The other day we called up our friend Ron Gantt, the Safety Differently thinker, to get his take on some standard ideas in traditional safety.
In particular, we asked Ron for his take on (1) safety and compliance; (2) safety indicators–lagging and leading; (3) safety measurement; (4) Heinrich’s safety pyramid; (5) SOPs, work as planned, and work as performed; (6) job hazard analyses, or JHAs; (7) the hierarchy of controls; (8) incident investigations & root causes; (9) behavior-based safety; (10) risk & risk management; and (11) safety culture.
Ron was kind enough to answer all our questions in helpful and thought-provoking ways (which is typical for Ron).
You can watch a recording of our discussion below (watch for the appearances of Ron’s dogs!) or read a transcript below. And we’ve included some links to earlier discussions about Safety Differently with Ron below as well.
We’d like to thank Ron once again and we are sure you’ll find this discussion interesting.
Check out these other discussions with Ron, too:
- What Is Safety Differently?
- Is Safety Differently Really Different Than Safety?
- Safety Differently and Incident Investigations
- Safety Differently and Safety Training
Let’s get right into the transcript of our discussion with Ron Gantt about some “classic” or common ideas in safety and get his critical perspective on them.
Convergence Training: Hey there, everybody and welcome. This is Jeff Dalto of Convergence Training and Vector Solutions. And today we’ve got an exciting guest, I think a lot of you might be familiar with him. This is Ron Gantt. He’s the Director of Innovations and Operations with Reflect Consulting Group. Ron does a lot of work in safety; you might think of him as a guy who talks a lot about safety differently.
He’s one of the more interesting and provocative people, I would say, in safety, and shares a ton of his knowledge and time and insights. So I’m really grateful for Ron, and I think he’s actually my intro to things that might be called new safety. So with that, I’d like to say Hi, and welcome to Ron.
Ron Gantt: Thanks, Jeff. I’m glad to be here. You’re a superhero for doing this.
Convergence Training: No, no, no.
Ron Gantt: Not for talking to me, but…maybe a superhero for talking to me. I don’t know. We’ll see.
Convergence Training: Well, thank you very much, and we’re excited to have you.
Ron has agreed to come on today to give some quick, off-the-cuff comments on some kind of classics of safety, safety thought, and safety techniques and methods And I think this will be interesting for everybody. So to just to jump right into it, we’ve got a list of 12 things here. Why don’t you go ahead and start by talking about item number one on our list, which is safety compliance.
Ron Gantt: All right, yeah. So compliance matters, right? I mean, it’s not like regulators are going to go away anytime soon. The question becomes, how do we manage compliance? And what role should it have in the broader safety management system? And those, I think, are questions that we need to answer because oftentimes, we just go right to compliance and many organizations stop there.
So I think we need to have a broader conversation in safety about seeing compliance as a potential tool,
amongst other tools that we can use, right? When are the times that we can and should have compliance be non-negotiable? And when are the times when we shouldn’t? And how would I know the difference between those two things? Because if we just treat everything as non-negotiable, well, everybody knows that’s obviously flawed, right? There’s no such thing as an environment where I can always do or not do something…it’s not black and white, there’s no such thing as that.
So, for me, it’s, it’s about situating that idea of compliance in our broader discussion about what does it take for this organization to be safe? What are the things that we’re trying to fix, if that makes sense?
Safety Indicators—Lagging and Leading
Convergence Training: Yeah, Yeah, it does. I think sometimes it’s easy to totally dismiss completely the importance of compliance, or the necessity of compliance in these kind of discussions, so I like that.
So I guess, following up on that, maybe you could talk to us a little bit about reporting on lagging indicators and use of incident rates and so on.
Ron Gantt: Yeah. So incident rates and things like that, again, are another thing that are not going to go away anytime soon. I would say that as a measure, because they’re often used as a measure of safety performance, as a measure of safety performance, they are notoriously poor. And even if we buy into the fact that whether or not you have an accident could indicate whether or not an organization was safe, we’ve run into a situation in safety where we are safe enough.
So from a statistical perspective, we’re not having enough accidents to actually know whether or not you get a reduction as a result of things we’ve done or anything, right? So the problem is our rates are low enough now that they’re not telling us anything new. We’re not learning anything. Especially in those organizations that go long periods without having any accidents. Does that mean they’re safe? I don’t know. You know, and so that’s that why if we measure safety by its absence, we run into these sorts of problems that actually can lead to logical conclusions that are flawed. If we have a long period without accidents, does that mean we’re safe? Everybody agrees that that’s just not true. But of course, that begs the question, then why are we then measuring the number of accidents we have as our sole measure of safety performance. As any legitimate measure, really?
Convergence Training: Alright, great. So that leads into our next question, which is about safety measurement. I wonder if you can address two parts of this. First of all, why do we feel compelled to measure safety? And should we? And then secondly, if you don’t think that measuring safety by incident rates is a good answer or the whole answer, what would you suggest?
Ron Gantt: Yeah, these are good questions.
So first off, we measure something to identify how close or far away we are from some sort of goal, right? So I think we would all agree that for safety, whatever definition of safety we use, and that’s going to be important in a minute. But safety, whatever definition we use, implies some sort of goal. Some people would have it be the goal into itself. But regardless, however you define it, there’s some sort of goal there. How do we know how close or far away we are? And so the only way we do that is to measure where we are or to measure some version of the gap.
Now, a lot of people will criticize the idea of measurement all together, because we’re in a complex environment and safety is an abstract concept. How do you measure that gap? And that’s a very good point. However, I think the idea that we can’t measure it all is just wrong. Humans are always sort of measuring and trying to understand in some ways. If measurement only is numbers, then I agree, but measurement is not only numbers, we use all sorts of our senses to measure, right? You know, like even just having an idea of how close I should be to this computer screen, there’s a form of subconscious measurement that’s happening. There’s no number associated with it. It’s just a qualitative measure–am I close enough or not?
