Steve's Safety Minute
#2
Fix the System! Not the Blame
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Safety management system (SMS) failures (root causes) always exist prior to the effects they produce. The effects they produce represent the surface causes of an accident. There are two general categories of system weaknesses.
System Design Failures. Inadequate system design include less than adequate design of SMS structure, inputs, and programs, policies, plans, processes, procedures, and practices within the various elements or activities in a safety management system. Design weaknesses represent the "deep" root causes. Analyzing for root causes takes more in-depth investigation, but results in long-lasting corrective actions and system improvements that can be much more effective in preventing future accidents. Bottom line, system design failures represent a failure to plan the work. The effects of a failed SMS are SMS performance failures.
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System Performance Failures. When system design is flawed, you can expect system performance as well. System performance failures are the predictable effects of flawed system design. System performance failures may take many forms, including:
- safety training isn't conducted effectively
- rules are generally not being enforced
- physical resources (tools, equipment, materials) and psychosocial support (workload, scheduling, etc) are not being provided
- safety supervision (inspections, observation, etc) is not being conducted
- supervisors and managers are not demonstrating leadership by example
Failure to plan the work will result in failure to work the plan. If the SMS is not designed adequately, yet followed precisely, the outcomes will still be flawed. the SMS must be planned and worked adequately for the outcomes to be effective.
With the above in mind, we need to understand that design/performance failures of the SMS, not employee personal performance failures, is the cause for most accidents in the workplace. All safety management systems each generate thousands of variables that may, in one way or another, contribute or cause an accident. Consequently, it makes sense to presume the SMS is failing, not the employee, when conducting a near miss or accident analysis. Why is this important? If you assume the system is failing, you'll naturally conduct SMS analysis/evaluation prior to placing any blame on employees. On the other hand, if you assume the employee is at fault, the SMS will not be analyzed/evaluated prior to placing blame. The result will be unfair/inappropriate employee discipline which is always counter-productive to effective business operations.
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