COMMENT ON THIS ARTICLE, BY WENDY LAMBOURNE, LEGITIMATE LEADERSHIP: Tom Lintner has synthesised 50 years of experience of safety in the transport industry in this thought-provoking article. Two things stick out for me. First, you can have a blame culture or a safety culture, but not both. Second, a safety culture depends on the four human (not system) qualities of trust, honesty, fairness and accuracy.
THE ARTICLE: It took 50 years to write this article – or perhaps 50 years of aviation experience watching how we respond to accidents – to form opinions about society’s actions when things go seriously wrong. This article presents an unscientific view of the human behavior that works against safety. It offers no solutions, but introduces sensitive topics that need honest discussion in the interest of enhancing safety for all.
My first, and strongest opinion is that, except for a small number of dedicated people, most of society does not prioritize safety because they never think it will happen to them – until seconds after a disaster when they realize there are things that should and could have been done to keep the smoke from rising and quiet the screams in their head that they will never stop hearing.
Over the past several months we have seen multiple conflicts between aircraft landing and taking off, and what seems like almost daily railroad train accidents.
The head-on collision of two trains in Greece resulted in immediate public protests and a rail station manager being arrested for manslaughter – all before the wreckage was removed. After a close runway incident in the US, an official responded to a media onslaught by saying, “I can assure the people our system is safe,” without explaining how.
Hearings have already yielded posturing by officials and calls for better safety cultures. Once again, we heard the question, “If safety is the number one priority, why hasn’t this already been done?”
This essay will offer thoughts on human nature and social behaviors that contribute to a reactionary response to accidents. It will examine an “elephant in the room” and, perhaps, provide the opportunity for an honest discussion of what is really involved in a safety culture.
What’s Preventing Us From Achieving A Good Safety Culture?
Basically, our own responses to incidents are a contributing factor.
It seems the pattern remains the same – deny anything is wrong with the system, take immediate action to demonstrate the problem was identified and something was done, hopefully find someone to blame or jail, and insist the system is safe.
But there is a question that is never asked: why can’t we talk honestly about risk and safety; have trust that the public will understand how things can go wrong in complex systems; and finally, enhance safety by listening to the people who live and operate in these complex transportation systems?
Perhaps the reason lies behind perceptions about safety and risk, and our reluctance to say, “We don’t know yet,” for fear of being held responsible for something we probably can’t control by ourselves.
I was trained and worked in the world of accident investigations during the height of the Blame Culture – when the role of the investigator was to find the one person in the chain of events who could be blamed for the event and label them, “The Cause.” Eventually, I began to refer to this person as “Eddie,” who became a meme before his time. Now, 40+ years later, I’m finding that Eddie represents society’s desire to blame any individual as the excuse for society not accepting its share of responsibility for safety.
Assisted by pervasive social media, society still continues to point the finger at “the one person” perceived to be responsible for an incident. But modern transportation systems are so complicated, it is never one single person, or one single mistake that causes an unwanted event – it is always the cascading domino effect of unintended actions that lead to an unplanned and unwanted event.
Let’s look at some of the complexities.
Does Society Really Understand What “Safe” Entails?
The short answer, in my opinion, is no.
A basic definition of “safe” is “freedom from harm.” But we need to acknowledge there is no such thing as “totally safe.” Anyone can encounter unexpected events at any time. “Safe” is a goal – not a guarantee – requiring constant attention. “Safe” is a subjective measurement influenced by an individual’s personal level of acceptable risk. What one person may consider safe another person may believe is dangerous.
But all organizations want to avoid disruption and the added costs – financial and social – of causing harm to customers or employees. Avoidance of harm requires organizations to recognize that what they do every day has the potential to injure people and damage property.
So, avoiding harm is already a goal since no sane person, or organization, will intentionally try to cause harm.
Then What Is “Risk” And How Does It Relate To Safety?
Risk is the probability that something – normally bad – may happen because of other factors, some within our control and others not. Risk always exists and mitigating risk is how safety is managed. It’s easier for people to visualize risk than it is to recognize something may be unsafe – but there is still a complex relationship between risk and safety that needs to be understood.
That is that risk is one part of safety, not a separate thing.