So I think measurement has a place. But again, it’s kind of like with compliance, we need to understand how is that situated in our broader conversation about safety? And so this leads to that point about the definition of safety, right?
What if safety is not the absence of accidents? You know, if that’s not good enough to define safety, then that begs the question, what is safety? For myself, I would argue that safety is a capacity to be successful in varying conditions. So, safety then is not a thing unto itself, it’s a set of potentials to allow us to get our job done as conditions change.
Read more about Ron’s definition of safety in our interview with him titled What Is Safety Differently?
And if that becomes our definition of safety, that actually leads to certain things that we can start to measure that would give us an indication of how likely we are to be successful in creating that capacity. So from a learning perspective, how would I measure a person’s capacity to be able to do certain jobs? So one of those things is knowledge and skills. Right? Those are things we can measure. The hard part is that we sometimes have to use proxy measures. And so the idea of measurement is complex. But if we start with the idea that safety is not just this absence of accidents, but it’s a thing that we’re trying to achieve, or that gets us to something we try to achieve, that actually breaks down the measurement discussion into something a bit more manageable. If it’s a capacity to be successful, I can start to measure that capacity or at least movement towards that capacity.
I know this is a bit abstract, but I think we need to deal with it at the abstract level. And then, with each organization have the conversation, “Okay, what would it take for me to be successful? You know, and how would I know that conditions are changing? And what would be my response pattern to those conditions as they change?” If that makes sense.
Read Ron writing more in depth on capacity at the Safety-Differently-dot-com website.
Measurement Continued—Capacity Metrics & Qualitative Metrics
Convergence Training: It does. But I wonder if I can try to nail you down a little. So could you give us some examples of things one might measure to measure capacity or ability or something like that, and then, two, some examples of a non-data measurement metric, if possible.
Ron Gantt: Yeah. Yeah, absolutely.
So, in terms of measuring capacity, let’s say we were a company that makes pizza, right? We are a pizza restaurant. You know, what are the capacities that need to be in place for us to continue to make pizza into the future? Well, one of the things is we’re not making pizza for ourselves we’re making them for customers. So what abilities do we need to have in place that would enable us to understand what the needs and desires of our customers are? Do we have those abilities in place? And you can think of knowledge, skills, space, things like that, that would allow us to do that.
If you take that and put it into what we would call a traditional safety space. You know, let’s say, okay, now we’re thinking of in terms of risk, which, you know, I start to get a little bit uncomfortable with because then I’m starting to wonder what are we talking about with risk, but let’s make it easy and concrete for people. So let’s say we’re going into a confined space, for example, we’re going into a tank that had stored hazardous chemicals, you know, acid or whatever, and we need to go in there and fix a leak because the wall was becoming too thin.
Okay, well, so how would we ensure that we are able to complete that job? Even as conditions change? What capacities need to be there? Well, right off the bat, there are some capacities that are obvious that are in within the normal, traditional safety space, right? You know, we obviously want to measure the air, we want to make sure people have the right PPE. But then we also start to think about, well, if the job is not just to make sure these people don’t get hurt, the job is to fix the leak, then we need to make sure the PPE that they’re wearing and the other things that we’re doing don’t interfere with the overall job. So how can we manage those trade offs?
And some people would say, well, that’s not my job as a safety person to manage those trade offs, that’s their job. The problem I have with that mindset, and the reason why I think it’s really important for us to make that part of our job is that someone has to manage those trade offs. And as of right now, I don’t know anybody in the organization that is uniquely qualified to do it, right? So when the work gets done, the workers have to find a way to make whatever safety requirements we gave them fit with their job, right? So if we can start to identify what those trade offs are, we can start to measure our ability to manage those trade offs, which then puts focus on the trade offs and helps us manage them better.
Which then kind of gets us to the second answer to your question, which is a non-data source, right? So once you start to get stories about how people are managing those trade offs, you can start to pull data out of them specifically, and by data, I mean numbers and things of that nature. But the story unto itself is a data point too, right? It is a source of information about what’s going on in the organization.
And one of the things that I think is really important for us to understand is that stories are compelling in ways that numbers are not. There’s some interesting research on how people make decisions about risk and things of that nature, that when we present information to people about a risk that is primarily in terms of statistics, on average, people will tend to take more risk. Whereas if we present information to them that is more qualitative in nature, like a story, people on average tend to take less risk. You know, it humanizes thins. An easy example is when you know, Sarah McLaughlin wants you to give money to save poor little puppies. She doesn’t tell you that there are 30,000 puppies that need adoption. She shows you this one little puppy, right? Don’t you want to love this puppy? Why would you hurt this puppy, Jeff?
Convergence Training: I apologize for wanting to hurt that puppy.
Ron Gantt: But you know, we can give them indications about the functioning of our safety organization and how it is managing those capacities. So yeah, we still want some data. But presenting stories as an equal source of information of measurement, I think is something that we haven’t done in safety, but is an untapped resource.
Convergence Training: Great. I’m glad you talked about stories, and we’ll leave it there. But maybe sometime next year, we can come back and talk about that, because I think that’s really important, that ability to not just capture and acquire information, but share it throughout the organization, and maybe not something that organizations excel at, whether it’s safety or not.
Ron Gantt: Yeah, I’ll just add to that real quick. You know, the reason why it’s important is, organizations may not accept it, but humans always excel at it. And so there are already our stories going through the organization and being used as an unofficial measurement. It’s just not always getting to where it needs to get, right?
