

nature of conversations in the workplace.

I am reminded of what my colleague
Andrew Hopkins stated in his excellent book "Lesson from Longford"
about the Longford gas plant explosion in Australia in 1998 (we deal
with this in detail within the Anatomies of Disaster Seminar Series
designed by TransformationalSafety.Com). Hopkins said high
reliability organisations are characterised by a collective mindfulness
about the possibility of disaster.
Collective Mindfulness is a way of
looking at the internal foundations
that are percolating though the roots
of a business. Whilst Safety Culture
is something that we can often see,
via way of external symbology and
behaviours; collective mindfulness is
something even deeper within the
psyche of the business.
The initial position of Collective
Mindfulness within the pantheon of
pro-active safety management
strategies was developed by Professor Karl Weick. He posited that if an
organization spent time showing
focus and attention on five (5) general areas they would be well prepared, as an organisation, to confront the deeper challenges. Weick's
five Collective Mindfulness dimensions are:1.
Sensitivity to Operations
2.
Deference to Expertise
3.
Tendency towards Resilience
4.
Pre-occupation with Failure
5.
Reluctance to Simplify
Safety comes with a price. That
price may be the constant worry that
one has not done enough to achieve
safety.
It is difficult though for organisations,
and the members that function
within them, to actually grasp the
abstract nature of many of these
deep, below the waterline, factors
that are so critical to managing optimally safe operations.
The development of the Collective
Mindfulness Survey followed a
speaking tour of South Africa in
September of 2009. It was during
the introduction of concepts in safety
such as Situational Awareness,
and Collective Mindfulness, that
quite a reasonable question was

asked.
"David, this sounds like a very powerful way to think inside the business, but how do we really 'know'
that we are?"
What a brilliant question! The answer by the way was (up till now);
we don't. That's a little unfair. We
actually do, but the only way was to
conduct some sort of anecdotal review. There certainly was nothing
freely available that had, at its core,
a sense of empirical analysis. It was
for this reason that TransformationalSafety.Com decided to leverage
our globally recognised survey technologies and develop one of the
Worlds first Collective Mindfulness
measurement systems.
We began with the premise that we
needed a way that we could effectively get an "understanding" of the
five (5) Collective Mindfulness dimension from within the workforce
itself. Standard interview techniques
etc often result in all sorts of imported bias - so we discarded that
approach pretty quickly. Interview
techniques by the way are excellent
tools for putting meat on the bones;
what we require though, in the first
instance, is a skeleton. Otherwise it
just wont stand up.
The Collective Mindfulness Survey
uses the same proven technologies
associated with the globally recognized Transformational Safety and
Leadership Surveys. Within the Survey items are t we nty five
(25) distinct questions about aspects
of behaviour, and thinking, associated with Collective Mindfulness.
These are randomly delivered - and
there are negative framed items as
well (this assists with determining
the statistical validity of the overall
results). Also contained within the
Survey Tool are five (5) behavioural
(outcome) items. These are the
same five (5) items that can be
found embedded within the Transformational Safety Leadership Survey - and are included to allow for
comparative studies in the future.
The Collective Mindfulness Survey
was launched in January, 2010.
Contact TransformationalSafety.Com for your FREE Collective Mindfulness SurveyIndividual
Form.
Page 2

Why do we just NOT Learn: (cont)

We really should be scared!
(Continued from page 1)

there is a corporate procedure saying that Board

members and senior executives should not be all within
the one (1) aircraft.

curred. That is why there

was a procedure aying No,
don't do it.
Now it is easy to say, posthoc, that the guys should
have downed tools and sat
on the apron of the airstrip,
probably in the sun, and
waited around for who
knows how long until extra
transport cold be arranged.

