Recently I had the pleasure to witness a brief presentation by Lieutenant General Robert Mood - fittingly in the historic surroundings of the Oscarsborg fortress in the Oslofjord. What follows are a couple of highlights from his half hour of reflections.
What struck me at first, was the humble attitude of this high-ranking, much decorated and acclaimed person. Especially because I had seen him in the news several times before, where he was not afraid to speak rather clear language about various subjects (notably, he has been awarded the Fritt Ords Pris earlier this year). He started by stating that he couldn’t teach much to others, including us, but he had a lot of experiences to share and it was up to us to draw conclusions and decide if his experiences were relevant for our situation.
He discussed a number of events from his active service in the Middle East and other locations in connection to ethical questions, like if you should return fire (or how much) when you suspect that there are civilians (children) in a building. There are no black and white answers to many of these ethical questions, so it is good to discuss ethical dilemmas before they arise and be prepared to handle them.
Leaders have to provide for that their people are able to solve the tasks that they are assigned to. It shall not fail due to lack of training or equipment. Leaders have also the responsibility to follow-up and take care of their people afterwards (debriefing, etc.).
One of the most important elements of ‘building’ a desired culture is to create a climate where it is allowed to make errors. We all do, and we must learn from them. It is important that leaders stand for their people, also when they make mistakes. Loyalty goes both ways! This is a central theme in culture, but little understood by many top-leaders. One must understand what loyalty goes up from the people to their leaders, and just as well must leaders understand what loyalty they have downwards to the people they are responsible for.
Responsibility cannot be delegated. Authority and resources can be delegated; responsibility stays with you. When soldiers are sent on a mission, they usually get objectives (general and some very concrete) along with a couple of things they shall not do. Micro-management does not work; the details they should be able to figure out themselves.
It was interesting to hear how the military had worked on their values. Not by defining them by the management team (or with some consultants), but by spending over a year and a half speaking to people at the sharp end and hearing what values they thought were important. Eventually this emerged bottom-up as the values for the organisation.
About speaking up freely, Mood gave two good guidelines:
- Firstly, you should be free to say what you want about your situation, your experience and your responsibility. But do not step over borders and talk about others.
- Secondly, do the ‘VG Test’ (VG is one of the major Norwegian newspapers, and also one of the more ‘populist’) before you speak: What would you say if you see your picture in the newspaper tomorrow and hear you self quoted? Would you think that would be all right? And what would your family (wife, mother, …) think if they saw it.
(A bit of needed context: Mood was speaking about giving opinions and statements to the media. For him it was perfectly okay to describe your horrible circumstances on a mission in Afghanistan, but you shouldn’t step in the shoes of the ministry and say that they made a dumb decision to send soldiers to Afghanistan. As an example, because there are nuances.)
Also published at Linkedin.
During our recent vacation, we had some nice walks in the Swedish woods. A while ago, I bought my wife a fancy iPod with an included step counter (and all kind of other fancy ‘health’ functions and statistics). She took this device when we went for a walk, just for fun to see how far it would be around the lake and that kind of things.
At one point, my wife mentioned that she recently had seen a news item as well as a scientific article that mentioned research which had ‘shown’ that step counters and similar devices did not work if you wanted to less weight.
The article tells us that “Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches”.
That is interesting, because it sounds really counter-intuitive at first. Besides, has other research not ‘found’ the opposite? But then, this is a rather typical phenomenon that you can find research and sources that shows different results. All the more reason to look critically at the sources and methods to find out what the research or source really is worth.
But that was not what I wanted to discuss at this point. Let us assume that the recent research is right and that these activity-tracking devices indeed do not help as we assume they should do. What the article does not mention is why that would be so. Here is my hypothesis:
I am fairly sure that we are dealing with a typical example of the means becoming the goal. Someone has at some point come with some advisable number of steps that one should go a day in order to stay healthy or lose weight. 10.000 is a typical number - what a coincidence that it would be such a nice round one (one would expect something more differentiated - also TNO makes some critical remarks). But whatever…
Assuming that 10.000 it is, what happens is that many people replace their original goal (getting healthier, losing some weight, getting in better shape) with reaching the numerical goal (go 10.000 steps, that is what the doctor said) without any regard if the real goal is reached. It is a rather typical effect of the System 1 and 2 substitution of a difficult question with a simpler, alike sounding version.