Convergence Training: That’s a good point as well. Are you familiar with that book Made to Stick by the Heath brothers and how they talk about the power of storytelling, amongst other things, the power of storytelling as opposed to data?
Ron Gantt: Now I’m going to have to look that.
Heinrich’s Safety Pyramid
Convergence Training: You bet.
Okay, so all of this kind of leads nicely into our next point, which is something called Heinrich’s Safety Pyramid. And before you tell us your thoughts, Ron, for those who aren’t familiar with Heinrich’s Safety Pyramid or don’t know about it by that name, can you just kind of explain what it is?
Ron Gantt: Yeah, so Heinrich was an insurance guy in the early 20th century. And he did a number of studies on accidents and causation and things of that nature.
Say what you will about Heinrich, but we have to give him kudos. He was one of the first people to really apply a sort of scientific or quasi-scientific approach to safety, industrial safety in particular. And that really kind of kicked off a whole sort of evolution. So it’s easy to sort of bag on him now. But he was a pioneer in a lot of ways. So we’ve got to give them kudos.
The Heinrich pyramid in particular was one of his very influential models. And the idea was for every major event…and I’ll use the numbers he used, but other people have expanded on it…so there are 29 minor events, minor injuries, and 300 near misses. Unsafe acts was the term he used, and things of that nature. So, sometimes it’s called the 329-1 theory, but most people know it as the as the pyramid or the triangle.
And a lot of people would point out that at the time and when he initially wrote up his theory, he was not necessarily saying that that ratio really matters, that we could like count how many unsafe acts we have and then predict whether we’re going to have an injury tomorrow or not. But subsequent to that, a lot of people have sort of taken that idea and used it as like a predictive ratio. And then others had you know, like Bird for example, an another insurance guy, have kind of done subsequent studies and come up with different numbers but similar idea that okay, we can look at the bottom of the pyramid and get rid of these unsafe acts and that will stop us from having that one bad injury.
So, how it’s been used may be a little bit different than Heinrich intended, but I don’t know, I don’t want to get into the weeds on that and try to read his mind. The bottom line is that a lot of people have this belief system that if we get rid of all of the unsafe acts and we deal with the minor stuff that will deal with the major stuff.
And as to the validity of that, it really depends on what we’re talking about. So the general idea that there’s always going to be more minor stuff than major stuff, that’s just true. I mean, there are always going to be a lot more people stubbing their toe than people getting killed at your organization. I mean, that’s just an obvious, right?
But the idea that the people stubbing my toe can predict whether or not I will have people getting killed, that’s more problematic. The thing I would have people think about is, is it predictive? That if you know, the number of ergonomic injuries that we have in our organization, is that going to be predictive of our propensity to blow up our factory?
No, I cannot see a causal connection there. Now there are going to be some instances where with a particular type of event, or accident, or risk, that there might be some kind of events that if they happen would predict to us, “oh my god that’s much more likely or makes us more likely to have that bad thing.”
So like, let’s say lockout tag out events, if we have a number of near misses where someone was working on a piece of equipment that turned out that it wasn’t properly isolated. Well, certainly, we could argue that if that keeps happening, eventually something bad is going to happen on a long-enough given timeline, right? Sort of makes sense. But to say that, lockout tagout events are related to slips, trips, and falls. I don’t see how those two things are connected.
So the Heinrich pyramid itself, I don’t see much of value in it. You know, a lot of people will say it’s completely invalid. I’m not sure I would go that far. I mean, certainly he found numbers, and whether those numbers relate to one another, that’s a separate question, they may be correlated, but correlation doesn’t equal causation.
To me, the most important thing for organizations is that we are looking at each individual sort of whether it’s risk or whether it’s work or a task and identifying how can things go wrong? How can things go right? And how can we manage that so we get more of the good stuff and less of the bad stuff.
Convergence Training: All right, great. Thanks for talking about that. And I know you didn’t want to get into the weeds on the question of what was Heinrich’s original intention, which is fine. For those who are interested in that, I think Carsten Busch is an interesting guy to get into weeds with on that. So we’ll refer you to Carsten Busch for that.
Ron Gantt: I had him in my mind when I was sitting thinking saying that.
Convergence Training: Yeah. Let’s just make the obligatory reference to Frank Zappa for Carsten and move on.
Here’s our recorded discussion with Carsten Busch discussing 10 Common Safety Myths.
Okay, maybe kind of summarizing this part of the discussion. Can you talk to us about safety bureaucracy?
Ron Gantt: Yeah, okay, so, safety bureaucracy is sort of…at least the way I perceive it. I mean, the term is used in a negative sense almost all the time and it’s unnecessary safety paperwork, or unnecessary safety procedures, or things of that nature. And even though it sometimes is talked about in an unfair way, it’s totally true. You know, one of the easiest ways to describe how safety bureaucracy comes about is ask any organization when the last time they removed a safety rule was. I mean, it never happens. You know, we just add more rules on top of rules. You know, best-case scenario is we replace one with another and often the one we replaced it with is more complicated and has more stuff we’ve got to do. And so the problem up with all these safety rules…
So one of the problems with bureaucracy and where it comes about often we do not have a clear picture and safety about why we’re doing what we’re doing, all right. So there’s no underlying theory. Yes, we want to have no accidents. And I kind of generally think that this thing is going to stop accidents. But there’s no connection that says, this gets me to not having accidents, because by doing this, it will lead to this, this, and this. And I think it’s important identified this, this and this, the A, B, and C, that leads to the ultimate end goal, because those things are often testable. Right? There are theories that we have.