So why were they all in the

aircraft on this occasion?
Was it a case of juts wanting
to get the job done quickly
and cheaply? Definitely not!
What happened here was a
constellation of factors that
just happened to all intersect
at that moment in time
which resulted in this horrific
outcome.
In this case the preparation
had been made (at least in part) for
Board members to travel separately
to the mine site that they were to
inspect for a capital purchase.
One group arrived. A senior board
member, who had his own personal
private aircraft, flew in to the central
airport as well. As they were about
to board two (2) separate aircraft
they became aware that the runway
at their destination was too short to
accommodate one of the aircraft.
At this point what would you have
done?
Would you have delayed the trip
until such time as a second aircraft
was available, which would be accommodated at destination?
It is too easy to say yes. I would
suggest that the majority of company boards would probably have
jumped on that aircraft.
By the way, this particular airline had
a known poor safety record; and had
been excluded from flying into many
of the Worlds international hubs.
So why did these guys not learn
from past known experiences. After all, that is why the Procedure
existed.
Let me suggest to you that just like
there were a constellation of interacting factors that led to this tragedy, so too were juts as many reasons why the fatal decision was
made.
For a start you dont get to be a
leader in business without taking
some risks. Or so the traditional

VOLUME 6 ISSUE 2

thinking appear to be. I happen to

have a different view. That is no
surprise to regular readers. So what
we have is a group of guys standing
around, who are used to being successful, thinking what's the problem.
They may, or may not, have mentioned the existence of a policy
which essentially said don't do it.
Even it they did have that conversationwe now know the decision
they made.
They may, or may not, have discussed the fact that it was to be
such a short flightso what's the
harm.
They may, or may not, have discussed the fact that they were all so
far from home standing on an airstrip in Africa, and waiting for another aircraft would mean they
would be away from home even
longer.
Who knows, We will never know.
What we do know is that many families have been irreparably damaged
by the loss of their loved ones.

Now it is easy to say, posthoc, that the guys should

have said thats it, and
gone back to their Hotels
and made arrangements to
conduct the inspection at
another time.
Again, none of that happened.
The purpose of conducting a Risk
Assessment on a piece of machinery, or upon a process, is to make a
passionless decision as to whether
we should accept, or reject, that
action.
If we were to use a very standard
globally recognised risk tool, such
as the tie-line risk nomogram - that
aircraft would never have left the
ground. It could have been the
safest aircraft in the world, and it
would not have left the ground.
Let me explain why.
The risk nomogram uses only three
(3) predictive dimensions;
1.

Probability

2.

Exposure, &

3.

Consequences.

Lets consider this decision of the

Board flying together against the
predictive dimensions of the risk
nomogram.
1.

What we do know is that a corporate

family has been irreparable damaged by the loss of close colleagues.

Probability = Conceivable
(but very unlikely)

2.

What we do know is this terrible horrific tragedy should NOT have occurred.

Exposure = Continuous (what

that means is that whilst on
the aircraft there is exposure
to the potential hazard)

3.

Consequence = Multiple Fatalities (what this means is, if

things go drastically wrong
what is the likely consequence)

Why do I say that so definitively?

Because it had already been considered long before this event oc-

(Continued on page 4)

Page 3

Why do we just NOT Learn: (cont)

We really should be scared!
(Continued from page 3)

When we put these three (3) dimensions together we see a result of High Risk. I have little
doubt that if the guys had stood
back from the path that they
were about to embark on, and
been told that they were about to
participate in a High Risk activity,
the outcome just might have
been different. Might not as well,
by the way.

Johannesburg?
So this whole question of learning
comes into play again.
1.

We hear it all the time when

considering all sorts of workplace accidents. Why did the
guy use a cut-off machine
without a guard?

2.

Why did the welder conduct

operations of the side of ladder near a potentially explosive atmospherethis guy
died

3.

Why do we see more rescuers entering confined spaces

without appropriate PPE
more rescuers often die than
persons trapped.

Again, we will never know.

Another thing we do know is that
the decision to abort risky behaviours is often a difficult one.
We seem to be hard wired, or at
least moist of us, toward achieving an outcome.
It is for this reason, and many
others that we seem almost predisposed toward taking the
famed shortcut. To read a little
more about this refer to Transforming Safety Vol IV, No 2 (April
2008).
So I am left thinking what would
have stopped this tragedy?
When I do focus on this I actually
do know that there are things
which would have resulted in all
these people being alive today.
That is what makes situation like
this, all the more tragic.
We just do not seem to learn. We
know, without any doubt, that a
business with a positive, robust
and resilient safety culture would
have not had their people get
on the aircraft.
Compliance with a well thought
out safety procedure would have
been so embedded within the
corporate, and individual, psyches that it is far less likely that
those guys would have gone up
the steps.
At this point I shall take a step
back and remind readers that
there was one young lady on the
doomed aircraft. She was a PA
to the Chairman - I would suggest it is unlikely her opinion was
even sought.
By the way, do you think for a
moment that the Company would
ever have booked their entire
Board on a commercial aircraft
travelling between Perth and
VOLUME 6 ISSUE 2