There may also be an adverse effect of bonuses at play, because many people promise themselves some kind motivating incentive (“If I go 10.000 steps today, I can eat a bag of potato chips before the telly tonight”). By that, the positive effect can be ruined by the unintended side-effects of the measure/bonus.
Of course, this is no exclusive thing for weight watchers. In fact, many KPIs have exactly this effect. Numerical goals tend to become an end in themselves, which leads to unwanted effects, like when responsible managers manage quantity, not quality.
When something becomes a numerical target, the target is easily separated from what it intends to achieve. Set a number of near-miss reports and incentivise reporting: you can be rather sure that you get the desired number of reports, not necessarily the quality of reporting or wanted improvement. Hopkins and Maslen say in their book “Risky Rewards” that this is not necessarily dishonest; it is merely the most practical way for busy people to ensure that they meet their targets. But dishonest or not, it undermines the value of the activity entirely.
So, you can manage what you measure, but very often it does not help you one tiny bit when you forget the real objectives that are behind that number and do not pay attention to unintended side-effects from your metrics and bonuses.
Also published on Linkedin.
This time I would like to look at a rather difficult subject. A subject that I don’t really know what to do with and I have no immediate solution for. At least we can start by being aware of it, reflect a bit and maybe discuss. Who knows where it goes…
A Critical Comment? Thank You!
I am pleased that quite many readers of my book get in touch or drop a line. Some just to tell that they enjoy it or to say that they are happy to see that they are not alone in their thoughts. Some also take the time to discuss some subjects a bit more in-depth, or make the effort to comment critically on specific elements.
One of those is Iván Ciudad-Valls whom I have to thank as the main inspiration for this posting. He pointed me towards some things that I knew about, but had not considered while writing the following on page 44 of Safety Myth 101:"As far as I know, nobody ever comes to work with the objective to do a bad job; getting up in the morning with a thought of "today I'm going to have me a nice little accident".
As Iván rightly points out the statement is too absolute. There I fell in my own trap. I did not follow my own rule: Do Not Use Absolutes (after all, many places in the book I argue against absolutes) and there you go. Of course I could try to talk me out of it (I did say "as far as I know") or some other excuse, but firstly, I am here to learn, so no excuses. Trial and error are often beneficial. Secondly, I do know actually that not everyone works to do a good job. Some do only a good enough job, or do just enough in order to stay under of off the radar. Dilbert’s Wally is a classic example of this attitude.
But things can be even worse. I cannot recall a Dilbert episode where Wally actually set out to create a proper accident (but do correct me if you know of one). We can assume that disengaged employees still are motivated enough to not have an accident. Even actively disengaged people like Wally probably want to get home in one piece after work…
A Wanted Accident
Iván, however, directed my attention towards some accidents in Spain where some cases have been of workers who themselves create ‘an accident’ to collect insurance - even going as far as amputating limbs. This may sound like the plot of a cheap crime drama or a run-of-the-mill episode of CSI with a semi-socially engaged tinge. Alas this is also the dramatic reality, and I have heard about similar events from other countries.
A news article that Iván forwarded (in Spanish, sorry) tells the story of a Slovak worker. He cut his own leg to collect 200.000 euros insurance, simulating a workplace accident. He was finally arrested by the police.
What has this to do with safety, some Safety Professionals may think. Wilful acts like these are of little interest for our profession. If someone is willing to hurt themselves, they will surely find a way. You cannot prevent them, and if the police gets them - good!
I might have said the same a few years ago, but firstly I do think that employers and Safety Professionals do have a role and responsibility in these cases also. Secondly, the harm will not be restricted to the poor people who create this ‘accident’. Also colleagues who witness the event or injury will be affected and maybe traumatized. There is a clear responsibility in that. Thirdly, these cases of self-harm, difficult and dramatic as they may be can also teach us about what drives people and rationality.