So posters on a wall is a classic sort of thing that people eye-roll about safety. You know, these motivational posters…what’s the underlying theory that would lead us to believe that that’s going to stop an accident from happening? Okay, well, someone’s going to walk by, and they’re going to see it, and they’re going to think to themselves, “Man, I should be safer today.: And that’s going to lead to subsequent behavior change out in the field. That’s all testable, right? Do people actually walk by it and when they do walk by it, do they notice it? We can measure that and see, does it actually do what I do?
But so the problem is, when we don’t do that, we often just keep things in place because it’s done in the name of safety. Right? You know, a safety rule is put in place, a procedures put in place. And the only way we validate whether it actually works is “Do people follow it or not?” And then when they don’t follow it, we blame them. We don’t go back and think, wait a minute, the whole purpose of a procedure is to change behavior. And if people aren’t using it, then by definition, the procedure is not working. So that safety bureaucracy just gets piled on top of, you know, one thing after another because we just believe that if it’s in the name of safety, it’s sacrosanct. It must be good, but that’s not always true.
Convergence Training: So if that’s one element of safety bureaucracy, and I think you spoke well to that, I guess maybe a second element is just simply reporting up. Do you have any thoughts on that?
Ron Gantt: Yeah, so a lot of times in bureaucracy, the underlying belief system that is kind of built in, in addition to what I just spoke about, is that we can’t trust people to do safety on their own, so we have to validate they’re actually doing it. So we do that through audits or inspections or things like that, or we have to report up to people to prove that we’ve done something, because we can’t trust people to do it on their own. You know, the classic thing I hear a lot in organizations is, we’re going to have a kind of pre-job conversation, which is a good thing to do. Well, then we’ve got to prove that they did it. So we gotta have some piece of paper to have that everybody sign because God knows that if they’re going to lie about doing it, then having them sign their name, they would never lie while signing their name, which makes zero sense, right?
And so you get this kind of idea that we have to validate everything they do, and the only way we can validate it is to write it down, like, you know, the whole kind of thing that if it wasn’t written down it didn’t happen. I mean, that’s nonsense. That’s going back to what I said earlier about proving our theories correct. That’s an easily disprovable theory and I can do it for anyone, anytime. You just tell me what you want me to write down, I’ll write down what I did, and I’ll tell you that whether it happened or not, right? So like, I can write it down right now that we’re on Mars, and you know, write it down on a piece of paper. Does that mean we’re on Mars? No. Right? So writing stuff down doesn’t prove anything happened. It just makes us feel better at the end of the day. And that’s another mechanism by which bureaucracy gets built.
Convergence Training: So it’s, there’s an element of nonsense to it. There’s obviously an element of inefficiency in wasting time and resources. But I think it’s corrosive. As you kind of pointed out, it’s corrosive to trust and team building, as well.
Ron Gantt: Absolutely. Yeah. Because, I mean, the underlying logic is I can’t trust you. Right?
Convergence Training: Right.
Ron Gantt: It’s amazing to me how many people in safety and in management believe the idea that if we removed all safety rules and all of our processes that there would be anarchy. Like where do you think these rules came from, you know? Is there only an enlightened few in the organization that want rules.? And the rest of us just want to run around with scissors all the time?
It doesn’t make any sense. Where does culture come from if we need some sort of, you know, bureaucratic system to create safety? It’s nonsensical.
Convergence Training: Yeah, this isn’t a safety example, and I won’t name a name of a company, but I know somebody who worked at a company. He created an additional workload for himself that essentially doubled the amount of stuff he was doing. And nobody even knew he was doing it. And then he told his boss about it and that it was having good results. And then he told his boss about it, and he immediately became responsible for tracking it and reporting up on it.
Ron Gantt: Oh, God, love it.
SOPs, Work as Planned & Work as Performed
Convergence Training: Okay, so touched on this a little bit already, but maybe you could talk to us about SOPs and the idea of work as planned as opposed to work as performed?
Ron Gantt: Yeah. So first off to the latter point about the difference between how we think work happens and how it actually happens. They’re always different. And that is really important for us to understand. Because it’s important for us to understand that that difference is not just always there. It’s that the reason why it’s there is not because we’re not trying hard enough. The reason why it’s there is because the world is fundamentally complex, that it is impossible to come up with a plan that will always be perfect.
You know, there’s the famous military line, no plan survives first contact with the enemy. You know, as soon as you have a system that is complex, and pretty much any system where people are involved is complex. It’s going to have variation in it and most of the time that variation is small. But sometimes it’s huge, right? And unfortunately, we don’t always get to know which times are going to be small and which times are going to be huge in advance. In retrospect, it’ll look easy—OK, how could you not know? And that’s one of the reasons why we often think that the difference between work as imagined and work as done is a product of people not choosing to try hard enough. But in reality, it is impossible for us to know, in looking into the future, how things are going to be next. Right, we always base what we do based upon what we has happened in the past. But we know that that’s not always what’s going to happen in the future, right? So that gap exists because the world is too complex for us to come up with a perfect plan.
Now, what does that mean for procedures? Does that mean procedures are useless? No, I don’t think so. I think procedures have value and kind of the best way I can think of to explain it is another quote by Dwight Eisenhower that says “In preparing for battle, I’ve found that plans are useless, but planning is indispensable.” And the way I kind of perceive his point is that, yeah, the ultimate plan you come out with may not have a lot of value when it comes time to actually doing the battle in his case, or the work in our case, but the process of coming up with it, thinking about it, going back to the idea of capacity and building that capacity to kind of adapt, that’s valuable, because that kind of helps us build in a mental model of how the work could happen or should happen, so that we can go from there.
You know, I think Rosa Carrillo said at one time online in a conversation I had with her where she said it really well: “procedures tell us what we know so far.” And I think that’s a good way of saying because yeah, so we want to take those lessons learned about how we think, OK, this is a good way to do the job, or this is a way that we’ve done it in the past that has worked. That’s valuable. But that doesn’t mean it’s going to work this time.