Allow me to continue on a theme

that has been percolating through
Transforming Safety for some years
now.
Why has BP not learned from the
deaths of fifteen (15) people at the
Texas City Oil Refinery?
On October 30th 2009 the US Department of Labour's Occupational
Safety and Health Administration
(OSHA) announced fines of
$87,430,000 in proposed penalties
to BP Products North America Inc.
for the company's failure to correct
potential hazards faced by employees. The fine remains the largest in
OSHA's history. The prior largest
total penalty, $21 million, was issued
in 2005. Guess who? That was BP
as well!!!
Safety violations at BP's Texas City,
Texas, refinery resulted in a massive explosion in March of 2005. BP
entered into a settlement agreement
with OSHA in September of that
year, under which the company
agreed to corrective actions to eliminate potential hazards similar to
those that caused the 2005 tragedy.
The eighty six million (US86M) in
fines came at the conclusion of a six
(6) month inspection by OSHA, designed to evaluate the extent to
which BP has complied with its obligations under the 2005 agreement
and OSHA standards. It is fair to say
that they were nowhere near any
level of compliance.
It needs to also be remembered

here that OSHA recommendations are

generally baseline levels of compliance:- certainly not what many of us
would consider up there in the realm
of Best Practice. So we are left with
clear indictors that one of the worlds
largest petro-chemical companies,
despite being found wanting in respect of the deaths of fifteen workers
(and injuring many more than that),
still does not see/feel the need to remedy those circumstances that multiple
investigations found required attention.
Even understanding the cut-throat
nature of the corporate world, I struggle to understand such an intransigent
attitude.
"BP was given four years to correct
the safety issues identified pursuant to
the settlement agreement, yet OSHA
has found hundreds of violations of
the agreement and hundreds of new
violations. BP still has a great deal of
work to do to assure the safety and
health of the employees who work at
this refinery," said acting Assistant
Secretary of Labour for OSHA Jordan
Barab.
This leads us to some very scary conclusions. When our employees go
looking for work-arounds, take shortcuts, fail to report, fail to remedy, walk
on by, etc; what are the really doing?
What they are most likely really doing
is just responding to the prevailing
culture (safety or otherwise) that is
alive within that work environment
etc. We find the question of safety
culture being explored by so many,
yet so many have no idea what it is.
So many more have no real idea how
to leverage the influencers within a
business to direct the safety culture
within the business toward the robust
resistance that is required.
When I speak to robust resistance,
that is precisely what is required.
What we need to see, is something
beyond the questioning attitude that
is so often written about.
It is fine to ask the question.
What is even more important though,
is having the strength of conviction to
act on the result. We now know that
the more natural state is to continue
with the behaviour, even though we
(Continued on page 5)

Page 4

Why do we just NOT Learn: (cont)

We really should be scared!
(Continued from page 4)

may acknowledge/recognise there

may be a high risk association
with that behaviour. Thats what is
scary.
One of the methods used to try and
gain a better understanding of
some of these behaviours, is the
study of what has been called
High Reliability Organisations
(HRO).
So what is an HRO?
A HRO is an organization that has
succeeded in avoiding catastrophes in an environment where normal accidents can be expected due
to risk factors and complexity.
Examples often given are the work
decks of aircraft carriers, nuclear
PowerStation's etc.
One approach which has become
quite synonymous with those organizations who trend toward the
HRO design has become known as
collective mindfulness. One of the
same guys who was instrumental
in refining the identity of an HRO
also happens to have been one of
the key individuals who developed
the Collective Mindfulness way of
thinking. His name, Profession Karl
Weick.
Now if Sundance Resources, our
welder up the ladder, or even BP
were mindful organisations, it is
quite likely that circumstances

would have turned out to be different.