In order to mitigate risks, we first need to admit risk exists. I was once told by a supervisor in a major air traffic control facility that, “We have a policy of zero tolerance for risk. We run a no risk operation here” – which was clearly impossible. At a major railroad operator, a system engineer told me, “I design tools to run the trains – I have nothing to do with safety” – yet those tools were part of a safety system. An airport operations manager said, “We don’t have anything to do with safety, we’re just a landlord. The airlines are responsible for safety,” – while airport vehicles drove through restricted aircraft gate areas.
These statements are troubling because they show a disconnect between how these people saw their roles relative to system safety. Their statements begs the question, “How can we
manage safety if we’re in denial that risk exists in the first place, and if we don’t understand the relationship between risk, safety, and human nature?”
All organizations struggle to provide a balanced message about risk and its role in safety, and the timing of these messages only makes it worse. When the head of an agency states, “I can assure the people the system is safe,” before all facts are known it sends a message sounding defensive. When the same type of event happens again the following week, all credibility is lost.
Speaking Of Messaging, What Is The “Elephant In The Room” Concerning Safety?
Trust in a system and the effectiveness of a safety culture depends on truth, honesty, fairness, and accuracy. Some of these elements rely on science and some are subjective. All depend on effective messaging which is challenged by today’s level of cynicism.
The most politically fraught statement following an incident may be, “Safety is always our number 1 priority.” Let us look at the harm that statement may cause and consider an alternative.
“Safety is always our number 1 priority,” is usually heard following an incident after the media infers there were mistakes or a history of risky practices. Invariably, there is a quote from someone stating, “We’ve been telling them this for years.”
A spokesperson may respond, “We take safety very seriously and will get to the bottom of this.”
Meanwhile employees will recall procedural compromises made in the past – shortcuts – to get a job done. They worry they may become a scapegoat and trust in the organization is lost – and the loss of trust makes a safety culture impossible.
So, let’s explore the relationships that exist before an incident happens and examine the semantics, messaging, and perspectives – which should all contribute positively to safety.
First, it’s important to acknowledge the organization is a business, and the most important priority of any business is the survival of the organization itself. If the business fails and no longer exists, nobody will care how safe it used to be, including all the employees whose livelihood depended on that business.
While it may sound crude, survival is dependent on making a profit – impossible if you’re regularly hurting customers and employees, damaging property, and being fined by regulators.
The business must safely provide a product people will feel comfortable buying. The provision of a safe product at a reasonable cost creates public trust. Safety and efficiency form a balanced symbiotic relationship to create that trust – they are equal partners in the survival of the business. Efficiency done safely supports public trust. Short-cuts taken carelessly will not support survival.
This narrative allows a better safety culture by understanding the shared relationship between the operation – the job – and the value added by safety and the importance of input from employees.
As well as being a pre-condition to continued operation, safety becomes an investment, not a cost – and safety reports become assets to be sought after, not liabilities to be ignored.
Leadership needs to recognize that all employees will make unintentional honest mistakes, including the CEO, and punishing people for an honest mistake throws away a valuable asset – the last person who will ever make the same mistake again.
Everyone from the CEO to the rank and file need to see the same relationship. But especially the CEO, who needs to empower employee involvement in reporting incidents so risks can be identified and mitigated. It’s the CEO who must acknowledge that some of the reports will be troubling and that change will take time – that nothing can be fixed overnight.
But What Is Society’s Role In Creating A Safety Culture?
There will continue to be challenges caused by societies’ desire for instant gratification – immediately knowing all the answers, demanding assurances that it will never happen again, and finally, demanding we get rid of “the one person” responsible for the accident so we’ll all feel safe…until the same thing happens again.
A good safety culture depends on truth and trust among all the people in an organization knowing they can share knowledge about mistakes and changing risk without being blamed for something they probably had no control over.
It requires truth from the external organizations who contribute to society’s knowledge and demands. In time, society will need to recognize there is no simple solution to complex issues, especially when humans are part of the system and ultimately, the Blame Game is incompatible with a Safety Culture.
So, in the end, society must choose what is more important, Safety Cultures that enhance safety or a system of blaming individuals who are in fact working to make your world safer.
A Final Thought
If one were to google, “DOT Airline Performance Measurements,” Safety is not listed. The top three metrics shown are Flight Delays, Mishandled Baggage and Oversales, which could suggest a surprising perspective on the agency’s priorities.
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