And in terms of what I would recommend for people is, is to find a balance there, right? Find a balance between habit and creativity, because all behavior has to find that balance. Everything we do, you know, we walk into it with a set of routines and beliefs about how the world works, but how that gets enacted in real time is sort of a creative action, right? We’re not doing anything the same exact way every time. There’s always subtle variation. In the same way when the work gets done, if we kind of see the habit piece of it as the procedure. Okay, cool, how are we going to build in the ability to creatively adapt as things change? And again, it comes back to the capacity, how are we going to know that it’s going to change, and what kinds of tools skills, personnel, time, space do we need in order to react to that in real time? And so procedures have a place in that, but it’s only one part of that puzzle.
Convergence Training: Ron, if our procedures tell us what we know, ideally, up until now, and then every time I do the job I’m learning more, any tips for updating procedures, getting the workers involved in that?
Ron Gantt: Anytime you have a procedure, always involve the people who do the work. And ideally, you want kind of different people who do that job, not just one or two people, because that sort of diversity is very valuable. So if you do that, you’re well anyway, right.
Job Hazard Analyses (JHA)
Convergence Training: We just finished talking about SOPS and worked his plan. How about JHAs, Ron?
Ron Gantt: Yeah, so job hazard analysis. It’s a commonly used tool for pre-job planning. I think the main thing that has value with a JHA is the planning that workers would do and thinking about the job, right?
So in the moment having a conversation with people about how the job is going to get done. I think that’s hugely valuable. And most workers I’ve talked to think that’s hugely valuable. Where it starts to lose value is when some of the other stuff we talked about earlier starts to come, in the bureaucracy and you know, when people try to proceduralize it, as if it’s got to be the same exact thing every time, or it becomes a top-down function. Right? Where in the worst possible cases and, and you know, forgive me because this might be a sacred cow for some people. The worst possible case is if we come up with the JHA on our own, as safety people, and then we just hand it to them and say read it and do this every time, right? That’s the worst because that removes all thought from the process. All the value of that JHA is gone.
Whereas kind of on the other side, if we use it as an opportunity to start a conversation about “Okay, what are we doing today? What’s different about today, how’s today the same as normal? What about today worries us? Have we done this job before and what are kind of the funny things about it,?” You know, just kind of have a conversation about, about what we’re going to do and how we can do it. That’s got a ton of value to me.
Convergence Training: Can you share from your experience, do you have a rough estimate of how many companies are in the worst-case scenario? And how many companies are best-case scenario in the way you just described?
Ron Gantt: That’s a good question. Um, most companies fall right in the in the middle, right? I think most companies…very few. There are a few that I can think of…now, I was actually talked to one today, that’s what they did, they just hand over the JHAs to people and say, read it, follow it, you know, shut up, that kind of thing. But that’s been, in my experience, the exception. And they will readily admit, nobody reads them. Nobody you know, so you’re not doing anything with those.
On the far side, I think there are companies that actually have a good conversation with the JHA. That also, though, is not the rule at all. There’s I don’t think there’s that many that do that, but there are some that are out there.
Most companies will do some version of both. So like commonly, most companies will do this, they have a standardized format that you always have to do the JHA in this format. You always got to check these boxes, you always have got to do X, Y, and Z. And the problem with that is if that, especially if that’s a top-down sort of thing that we came up with, what we think is the best format for a JHA, the problem then is, you know, it becomes a check the box kind of thing for workers. In most cases, you know, unless they’re more involved in developing that, they’re not going to see it as having a lot of value.
Also a lot of organizations will have a conversation, or I’m going to put conversation in air quotes. Because it often is a supervisor who filled out the JHA just talking about it. Basically reading it to the workers. And that’s it, you know, and then they’ll say “Any questions?” And nobody has questions, and they move on.
To me, if again, you want to go back to safety measurement, I think that’s a really good measure. If you have a job hazard analysis, and anything less than two or more people are talking, that’s a sign that you have a pretty poor process, right? Because people are not engaging with your process. Now that doesn’t mean that the people are unsafe per se. I think that means though, that your process isn’t working. Because they’re not thinking about it. They’re not buying into it, they’re not seeing that that’s a good safety metric.
So I think, you know, most companies will have a very proceduralized process that is top-down. And they will have some version of the conversation. But the workers often see them as having very little value to what they do. And so this was a recommendation I gave to the person I spoke with today. If your workers are not engaging with your JHA process, that doesn’t mean they do not do a JHA. I find that often the workers are doing their own version of it, because they want to think about the job in advance and come up with a plan and do it what they believe is the right way.
And so, you know, rather than just going into change the process, I would say, step one is go and figure out what they’re doing. So like, in this particular case, he was talking about how the workers had a pre-job meeting where they were at a trailer and they talked about it, and then the workers would go out to the field. My recommendation with him was go out with them to the field and see what they do after they leave the meeting. I guarantee they’re probably talking amongst themselves on the way there or when they get there about what they’re going to do and how they’re going to do it. That’s your JHA. Incorporate what you do into what they’re doing and it will be more effective.
The Hierarchy of Controls
Convergence Training: So many safety professionals will preach the importance of the hierarchy of controls. What are your thoughts about the hierarchy of controls?
Ron Gantt: So again, for a beginning safety professional, it might be an okay place to start to get us past the idea that all the solutions need to go to the worker, right? And to get us to start to think about design, right?
So you know, kind of basic hierarchy controls, engineering controls, admin controls, and PPE, and then, you know, they expand from there, depending on whose hierarchy of controls you’re looking at. And the idea is that, you do the engineering-ish type solutions, whether it’s engineering controls or design or whatever, first, and then you do the PPE last. So as a beginning level, that’s not a bad thing to teach beginner level safety people.