Why is that?
Because one of the five key elements of a mindful organisation is
referred to as, a pre-occupation
with failure. What that means is that
the organisation is forever vigilant
for these things, particularly the little
things, that might just go wrong.
How often, when we conduct an
incident investigation into a big
accident, we find that it has occurred
due to a number of the little things
intersecting at that moment in time.
In a Mindful Organisation those little
things are far more likely to be recognised and appropriately dealt
with/resolved.
Within an organisation that encourages mindful leadership we would
see a sense of unease dripping
down through the layers of the organisation. Now, that is a good
thing. When we are a little uneasy,
we are far more likely to be somewhat more vigilant.
I recall when I was first taught to
drive a motor vehicle. This is a very
relevant environment to consider. In
many countries, once we exclude
the workplace, the roads environment is the most dangerous place to
safely function. Anyway my instructor of the moment made a very valid
point, and one that thirty (30) years
later I still apply. That instruction

were words to the effect of Always

assume the other guy is likely to make
an error in front of you, if you do that
then you will always be considering
how to escape. Never a truer message, and it has come in handy more
than once in my driving career.
Similarly a very good friend of mine in
South Africa who flies a little Jabiru
aircraft said to me late last year.
when you are flying you are also always looking for somewhere to land.
In other words the pilot is applying a
mindful approach to the task of flying

an aircraft.
Now, why should we be scared?
We should be scared because there
are very few organisations and/or
leaders who are actually mindful.
Our entire industrial system is
founded on a system that leaves us
prone to be mindless. That is certainly what you would have to say
about the BP organisation.
In the next Edition of Transforming
Safety I plan to explore the foundations of the Mindless Organisation.

The SAFE-T-NET Integrated Behavioural Safety Technologies

Essentially Behavioural Based
Safety, commonly referred to as
BBS, began existence as a suite of
interventions heavily grounded in
basic behavioural psychology. The
sort of stuff the late Professor BF
Skinner was famous for. We should
not forget that BF spent most of his
life working with rats. Indeed one of
the most famous tools for assessing
the outcomes of the behavioural
model is known as the "Skinner
Box". It is important we know and
acknowledge the history of where
BBS comes from. Having made
those observations BBS works!
Yes, BBS is an effective tool (or
more importantly, suite of tools) that
when implemented appropriately
can have a significant positive influVOLUME 6 ISSUE 2

ence on the safety outcomes within a

business. It is critical though we do not
try and think of BBS as some sort of
"magic"; it is far from that. Implemented poorly it will surely result in a
range of hazards being deliberately
"hidden"; they are still there and they
shall still bite you - one day.
You often hear behavioural safety advocates saying things like ninety percent of your accidents are caused by
unsafe behaviours; therefore if we can
modify the unsafe behaviours we get
rid of the accidents. Now, this is actually nothing new. It is actually the work
of H. W. Heinrich. Heinrich was an
Assistant Superintendent of the Engineering and Inspection Division of
Travellers Insurance Company during
the 1930's and 1940's. Thus the claim

that 90% (or a similar number) of injuries

are due to unsafe acts is a straight lift
of Heinrich's work.
Heinrich's conclusions though were
based on poorly investigated supervisor
accident reports, which pretty much held
workers accountable for their own injuries; accident causation, as a science,
did not exist at the time. Heinrich actually concluded that 88% of all industrial
accidents were primarily caused by unsafe acts (his actual data only gave
70%). DuPont says that 96% of injuries
and illnesses are caused by unsafe acts.
Behaviour Science Technology (BST)
has stated that between 80% and 95%
of all accidents are caused by unsafe
behaviour. When we really try and explore the science behind these claims

Page 5

The SAFE-T-NET Integrated Behavioural Safety Technologies (cont)