Rational? This? Que?
People are often puzzled about the things others do. Things that are clearly illogical to them - like cutting off a limb. What many forget or are not aware of, however, is that the assumption that behaviour and logic/ratio are always connected is false. Also it is little understood that full rationality is merely an illusion. It has been written before, by me and others, and let’s just do it again because not everyone has understood the message yet: people act out of their local rationality, not out of some form of clinical logic.
In general, people do not break rules because they are stupid, or because they are bad people. Safety rules get broken, people do things and people do not pay attention because it makes sense to them at the time. Not because they are idiots or evil, but because of conflicting goals, because of circumstances, because they do not have all the information, because they get an overload of information, etc.
Sadly this includes also the poor people who set out to harm themselves. In their local rationality this is the best way to provide for their families or whatever goal they strive for. For them it makes actually sense to sacrifice a limb or their health for money. Of course the problems that these people experience, and the things leading up to such a dramatic decision are much more complex than I can describe here or that I have competence of to discuss.
What To Do?
What can we do about these things as Safety Professionals? I seriously wonder. As I said in the start of this article, we can begin by acknowledging that these things can happen. Secondly, I suspect that some sectors and worker groups will be more susceptible than others, and if you notice something the very least would be that you have to raise the issue. Thirdly, if it were an ‘ordinary’ accident we were discussing here, we would probably look at opportunities to change the situation in order to change the local rationality. The same we could try in possible cases of self-harm of course.
There are definitely factors that are likely to be valid predictors for behaviour like this. I don’t know if there has been any research, but I would assume that cultural factors, people being underpaid or working under very bad circumstances are relevant.
I saw an example as a headline of a Norwegian newspaper earlier this week. The OHS Authority (Arbeidstilsynet) had found a case where eight foreign construction workers were forced to use the floor of a cellar as toilet. Under circumstances like these, who knows what people can be driven to...
Also published on Linkedin.
A few weeks ago, I was at an international meeting where I (among other things) presented some learning points from recent work that we have done with regard to the use of a particular breed of dogs in the police force. This was one of the most fascinating projects I have ever worked on, and one that I am rather proud of, because we managed to turn the initial reaction in the line of “remove the bad apple” to a more system and context oriented approach.
After the meeting, a colleague approached me. He told me another dog story that contains some good learning points as well. This true story (somewhat altered below to make it more anonymous) also illustrates perfectly our initial desire for justice or retribution versus a more systemic view that makes one wonder if the concept of cause and effect applies here.
This colleague, and his family, had visited a cousin. This cousin and her husband love animals, and they had taken in a former stray-dog from a dog asylum. While this dog had seen a lot of neglect and abuse earlier in its life, it had become rather well adjusted to family life and being around people. It had not caused any real problems so far. Still, because of its experiences, the dog would feel threatened and react accordingly when it was surprised, especially when approached from behind.
Therefore, the hosts told their visitors to be careful around Max, the dog. It was fine to pet him and play with him, but they were not to frighten or scare Max. They were told to always approach the dog from the front, as much as possible, to avoid surprises.
Everything went fine. The family had a good time together and the colleague’s kid, aged 5, played a lot with the dog. The kid and the dog went very well together and seemed to enjoy each other’s company.
The next day something terrible happened. The kid went to play with the dog again. Since they had played all day before and she and Max had become best friends, she dropped all caution. And so it happened that the child approached the dog from behind. The dog was startled, reacted instinctively and bit the child in its face. The kid was seriously injured and had to be brought to the hospital a.s.a.p. for stitches and treatment. Luckily, the damage there was no permanent. The result could have been fatal, however. Had the dog bitten about 10 centimetres lower, he would have injured the main arteries or other vital parts.
We MUST have accountability!
So, what was the cause for this unquestionably unwanted event?