At an advanced level, I think we need to move beyond it. One of the reasons I think we need to move beyond it is because it, it paints the really, really bad idea that you can either end, when you’re dealing with people, you can either engineer out the problem, or you can change the individual, and there’s no middle ground there, which is crazy. Like, one of the things I hear people talk about all the time is BBS, or behavioral based safety solutions. And they’ll say, but Ron, there’s only so much we can engineer out. Right? And then once you’ve engineered out all the problems, you’ve got to deal with the behavior. Well, I think the hierarchy of controls encourages that mindset, and that mindset is wrong.
Because it makes it like, we engineer out hazards, and then we deal with people using behavioral interventions. But no, wait a minute. Think about that for a second. Doesn’t the design of the process affect behavior? And doesn’t behavior affect the design of the process and how the process is used? Of course, right? They’re not two separate things. They’re mutually interacting. And if we see them as two separate things, we come up with worse solutions and we completely misunderstand the problem.
So I think for advanced level safety professionals, we need to stop seeing it so linearly as like, okay, we can we try to engineer down and if we can’t engineer it out, then I’ve got to come come up with an incentive structure or something like that. No, let’s start to see it as a connected whole, talk about how the culture in influences, how the designs are used, how the equipment’s used, how the permits are used, all of these things are mutually interacting.
Convergence Training: Great. I wasn’t sure I was following you at first, so I’m glad you continued. When you were saying that the hierarchy suggests engineering controls, and then behavior modification, essentially, I was trying to think of the hierarchy and I was thinking, the only behavioral things I can think of, I guess, are under administrative controls when I talk about, you know, either changing shifts or training, I think gets lumped underneath that but I think your point is you can work
Work your way through the hierarchy. Then once you’re done with that support, the thought is all I have left now is behavior modification, which is going to lead us to behavior-based safety. So you’re I think you’re saying it’s inappropriate division as opposed to thinking from a systems view.
Ron Gantt: Yeah. And I would say, even though PPE isn’t behavior, it always requires behavior. Yeah, you know, they got to find a way to do it. So yeah, that that sort of separation between, you know, we change behavior by training and we engineer out hazards. I think that’s encouraged by the hierarchy. And I think that’s problematic.
Read our introduction to systems thinking and watch for more from us on systems thinking in the future.
Incident Investigations & Root Causes
Convergence Training: Alright, great, let’s talk about incident investigations, especially as traditionally practiced.
Ron Gantt: I think they’re good. Next question. I’m just kidding.
No, I think incident investigation obviously is a good thing. You know, it’s certainly something we want
to do when something bad happens, is learn from it, right?
The mistake I see, I have a lot of thoughts on how I see lots of organizations trying learn from incidents.
So I guess I’ll kind of lump them into a couple categories.
So number one, they see incident investigation as an indication that there is a broken part of their system that just needs to go in and be fixed. You know, it’s sort of like, my tool broke. And so I just have to go and get a new tool and we are going to fix the part that broke and everything’s fine. That’s not really how these things work. Human systems don’t break like machines do. Right? So this thing that you say is broken is actually a functional part of the system that’s working exactly as it was designed.
And so rather than seeing incident investigations, as an opportunity to fix what’s broken, we should start with the mindset that we should see them as an opportunity to understand how our system is working right now. That doesn’t mean it’s working well, because obviously we had a bad outcome.
The difference is subtle, but critical, because if we only are going in there to figure out what’s broken, then we get into root cause analysis, right? And that gets into this kind of linear mindset. And I’m already thinking of what people are going to say, there’s a few people out there that say, “Well, root cause analysis isn’t always linear.” But root cause analysis, as it is applied and used in the majority of organizations that I’ve ever seen, is a very linear process that is only interested in how and finding what broke and removing what broke, whether that’s one thing or 900 things, I don’t really care. It’s the same underlying idea.
By contrast, if we take the perspective that accidents are a result of how our system is working, then we need to look at the whole system and how things are interacting with one another. That thing that you see as broken is actually a functional part of the system that is interacting with other parts of the system. And if you simply remove it, you might actually create unintended consequences that you didn’t even know about. And so we start from the perspective that the idea is not to fix the problem, the idea is to learn about what’s going on. And once we do that, then we’re in a much better place to actually fix things.
But step one is learn and learn about how things are working, not fix and remove the bad stuff, if that makes sense.
Read about how to conduct a Learning Team Event after a safety incident to increase organizational and operational knowledge.
The Safety Pyramid & Behavior-Based Safety
Convergence Training: Yeah, yeah. Back to systems again.
Alright, so our next topic of conversation is behavior-based safety, human error, and
situational awareness, and I was wondering, it just occurred to me during this discussion and I probably should have had this thought years ago, is the safety pyramid with the unsafe acts at the bottom, is that the origins of behavior-based safety?
Ron Gantt: So that depends on who you ask. But a lot of people will say that and whether or not it is sort of depends on which behavior-based safety person you’re probably talking to. I would say it is the theoretical underpinnings of it, right? So I would say yes, in general, but I know there will be people who disagree with that.
Convergence Training: I guess it should be obvious and it should have…but on the other hand, there’s so many kind of bastardized versions of that pyramid, and they have different things at the bottom level anyway, that I’ll give myself a pass on that. But could you talk about behavior-based safety, human error and situational awareness?
Ron Gantt: Yeah.