(Continued from page 5)

we find a fair bit of poetic licence

being used (To read more about this
request a copy of TransformationalSafety.Coms paper, "Leading your
Safety Culture toward Best Practice").
Managers like behaviour based
safety because it shifts much of the
responsibility for health and safety to
the workforce itself and does not
require significant change in the work
process, engineering design or management system. Or at least that
seems to be how it is most commonly promoted/practiced.
Companies promoting behaviour
based safety programs as the OH&S
panacea claim the number of lost
time injuries (LTI's) drop with these
programs. Lost time accidents are
known to be amongst the least reliable measures in determining the
effectiveness of a health and safety
program, since they are often highly
dependent on a company's ability to
put injured workers on light duty etc.
The overt and covert manipulation of
LTI data by people at all levels within
a business is often frightening to
behold.
Injuries and illnesses are caused by
exposure to hazards. Hazards include any aspect of technology or
activity that produces risk. Injuries
and illnesses occur when our bodies
come in contact with levels of energy
or toxic material that are greater than
the threshold which our bodies can
stand. The greater the amount of
energy, or the more toxic the material, the greater the severity of injury
or illness. The probability of incidents
is mostly dependent on the duration
and frequency of exposure. Of
course there is a significant behavioural input into this equation. My
issue is that behaviour is but one of
many; the BBS community strongly
assets it is really the "only one".
In 1950 the US National Safety
Council began describing a hierarchy
of controls to apply when reducing
and eliminating hazards. The hierarchy is accepted globally. Proponents
of behaviour based safety programs
can't really support it because it contradicts the theory that 95% of accidents are caused by unsafe acts of
workers. Within the globally recognised Hierarchy of Control "training of
workers" is at the very bottom. Within
BBS it is near the very top.

VOLUME 6 ISSUE 2

Traditional behaviour based programs

often implement low level controls,
rather than controlling hazards at the
source. Let us consider a very powerful and emotive example. In the 1950's
manufacturers bitterly fought passage
of the US Refrigerator Safety Act;
which eliminated locks on refrigerator
doors and established a very low
amount of force needed to push open
the door from the inside. The catalyst
(or trigger event/s) was the death of
significant numbers of young children!
The manufacturers position was that
these deaths were as a consequence
of poor behaviour being exhibited by
both parents and children. Weve
heard that before, and still here it today. Also kids were not being "trained"
about the risks associated with playing
around refrigerators and parents were
not "supervising" as they should be.
The US Refrigerator Safety Act
passed in 1956. No child has died in a
refrigerator designed since enactment
of the this Standard.
I make the point again BBS works, but
only when it is part of an organisationally appropriate cultural change program. There are some organisational
environments where it will not have a
significant influence. TransformationalSafety.Com is optimally placed to assess suitability for a BBS based solution; and to design a bespoke intervention that considers the unique
needs, and maturity, of every unique
safety culture.
TransformationalSafety.Com recognises the invaluable place of BBS
within the repertoire of tools to make
our workplaces safer. It is for this reason that we have developed the service of BBS Cultural Mapping. In other
words we are able to assess the
safety culture of an organisation with
special reference to the implementation and application of BBS Systems.
By mapping the culture we are then
able to customise interventions that
serve to fill any transformational safety
cultural gaps. We believe this is the
key to sustained BBS outcomes.
The popularity of the behavioural approach stems in part from the widely
held view that human factors are the
primary cause of the great majority of
accidents. A conclusion which is frequently drawn from this observation is
that the focus of accident prevention
efforts needs to be shifted from engineering solutions to ensuring compliance with safe work practices.

This is the basis of the famous DuPont approach. Those responsible

for developing the DuPont system
assert strenuously that it is far more
than a simple behaviour modification
system, yet its emphasis is undeniably on behaviour modification and
that is how it is understood by many
of its advocates as well as its critics.
There is a basic fallacy in concluding
that because the great majority of
accidents are the result of human
factors, in particular unsafe behaviour, the sole solution is to try to
modify this behaviour. The fallacy is
the presumption that accidents have
a single or a primary cause; often
referred to as mono-causality.
Modern accident analysis proceeds
on the opposite assumption, that
there is a potentially infinite network
of causes which contribute to an
accident, and if those causes had
taken a different path, the accident
would probably not have occurred.
What this means is that while unsafe
behaviour may have triggered the
accident, that unsafe behaviour is
better viewed as something requiring
explanation, rather than itself an explanation. The moment we begin to
ask why the behaviour occurred we
move back along various causal
chains which invariably implicate, in
some way, local cultural factors. Just
as the great majority of accidents
can be attributed to unsafe behaviour
by front line workers, the great majority of accidents are at the same
time attributable to actions or inactions by others (cognitive behaviours).
Consider this reference to falling
down the stairs.
Behaviour: A worker descending a
steep set of stairs, falls and is injured.
Question: Why did he fall?
Behaviour: He was not using the
handrail, as he was required to do by
company policy.
Many behavioural incident investigations draw to a conclusion at around
this point and focus on the "tip of the
iceberg"; counsel the employee
about using the handrail, provide
"training" regarding safe use of stairways, add a small "slap on the wrist"
and off you go. It is no surprise that
the global position of the organised
labour movement to the traditional