- The dog, for biting the child, injuring it badly and potentially killing her, had it bitten 10 centimetres lower?
- The child, approaching the dog from behind, even though she had been told not to do this?
- The hosts, for allowing the dog (who was a known potential problem after all) inside the house with guests and children present? Or for taking in an unstable pet in the first place?
- The parents, for not watching out more carefully, and reminding the child to take care?
Whom or what are we going to hold accountable? Whom do we blame? When something terrible happens we must have someone who is held accountable, after all.
Or do we?
None of the choices feels fully right. Just mentioning some factors:
- Max, the dog, was minding his own business until he was provoked. The dog reacted aggressively, sure, but an instinctive defensive reaction is perfectly normal, given the sudden stimulus and his history.
- The child acted out of her expected pattern. Even though she had been warned, successful practice had made the warning look overly cautious. She had played with the dog the entire day before and everything was fine. Besides, children are often forgetful when they play.
- The hosts love animals and they figured they did society and the animal a favour of taking Max in their home, instead of having him killed at the dog asylum. They were used having the dog inside the house and they had never before experienced trouble when they had visitors.
- The parents had warned the child, seen that everything worked fine the day before, and besides, they cannot go after a child all day long.
It is hard to argue that we have an incident caused by broken parts or bad apples. The various parts functioned fine in isolation and had functioned fine together the day before. Was this then a case of normal people (and animals) doing normal things? I would say it definitely was. This is a case where an unlucky combination of several rather normal factors led to a serious outcome. Surely, it could have been worse, which is very easy to imagine seeing the injuries in the child’s face. But, the outcome could of course also have been better had the dog missed the child, or only snapped a warning. In that case, I would probably be sitting here and writing another story. The kid would have been frightened for a moment, calmed the dog and most likely have carried on playing. At worst, it would have run to its parents and probably ignored the dog for the remainder of their stay.
No action was taken in this case and while the colleague in question said that this was rationally the correct decision, he felt só unsatisfied. His child was hurt and could have been disfigured for life or even dead, so someone must be accountable. He would not have lost any sleep over putting Max to death for reacting the way he did. After all, it is only a dog. I think many of us can sympathize with that view, emotionally. Reason and emotion are two different things and they are not always in tact.
Know any Maxes near you?
We see often that the easiest way to deal with problems is to pick on Max (the weakest party). It is also a rather satisfactory solution (to a certain degree) for many, because the party who did the harm receives punishment (satisfying our “eye for an eye” desire) and there is some quick and decisive action. But would it be fair? Or logical? And would it really solve the problem?
Now translate this story to a workplace accident near you and reflect.
(And do read Ron Gannt's fine article on where failure comes from)
Also published on Linkedin.
The past few weeks I have (among other things) read Doug Hubbard’s book “The Failure of Risk Management”. The title and description sounded promising, but I think the book has only limited value for practical safety work (even though it does at times mention safety issues). Still, thinking about risk is ‘core business’ for many Safety Professionals and so reading and thinking about risk in its various forms (also from other sectors, like finance) could provide learning points.
It quickly turned out that the author and I are on different planes (planets) philosophically, but that might make reading the book even more interesting, or so one would hope. As a whole, it has been a bit of a rollercoaster between sheer boredom, annoyance and interest. Regrettably there are also parts that really make me cringe. Let’s look at one of these occasions.
A Cringe Quote
Early on in the book, the author argues that virtually all of the risk analysis methods used in business and government are flawed in important ways and most of them are no better than astrology. And so he comes to a ‘profound’ conclusion:
“Obviously, if risks are not properly analysed, then they can’t be properly managed”.
Further on in the book he more or less repeats his claim:
“Most of the key problems with risk management are focused primarily on the problems with risk analysis. That is, if we only knew how to analyse risks better we would be better at managing them”.
Hmm, let’s think a bit about this. Can this really be true?
Shit In = Shit Out?
In a way, it seems to make sense. After all, the First Law of Quality Management says “Shit In = Shit Out”. So, feed a bad risk analysis into a system and you will get bad risk management. Common sense, end of story.