And to your point about their being so many different versions of the pyramid, there are actually so many different versions of behavior-based safety and, similar to root cause analysis that I mentioned earlier, it’s not one thing. And that’s the problem with these sorts of approaches. I mean, if you look at the definition of behavior-based safety in Wikipedia, it’s the application of behavioral science to safety. Couldn’t that then be everything? I mean, what isn’t behavior-based safety, then, you know? It doesn’t make sense. It sort of becomes this catch-all for anytime we want to use psychology in safety, which is a bit odd, and sort of makes a meaningless phrase. So you kind of have to ask what people mean.
So when it comes to behavior-based safety, and what I’m going to speak to now is the idea that we can identify a set of behaviors that we think are always bad, and then we create some sort of reinforcement structure to get rid of the bad behaviors and encourage the good behaviors. And that reinforcement structure can be through coaching, with peer-to-peer coaching, or some sort of incentive structure, or..
Convergence Training: Posters!
Ron Gantt: Yeah, exactly. But it all starts with that first step of: we can identify what is safe and what isn’t safe, you know, and they use terms like at-risk behavior or something like that, to define what is safe. You come up with a checklist, and so on and so forth. And that that underlying definition, I think, is critical, that’s what I think behavior-based safety has to do. Because it also leads to the second thing in your list about human error, and I don’t think that that’s objectively possible. I don’t think it’s possible to come up with a set of behaviors that are bad in all contexts. There’s no such thing as a human error, in my opinion.
And the reason I say that is because anything that we would call an error is always contextual. It’s always something that’s bad in that environment. But if you put it in a different environment, it would be good. And so there is no behavior that is always unsafe. Right? It’s only safe in a certain context. And kind of an extreme example, is, you know, running with scissors is kind of the jokey thing we always say about being super-duper unsafe, when would running with scissors be safe? I mean, EMTs do it all the time, right? They have scissors that they use in their in their work, and they have to run with them sometimes. So it isn’t always bad, right?
And, in the same way, I just don’t see us being able to identify any unsafe act, unsafe behavior, at-risk behavior, or human error. You can’t define your point to any of those terms without pointing to a context. And that, to me, the critical point, you know, human error and unsafe behavior are always a product of the context. Going back to even the discussion on hierarchy of controls, if it’s not a behavior problem, or a condition problem, or an engineering problem, if it’s a problem of the combination between those two, then dealing with it by just trying to coach people to do the right thing all the time, is not always going to work.
You know, certainly there’s some contexts where we could say, “Hey, you know, Hey, Jeff, don’t touch the hot stove, it’s going to hurt you.” But if you think of the complexity of work, there are very few things that are absolutes. There’s some stuff that’s going to require thought and planning and adapting your behavior to certain conditions. And so the problem with behavior-based safety and the problem, to be honest, with a lot of approaches to dealing with human error, is they don’t recognize that interaction. They don’t recognize how the system is influencing the behavior. And so if I want to change the behavior change that that underlying system, you know, trying to fix it by telling people to try harder, or to not have any more errors, is not going to do it.
And that sort of leads, I think, to the last point about situational awareness. You know, situational awareness as a concept may have some value. Of the three, it might have the most value, but the problem with situational awareness is it’s often used retrospectively to say, “Okay, this person didn’t have appropriate situational awareness. So why aren’t you more situationally aware of this? You know, this bad thing before you got hurt?” And it doesn’t really make sense. And I think Sydney Decker said it really well, like, if someone’s not situationally aware, where is their head? Right. I mean, people’s heads aren’t just nowhere, right? It’s sort of the same kind of idea to me is like someone wasn’t paying attention. If I lose situational awareness or if I’m not paying attention, where’s my attention, then? Where is my awareness?
To me, those things don’t exist, right? Loss of attention or loss of situational awareness are not things that actually happen. If I’m, from your perspective, not situationally aware, that might be an interesting thing to talk about. But I’m always aware of the things that I think are important to me in that moment. My attention is always on the things that I think it needs to be on at any given moment. It may not be on the things that in retrospect, we say were the important things, but that kind of doesn’t matter in the moment, right?
And so I think these terms are often used in a way that’s inappropriate. I think situational awareness, of the three concepts you talked, about would be useful if we used it to say, “Okay, what was the person aware of in that moment?” You know, was that thing more interesting to them. Why did you know that makes sense to them in that moment, rather than like having this broad concept of situational awareness that someone can be situationally aware of everything at all times, which I don’t see how that works in real life.
Convergence Training: But I guess one of the key distinctions you’re making there in regards to situational awareness is studying it to figure out what the person was thinking of as opposed to simply using it as a way to point out an imagined flaw or fault on their behalf.
Ron Gantt: Totally. Yeah, I think that’s a really good way of saying it, because situational awareness is often talked about, like it’s this threshold, like if I get above this level of awareness, then I’m situationally aware of everything that’s going on around me. And I mean, I don’t know maybe the Buddha could do that. But the rest of us, we are mortals, we’re going to be aware of what we think is important to us in that moment. So if we want to change that, then step one, get in the head of the people that you’re trying to influence, and figure out what in this system was telling them that those were the important things to pay attention to, and change those things, rather than trying to tell people to try harder.
Convergence Training: Yeah, that’s completed my point. Well, thanks. Aren’t you soon going to be speaking to the ASSP in Seattle on human error, whether or not that’s a viable idea?
Ron Gantt: I believe so. Yeah. Yeah. So I think the Puget Sound ASSP meeting in October 16.
Risk & Risk Management
Convergence Training: On two more points, the first being risk and risk management.
Ron Gantt: Yeah. So I guess how do we define risk is sort of the question, and the traditional way we define risk in safety is probability and severity or, you know, some version thereof: frequency, likelihood, likelihood, and consequence.
And that works well in some contexts. But I don’t think it really captures how people interact with risk in real time. And so actually a definition that I actually like is, there’s an ISO definition for risk, which is the effect of uncertainty.