Page 6

The SAFE-T-NET Integrated Behavioural Safety Technologies (cont)

(Continued from page 6)

behavioural intervention is to oppose

it. Why? Because they believe that
theres to great a focus on trying to
identify employee fault; rather than
look at the issue more systemically.
TransformationalSafety.Com shares
some sympathies with the International Labour Organisation, as the
traditional model upon which the
majority of behavioural systems have
been based, clearly identifies "worker
fault" as a key element in the causal
chain. We believe this is far too simplistic a criticism and the position of
TransformationalSafety.Com is to
continue to ask the questions.
Consider the previous example a
little more deeply.
Behaviour: A worker descending a
steep set of stairs, falls and is injured.
Question: Why did he fall?
Behaviour: He was not using the
handrail, as he was required to do by
company policy.
Question: Why not?
Behaviour: He was using both hands
to carry tools?
Question: Why?
Conclusion: If he used one hand to
hold the rail he would have had to
make more than one trip up and
down the stairs to get his tools to the
lower level.
Question: Why didn't he do this?
Conclusion: Because there was
"pressure" to get the job done
quickly.
All manner of both external and internal pressures routinely lie behind
unsafe actions by workers in this
way. Despite all the rhetoric about
putting safety first, the reported experience of many workers, not all, is
that when "push comes to shove",
production takes precedence over
safety. We can though take these
behavioural observations further if
we wish. The failure to use the handrail is not the only reason the worker
fell.
Observation: He fell because the
stairs were too steep, far steeper
than would be acceptable in the
building code for houses.
Question: Why were they so steep?
Observation: Because the designers
VOLUME 6 ISSUE 2

had not considered the hazards of

steep stairways.
Question: Why had the designers not
considered this hazard?
Observation: Because they had not
adopted the philosophy of designing
out hazards at source.
Question: Why not?
Conclusion: Because the regulator
was not enforcing the relevant regulations.
Question: Why not?
Conclusion: Because the regulator
was short staffed and spending all of
its available resources on other priorities.
This example could easily be developed further, but this is far enough to
demonstrate the truly multi-causal
nature of every accident.
All of the factors that contribute to "atrisk" behaviours therefore need to be
identified and addressed for them to
be effectively managed. It is for these
reasons that TransformationalSafety.Com's approach is not to deny
the existence of risk in the workplace.
Just as we all take numerous risks
from the moment we arise in the
morning just to arrive at work, it is
unrealistic to then not give direct attention to the constructs of risk within
a workplace system. We are amongst
the first to utilise the tools associated
with Operational Risk Management
(ORM) in the Australian workplace
context. Our ORM resources have
been sourced from the United States
Military; where the impacts of poor risk
outcomes are generally quite severe.
What the TransformationalSafety.Com
Safety Culture Improvement System
does, is to examine and identify those
specific underlying perceptions and
attitudes which contribute to poor
and/or unacceptable management of
risk. Having established these attitudes, it responds by developing targeted tools and training to develop a
culture of safe risk application and risk
management in consultation with the
organisation. What this means is that
we do not, and will not, just provide
"off the shelf" tools that require your
operation to reengineer itself. These
types of intervention invariably are
very difficult to sustain and are prone
to system failure. The reason they
invariably fail is that they are externally imposed rather than internally
developmentally evolved.