But wait, there is more to say!
Firstly, the above line of reasoning assumes that risk analysis is the only way to risk management. I would say that there are more ways to risk management than always through analysis. We get back to this in a minute.
Secondly, the above line of reasoning also assumes that risk analysis is the direct (and only) input to risk management. There are, however, a couple of steps between analysis and action, one of those deciding what to do. You can do a perfect analysis, and then decide to do something entirely ineffective, for example because you have incentives to do so, or because you do not have the means to initiate successful actions. Even if you take a good decision based on your perfect assessment, it is fully possible that your management is unsuccessful when external influences or unforeseen circumstances interfere with the results. To mention just some problems…
Decomposing a statement, phase 1
But let’s decompose the statement a little further. What does “if risks are not properly analysed, then they can’t be properly managed” actually say? The key points to look at would be the terms ‘analysed’, ‘properly’ and the connection between analysis and management.
Point one: what do we mean by analyse? Looking up ‘analysis’ tells us that it is “the process of breaking a complex topic or substance into smaller parts in order to gain a better understanding of it” (Wikipedia) and “a careful study of something to learn about its parts, what they do, and how they are related to each other” (Merriam-Webster).
It is clear that this is some kind of a formal and structured process, but according to the definitions above not necessarily involving numbers. Hubbard does (grudgingly?) agree on this part because he acknowledges at one point that also qualitative approaches are “an attempt to analyse risk”.
Decomposing a statement, phase 2
Point two: what does ‘properly’ mean. I presume that I would define it somewhat differently than Hubbard would. Hubbard is rather clear that the only acceptable form of risk analysis involves numbers and probabilities. Everything else is “soft”. I on the other side, would argue that the automatic, qualitative and even rather sub-conscious response before crossing a street is a good example of a proper analysis (although assessment may be the better word in that case) without any calculations whatsoever. And many practical assessments with regard to risk are made every day, just like that one.
When you ask me what a proper analysis is, or proper management means, then I would say something that is effective and fit for purpose. Others like Hubbard, however, hinge very much on qualitative and (semi) scientific rigour. Now, I am very much pro-science, but I think we should be aware of the fact that more numerical or more statistical is not always the same as more scientific or better science. It only looks that way.
Neither does more numerical or more statistical always lead to better decisions. And while we may be intuitively bad at dealing with probabilities, models don’t necessarily improve our decisions. Research has even shown that under some circumstances (especially with great uncertainty and little knowledge) less information actually can be an advantage.
Decomposing a statement, phase 3
Point three: what is the connection between analysis and management? We already touched upon the subject before and I have come across examples where the right things were done in spite of the risk assessment that came before it. Granted the analysis/assessment was in most cases not the best, but the risk management was initiated without any analysis whatsoever.
I am not familiar with any research about the connection or correlation between the quality of risk assessments and the quality of measures taken or safety management in general (leave alone the level of safety). There is a problem of how to measure these things, of course. We generally assume that good risk assessments contribute to good decisions and good safety management. Not at least because a good risk assessment gives opportunities for a systematic and documented review of possible problems (risks) instead of leaving it to coincidence what person, what competence, what authority or what political agenda was part of a decision process. On the other hand, organisations that are good at safety management are probably doing better risk assessments and using them better, so causality is bound to be fuzzy.
Finally, I mentioned crossing a street as an example above. Many decisions about risk are actually based on perception with no analysis at all. These decisions are not necessarily better or worse, they are different. The judgement about better or worse is only in the eye of the beholder. Many people do not want a nuclear power plant in their neighbourhood, based on their perception of the risks. Analysts may think this is crazy, because they can calculate a ridiculous low risk. Who can say what is right from a risk point?
Summing up, I am afraid that there is little which supports the rather strong quote from the book. You Cannot Manage What You Haven’t Analysed? It sounds superficially okay, but if you really think about it, it is more a smooth sales pitch from a consultant. It is also a good candidate for another Safety Myth.
Also published on Linkedin.