… Its not our fault: the neglect of health & safety

April 6, 2007

This is the first of three blogs arising from my visit to Moscow this week, for the first time since the aftermath of the events of 1989. One will represent my reflections on Moscow itself, the second will summarise my various presentations and discussion on How to get started in Knowledge Management. I am not, by the way, going back on my Whence goeth KM? comments. Instead I want to consolidate my various comments on social computing, expert location and linking knowledge objects to organisational strategy. More of that over the weekend.

Today I want to reflect on a question asked at the end of the conference relating to issues on Health and Safety. By the time the question was asked we had lost our (very) professional translator, so it took a long time to say little and I promised to blog a fuller response for those interested. There was considerable interest in my comments on the critical role of narrative in any modern knowledge management system, and the specific question related to its possible use in health and safety. Now this is an area in which I have found myself increasingly engaged over the years, and it seems to be one to which complexity and narrative approaches are especially suited. So what is my response to the question?

Let me start with some cynical (in the best sense of the word) comments:

  1. We have to realise that these days one of the main functions of health and safety groups is to prevent the company getting sued for negligence To this end the function is engaged in making sure that notices and rules are created covering all possible circumstances so that if any employee is injured the company can absolve itself of responsibility. Aside from the fact that humans cannot remember rules, or follow a myriad of regulations with any ease, work pressure, performance targets and the like may mean that they face a choice between loosing their job and breaking the rule. This puts the employer in a win-win situation, the work is done and targets are achieved, but if anything goes wrong the managers can wring their hands and say, in the manor and style of Uriah Heap, but we told them not to do that, its not our fault
  2. Training courses on induction are too quickly forgotten and will not be recalled in a crisis. It is another example of box ticking. We now seem the same thing with ethics in accounting systems, post Enron. Several trainers are making a fortune running accountants through three day training courses in ethics, giving them (and the company) a certificate and thereby assuming that ethics will prevail over mammon. The same with training. The old adage is that if you don’t practice something within a few weeks, you will not recall it when you really need it. Given that we know this, I find it amazing that people think they can created a skill or awareness on an induction week course, that will sustain itself for any period of time.
  3. Finally I return to an often repeated theme. If you look at the stories that people naturally tell in the workplace, they are overwhelmingly stories of failure not of success. The reason for this is simple, in a complex, ever changing, never repeating world of threats and oppotunities; avoidance of failure is a more successful strategy than imitation of success. All traditional story forms have developed types (such as the archetypal story form) to allow people to distribute stories of failure without allocation of blame. It follows that if you attempt to create a best practice system, THIS is the way that thou shalt do X they you are flying in the face of millions of years of evolution which says it is a bad thing.

So, what can we do differently? Will narrative help? To the first question, yes it will and considerably so. Start with a focus on gathering stories from multiple stake holders around the general issue of safety. If you use SenseMaker™ then it can be a large volume, but you can do this manually without benefit of software using lower volumes of material. If you interpret those stories, and look for the wider patterns you are much more likely to sense some of the underlying cultural (or more precisely ideation) aspects of the situation which are contributing to an overall climate of un-safety. Once you have that material, you have a sense of what sort of interventions and actions you can take. The following suggest themselves, but there are others:

  1. Take the stories you have already created and formalise capture of more at end of project reviews, key milestones etc etc. Remember you capturing raw anecdotal material without leaving a foot print. Do not suggest, or approve/disapprove of individual stores or story tellers, to do so would pollute the sample. Given people fee and open access, publish some of the more amusing ones, celebrate idiocy from which we have learnt: you have just created a worst practice system and it is more likely to be used.
  2. Look to the stories of work practices that precede narrow escapes. See what actions brought people to pay attention to previously ignored signals just in time. Can those actions be institutionalised as a trained habit (habits are very different from rules, as are heuristics)
  3. Are there any rituals that you can institute that would increase awareness of danger? One project I worked on involved using heated belts as a trigger mechanism to make people think differently, to assume a new identity. Think of the way that crews (for example the pilot of an aircraft) go through a set of ritual steps that bring to the forefront of their memory patterns associated with their skill as a pilot rather than their concerns as a mother (to take one example). Ritual is one of the most important, and most neglected of the evolved methods to achieving changed attitude and have emerged from the interaction of people with their environment over time.
  4. Start to work on the extension of ritual to creating a state of anticipatory awareness. This means creating a capability to engage the habits (that word again) or people, rather than seeking to get them to confirm with rules. There are several techniques that can work here. Pre-mortums in which people assume that their chosen course of action has failed and discuss the reasons. Rehearsing the story of what will happen, before it happens. There are many including our own ritual dissent. I came across a case last year with Power workers. They used, before they started work on a pylon, stand around the back of their truck having a cigarette and walking through the job, in anticipation of practice. This worked very well for some years until two things happened. Firstly people stopped smoking which meant there was not a natural process that slowed up engagement, instead of talking through things they went straight to it. Secondly a consultant (why do so many negative stories start this way) discovered the natural practice, documented it and they destroyed it by institutionalising the process with a check list. Give people a form and they will just tick the boxes; give people beepers with two many false positives and they will switch them off. I could go on, the list is endless.
  5. Look at all the ways in which false confidence can be created at individual and organisational level. If you are clever you will design your narrative capture to make sure that you specifically flush out and can identify these stories. Once you have them take a scythe and destroy or radically alter all rules and regulations associated with the complacency.

This is a preliminary list, there are others but it is enough to be going on with. Finally, and this is a very serious suggestion, keep the health and safety department, but report them into legal. In parallel create an accident prevention task force, into which field operatives cycle for short terms of duty. Don’t create full timers, make sure people stay linked to their colleagues through doing the job. Do not allow anyone with a formal health and safety background into the group, other than one person whose role is simply and solely to assist the group in breaking or modifying mandatory process. Its time to keep the legal and practical aspects of health and safety apart, before the former prevents the latter from being effective.

I could say more, and do on the Cognitive Edge accreditation programme. However I have seven minutes of battery time left and the plane has started its descent to London. Accordingly I will stop there. Tomorrow: how to get a KM programme started.

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The Cynefin Company (formerly known as Cognitive Edge) was founded in 2005 by Dave Snowden. We believe in praxis and focus on building methods, tools and capability that apply the wisdom from Complex Adaptive Systems theory and other scientific disciplines in social systems. We are the world leader in developing management approaches (in society, government and industry) that empower organisations to absorb uncertainty, detect weak signals to enable sense-making in complex systems, act on the rich data, create resilience and, ultimately, thrive in a complex world.

Cognitive Edge Ltd. & Cognitive Edge Pte. trading as The Cynefin Company and The Cynefin Centre.


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