Are you an Unintentional Exposure Amplifier?

What is an Exposure Amplifier?

Amplifiers are one of the three elements of Serious Injury and Fatality (SIF) precursors. An amplifier is a condition, factor, or situation that increases the severity of an exposure or increases the probability that an exposure will go uncontrolled. Amplifiers can be episodic, like an ice or windstorm, or they can be systemic, like a business model that discourages preventative and predictive maintenance and instead lets machinery run until it stops. How amplifiers are addressed depends on how they originate.

Three Examples of Leadership-Sponsored Amplifiers

Amplifier Example #1: An Important New Client

IEveryone on the leadership team was ecstatic; the organization had just won a major contract to help in the construction of a data center. Not only was it a 3-year contract that would provide stability, but it also created opportunities for additional contracts.

The Head of Sales met with Operations leadership and told them, “This project has to stay on time and on budget.”

Operations leadership decided to pull in one of their top Superintendents to lead the project. This Superintendent had a history of “getting projects delivered on time,” but their safety record was not stellar. Sales and Operations Executives met with the Superintendent to discuss how important this project was to the future of the company, and that the client needed the data center delivered on time.

There was nary a word spoken about the project being delivered safely on time. Leaders cannot assume that everyone will know that safe execution is expected.

The lack of this conversation started the amplifier flywheel in motion.

Amplifier Example #2: My Way

Chuck was nicknamed My Way. While the company had spelled out policies and procedures, Chuck was known to ignore them and told people who worked around him he was going to do it his way. Chuck was a hard worker, and the supervisor saw him as a person he could count on to get the job done, no matter the circumstances.

Chuck’s peers did not like working with him; they knew the risks he was taking also put them at risk. Employees had talked to the supervisor about their concern, but the supervisor brushed off the comments and joked that Chuck was unique.

When the employees pressed the supervisor, he acknowledged that Chuck took risks and agreed to talk to him. He never did. Leaders establish the level of safe behavior and exposure within their workgroups. A leader who ignores people who do not abide by the standards lowers the bar for everyone.

When this supervisor did not address a known risk-taker, the amplifier flywheel went into motion.

Amplifier Example #3: The Customer is in a Jam

An important customer called the plant manager directly and told her that if they cannot get the parts delivered by next week, he will have to shut down his production line. He shared that his business would be put in jeopardy. Running normal production rates for the week would not make delivery possible, so the plant manager called a meeting with the production managers and asked them to produce a plan to get the needed parts to the customer.

The managers came back with a plan requiring operators to work more than 14 hours per day for the next 7 days. This would be a clear violation of the fatigue policy. They would also have to run the manufacturing equipment near the red line and delay maintenance activity. The plant manager, remembering how the customer implored her to find a way, told the team to make it happen.

An hour later, the plant manager was still thinking about her decision. She went to the production floor and held an all-hands meeting, sharing the customer story and why she wanted to help them. She then said, “It is not worth taking safety risks to make this happen.”  She took the time to tell the crew that if anyone felt tired and needed a break, they should let their supervisor know; if they needed to be off at their regular time, let their supervisor know, and if they had concerns about the production equipment, pause the work and get an engineer or a supervisor involved. She told the crew that leadership would be spending more time on the floor doing safety observations, herself included.

This leader recognized that the decision she made would have been an amplifier, and she took the necessary steps to ensure it didn’t become one. She put the brakes on the amplifier flywheel.

How to Identify Amplifiers

Amplifiers are a challenge for all organizations. Episodic amplifiers are typically the easiest to identify and prepare for. For example, in areas that experience heat waves or ice storms, preplanning can occur, and preventative actions can be taken. A push for production at the end of the month or quarter can also be anticipated, and steps can be taken to lessen the impact.

Systemic amplifiers are more difficult to identify. These amplifiers can be woven into the culture or built directly into the systems. In some instances, it would not be culturally acceptable to raise the concern. In other instances, the amplifier can be a known problem without a clear solution. In the latter case, people give up trying. Identifying and addressing Systemic amplifiers requires upward communication and a willingness to discuss alternative solutions to the problem.

There are two primary ways to identify Amplifiers.

1. Review Root Cause Analysis (RCA) Findings from a series of incident investigations conducted on incidents with SIF potential. Amplifiers should be identified from these investigations. This is not always the case, especially if the person leading the RCA is not specifically probing for amplifiers. The organization may also want to conduct Safety Decision Making Analyses. These analyses can provide important insight into how leadership decisions are influencing the level of exposure in the organization. (Insert content about SDM analysis and link)Interviews and focus groups.
2. Meet with production leaders and front-line employees and introduce the Amplifier concept. Next, lead a discussion of the amplifiers they experience and the impact on exposure. Doing this exercise with multiple groups will lead to a list of common amplifiers. The last step would be to compile a single list and categorize each amplifier as episodic or systemic, and then prioritize. In our experience, these Amplifier discussions are best led by someone outside the team or organization. An outsider is not hindered by being part of the culture, and they can deal with an uncomfortable situation where specific people are identified as amplifiers.

Once the amplifiers are understood, a plan of action can be taken to develop mitigation strategies.

Conclusion

No one sets out to become an amplifier. Amplifiers can result from well-intended decisions made in pursuit of production goals, customer demands, or cost pressures. The challenge for leaders is recognizing that these decisions can send an unintended call-to-action message. Employees pay close attention to what leaders prioritize.

Effective leaders pause and ask themselves a simple question: “Could this decision increase the likelihood that an exposure goes uncontrolled?” If the answer is “Yes,” they reconsider the decision or what needs to be done to assure it does not lead to risk-taking behavior. By considering the amplifier effect, leaders can prevent the amplifier flywheel from starting. Identifying and managing amplifiers is a leadership responsibility. When leaders actively remove amplifiers, reinforce critical controls, and encourage open discussion about risk, they create the conditions for people to succeed safely while still achieving operational objectives.

In the author’s experience, the discussion of systemic amplifiers is difficult for an “insider” to have. We have heard EHS professionals and middle-level managers say that the amplifier needs to be discussed at the Executive level, but see raising the topic as career-limiting or leading to a significant negative reaction. In some cases, the amplifier itself may not be addressable in the short term, so the discussion needs to be steered toward actions that can be taken to mitigate the impact. It is for these reasons that it is helpful to have a partner from outside the organization delivering the message.