And I think that sort of ties risk to something that I think is closer to how people tend to interact with risk. It’s more about how we manage the uncertainty and ambiguity of the situation, both good and bad uncertainties. And I think if we say to people, sort of adopt that definition, in some context, or maybe other contexts we’re having the older definition may work, I don’t know. But if we adopt that definition of seeing it as how people deal with uncertainty, then the question becomes “Okay, can we reduce that uncertainty in some way for people? Can we make it so that they can adapt to that uncertainty in real time?” You know, that gets more to the capacity question than the traditional way of looking at risk, which is more linear and almost top-down in some ways, we get to decide for you what is acceptable, what is an acceptable risk, whereas this is more about enabling people to deal with uncertainty.
See our What Is Risk? article for more on this.
Convergence Training: Right, yeah. And then, I guess the last one, when you brought up this idea of safety culture.
Ron Gantt: Yeah. So, this one, it’s hard for me to separate my feelings on this one, from you know, is it being very practical, or am I just being like a bugaboo, and kind of my academic side coming out, but the idea of safety culture is weird in safety, because I don’t even know what the heck we’re talking about when we talk about safety culture, oftentimes, and you see it all over the place. People use it like it’s the Holy Grail. Like if we can get a safety culture, we will be great, everything’s going to be fine.
But when you start to try to nail down what is it that people mean when they talk about safety culture? You know, it’s not always clear. Now sometimes they’ll point to things like, you know, caring for other people and putting safety above other things. Which is all well and good, but then it starts to ask questions: “Wait, are there times when that’s bad? Are there times when caring for other people above other things could put someone in harm’s way?” Yes, absolutely.
In fact, I’ve dealt with clients where they had what probably others would describe as a good safety culture. But because everybody a really good strong family atmosphere, with people caring for one another, in certain conditions it led them to do things like non-reporting of accidents, because they didn’t want to get other people in trouble, or working harder than they probably should and throwing out their back as a result, because they wanted to help out a colleague and a coworker.
And it’s easy for us to say, well, that’s them not putting safety above everything else. But we just have to note then that that means the definition of safety culture contains a contradiction. We want people to care about other people, except when it comes to their safety where we want them to be selfish. Right? How do we manage that? I don’t know. Nobody talks about that. Right? And so my problem with safety culture is that we make it seem like this really simple concept, but culture when you go to the science where people actually study cultures and the research on this, it’s complex. It’s messy. When you look in the sociology and the organizational sciences, when they start to look at, like this thing that we have in safety called safety culture, they’re scratching their heads and saying, “I’m not even sure there’s such a thing as a safety culture. How do we, you know, what does that even mean?” And, you know, they’re wondering what the heck we’re talking about.
And I think it’s time for us in safety…I’m okay with the idea of culture, I get a little twitchy, because I think it’s a buzzword. But I understand that there are times when the word culture and the concept and whatever it is, may be valuable for us. But if we’re going to continue to talk about culture, we should go back to the people who research this all the time and start asking questions about how do they talk about culture? What is the downside of culture? When do cultures lead to bad things, even good cultures? You know, how do social structures create space for people to both do good and bad, even at the same times in some situations, because we’re getting in the world of sociology, and in safety all we’ve ever talked about is psychology. And so we’re totally ill-equipped to know what we’re talking about. But it feels good to say that safety culture is the end all and be all.
And so, for me, I think we need to have a little humility in safety when it comes to safety culture in particular, but in general humility, but with safety culture, you know, we’re talking about things that are way beyond our pay grade. Let’s take a step back. Let’s start asking questions before we start getting prescriptions all over the place.
Convergence Training: Yeah, yeah, good point. I have got to confess, not only do I hear about safety culture all the time, and not only do I not know what it means, but I really don’t know what culture means or what organizational culture means or any of that. Certainly something I could study more.
Ron Gantt: A good place to start for people who are just looking to get started in understanding what I think is a good perspective on safety culture is Edgar Schein and his work. You know, an good introductory book is The Corporate Culture Survival Guide.
Convergence Training: That was going to be the question I was going to ask. And that was the answer I was anticipating. So thanks.
Ron Gantt: No worries.
Convergence Training: I think he was just on Todd Conklin’s podcast. Is that not correct?
Ron Gantt: That is correct. Yeah. So he’s done a lot of work in organizational culture. So he’s a good place to start. There’s certainly more references to issue of culture other than just him, but for people who are just starting out that’s, that’s what I’d recommend.
Check out this Todd Conklin/Pre-Accident Investigation podcast with Edgar Schein (note it’s the first of two, so check the second podcast as well).
How to Connect with Ron Gantt
Convergence Training: Cool. All right, Ron, thank you a million.
Are there other places where people can connect with you and upcoming conferences where people can see you talk or anything you want to tell people about how to find you and talk to you and listen to you?
Ron Gantt: Um, well, so I’m around you find me on LinkedIn, of course. That’s probably the easiest
Because then you can just like search for me on there–Ron Gantt. But I do go to a lot of conferences and stuff like that. The next one’s obviously in Seattle, I don’t think I have any more for the rest of the year.
But early next year, I should be at a few, I think one in the Bay Area, the Bay Area safety symposium, I think it’s what it’s called. But I try to put these up on my, my website at Reflect. So people can check out there, but I always love people coming up saying hi, talking to me, telling me I don’t know what the heck I’m talking about. I love that. That’s good.
Convergence Training: All right. So everybody, make sure to get out there and tell Ron he doesn’t know what he’s talking about. I’ll get the link to your website. And again, Ron, and you went for an hour and 20 minutes, a lot of information. Appreciate your time, and all the insights. And for everybody out there again, this is Ron Gantt.