Learning Safety from Unplanned Events

Dec. 6, 2017
Blame and Punish? Or Learn and improve?

I recently heard the above question during the Safety Conference at the Lineman’s Rodeo in Overland Park, Kansas. It was posed by Stephanie Swindle during her presentation and echoed by Jeff White on a follow-up phone call, both of whom work for Southern Company in Birmingham, Alabama. They were describing their relatively new approach to learning from unplanned events.

I was struck by their description and decided to learn more. I listened carefully, asked many of the questions I think most of us would ask, and then ran to the books to see if the science was valid. It was. This journey of discovery, therefore, had two distinct steps that were: first, hearing the facts and second, learning the science.

The Facts – Learning Teams at Southern Company

Southern Company has decided that they will approach the treatment of unplanned events through a Learning Team approach. This path is different from the classic Investigate, assign Blame, and then administer Discipline approach (we’ll call it IBD for our purposes). Their belief is that the “IBD” approach prevents learning about systemic conditions that frequently contribute to unintended consequences. As Jeff queried, “Do you want to fix the worker or fix the system?” In other words, do you want it to happen again?

Pointing fingers is easy, but it overlooks the fact that most of us want to do a good job, ignores hidden influences and assumptions, creates dysfunctional relations over the long term, and destroys collaborative problem-solving. Although the Learning Team approach avoids pointing fingers, it does not let employees off the hook if they are truly responsible. Jeff has been working at the Southern Company for 40 years and it was my impression that he does not suffer fools gladly. There is nothing easy about this approach compared to the classic investigation process (IBD). In fact, it is harder, but in Stephanie’s view, it is absolutely necessary.

Stephanie shared that, unlike the traditional investigative process (IBD), the Learning Team approach does not begin or end with blame and punishment. Rather than call in employees one at a time for questioning, the Learning Team process gathers many at once. In fact, when appropriate, employees can simply bring along a colleague. The idea is to learn, to clearly understand the difference between the Black Line (the way work is nominally supposed to be done) and the Blue Line (the way work is actually done). She says that employees get to “tell their story,” without judgment or blame. Then others are invited to add additional insight to complete the discovery phase. The next day the team meets again to begin discussing solutions or to prepare an improvement plan.

“There is no easy button,” she adds. The meetings can be arduous and require significant work from the team. It is taxing. Over time, the Human Performance (HP) team has earned the trust of many of the employees, an important element of this method. Employees know that once the process has started they won’t be punished for telling the truth.

When an employee is truly culpable, they are disciplined. But, over time, even this discipline has decreased in severity because managers can now more easily see systemic drivers and complications that were previously overlooked. The Southern Company wants to design safety into their work practices, essentially making most tasks “fail-safe,” such that even blatant mistakes can’t lead to catastrophic failure. It is an admirable goal and a mindset worth retaining. They try to design barriers that will prevent recurrence, without overly complicating the work task.

Both Jeff and Stephanie told me that the manager is not usually invited to the learning event, but that they are provided a personal update immediately after the meeting. The idea behind limiting involvement of managers is to provide a comfortable environment where workers feel they can tell their truth and also to prevent management from taking decisive, but misguided and premature action. As Jeff shared, “it is human nature to issue an immediate fix,” although the quick fix may not be the best solution.

Managers frequently confuse performance management for safety-related discipline. The former is harder than the latter, but in my view, this is because we don’t give it enough attention. It is an area that requires constant practice and repetitive training, a skill that demands overlearning—learned to the point that you can’t get it wrong. Jeff reminded me that “once the event has occurred, the company has already failed.” Both Stephanie and Jeff think it is best to think of events in those terms and concentrate on further-reaching, systemic solutions.

The Science – Hess and Smerek

Southern Company’s approach drove me to the books to review how organizations learn. At first, I was put off by the rather dramatically titled Learn or Die: Using Science to Build a Leading-Edge Learning Organization by Edward D. Hess. But, over time, I determined that it was actually perfectly and legitimately titled for our industry. The second book was Organizational Learning & Performance: The Science and Practice of Building a Learning Culture by Ryan E. Smerek. Both are outstanding and helpful books. A Skillsoft book summary of Learn or Die crystallized five key practices:

  1. Overcome Lazy Thinking
  2. Understand the Role of Emotions
  3. Create a Learning System
  4. Have Critical Conversations
  5. Use Critical Thinking

The Learning Team process drives all of these practices, including acknowledging what we don’t know. The summary continues, “fear and ego are major barriers to learning.” To which I would add that especially includes the fear of job loss. We must be able to fearlessly admit when we don’t know as much we think we do. Then learning is possible. The summary authors state bluntly, “feelings such as embarrassment, vulnerability, and incompetence tend to short-circuit learning. Psychological research has shown that we learn better when we do not feel afraid or threatened and when we trust that our mentors (supervisors/managers) really care about us as individuals.” Eliciting Blue Line reality from Black Line planning necessitates an open exchange of the reasons behind the steps taken by individuals during the event. Understanding our reasoning “in the moment,” and determining why it was flawed, will likely lead to a more accurate, long-term solution.

Smerek adds, “With a strong set of social norms that foster learning from failure… and discovering new ideas in the service of [safety], we can develop new thinking dispositions. The goal is transparency (being open about what we think) and the pursuit of truth (being motivated to get to the bottom of things).” The findings in these books not only substantiated the Event Learning Team Process, but also opened my eyes to a new way of thinking about learning.

As always, we’d love to hear about the approaches other companies are taking to improve safety.  If you have landed on an approach that seems to work well, measurably or anecdotally, please let me know.  I’d love to discuss it carefully and we’ll try to square it with existing and unfolding learning science.  To share our very best approaches industry-wide is a tremendous learning opportunity, no travel required.  We all – including our families – win.  Wishing you a wonderful Holiday season.

In Learning,

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