When considering the implementation and/or integration of any Behavioural Based Safety (BBS) Program
we must give careful consideration to
the environment in which it is to be
incorporated. You would be mistaken
in believing that you can just
"borrow" something that another
Company has developed and transplant it into your own business. Yes,
it may well work for a time. Most new
things do. It's called the "Honeymoon
Effect".
This observation absolutely applies
to the world of BBS.
The first thing you need to appreciate, is that a Company can decide to
implement a BBS based program
within the business. Of course they
can, it's their business. Without the
active and genuine participation of
the operational workforce though it
will fail!
Of all the approaches to Occupational Health and Safety, BBS is the
most exposed to this factor. Why?
The answer is in one of the foundational elements of the majority of
BBS Systems - the Observational
Component.
The key tactic, for want of a better
word, to ensure the success of BBS
is to "develop" it with the workforce.
Not "for" the workforce. That means
seriously involving the "people" in the
design, development, and implementation of the BBS elements. Since we
are talking about "peer to peer" observations, then a blame-free culture;
with trust and integrity are key pillars.
Here's the rub. The International
Labour Organization (ILO) and almost all organized labour around the
World opposes the implementation of
BBS. Their main argument is that it
simplifies accident causation to
"blaming the worker". That is a critical risk to success. Why? Because
they are right! When I am asked to
cast my eye over BBS Systems that
don't appear to be working optimally,
it is almost always due to the failures
at the point of "integration". What I
mean by that is that you can have all
these wonderful BBS "tools", and yet
when you put them into the business
they don't seem to work. That is because there has not been enough
attention to up-skilling in the areas of
point-of-contact communications.
The power of the Observational
Component is really the communicaPage 7

Consider aligning the

Beyond Compliance Seminar

with your next safety forum
Participants leave with a:-

TransformationalSafety.Com
A Division of Strategic Management
Systems Pty Ltd
Unit 3, 12 Ken Tubman Drive
MAITLAND, NSW, 2320
AUSTRALIA

Phone:
Fax:
E-mail:
Skype:

61-2-49342351
61-2-49343651
broadbentd@transformationalsafety.com
d.g.broadbent

WE EXIST TO
ASSIST

State-of-the-art understanding with respect to how culture impacts workplace safety behaviours.
A recognition of the power of values and a framework for addressing value
dissonance within their organisation.
A powerful understanding of the impacts of leadership practice on organisational metrics at every level
Specific understanding of transformational safety leadership competencies
including a transformational self-assessment.
What the term safety engagement means and why it is critical to ensure
that the workforce is cognitively engaged in the safety conversations happening throughout all levels of the workforce.
How to go about developing safety champions and providing them with the
competencies and tools to be beacons within the culture of the business
An ability to map their organisation against Transformational Safety competencies and design a Transformational Safety Program for their organisation.

We are now taking bookings for 2011!

Were on the Web at

www.transformationalsafety.com

The SAFE-T-NET Integrated Behavioural Safety Technologies (cont)

(Continued from page 7)

tions between the peers at the conclusion of the observation - not the paper
process itself. Of course, the "paper
process" allows you to continue to
build your behavioural database. That
database then serves to "inform" other
strategic decisions you may make in
regard to the direction of safety training etc.

that our "hammers" are engineered to

the unique needs of your business (via
our ground-breaking safety culture and
safety leadership frameworks). We
then embark on an engineering process, where we focus on point-ofcontact integration of the BBS Tools.

So what makes TransformationalSafety.Com's approach to BBS different from almost all others.

Off-the-shelf self installed BBS Programs do NOT work!

It is our key focus on System Integration. Yes, we develop bespoke BBS

tools for use within the business, eg.,
SAFE-T-START, SAFE-T-SCAN,
SAFE-T-VIEW, etc.
At the end of the day though a
"hammer is a hammer". At TransformationalSafety.Com we make sure
VOLUME 6 ISSUE 2

Allow me to be very clear.

This is a case where if you wish to

maximise your investment, then a specialist with a thorough knowledge of
behavioural psychology and industrial
integration is the key element.
The fancy names like STOP, PASS,
TAKE-5, and SAFE-T-START are exactly that; fancy names. It is about
how they are developed for use within

the particular safety culture of the

business which offers the real value
for the investment.
Another key (and REQUIRED) element is that any BBS based safety
program be supported with effective,
and proactive, transformational
safety leadership. If the genuine
leadership is not present, supporting
these developments, they will fail.
In the next Edition of Transforming
Safety we shall begin describing the
modules which make up the SAFET-NET Technologies behavioural
safety interventions.. More importantly we shall also describe how
and why they work.

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