Safe Decision Making for Safety Leaders: Part 1
New Research and Implications for SIF Prevention
Introduction
The notion that leadership matters to organizational safety is intuitive for most people. Over the years, we have accumulated a thorough understanding of certain aspects of safety leadership, what excellence looks like, and how that leads to safety improvement. Countless books have been written, leadership assessments have been developed, and organizations have entire programs dedicated to developing the safety leadership skills of their employees. Despite this progress, safe decision making is an aspect of leadership that has not received enough attention. Until recently, we hadn’t recognized the extent to which two things matter:
- The people making the most important safety decisions are not front-line workers. Workers have a role, but the most critical role in safe decision making is the one played by leadership.
- Leadership decision making is pivotal to the understanding and prevention of Serious Injuries and Fatalities (SIFs).
In this two-part series, we examine the evidence for these statements and their implications for policy, strategy and the role of senior leaders in SIF prevention. In Part I, we explore significant, and previously unrecognized, findings that can impact safety. Part II takes a closer look at key highlights from the study and the implications for business performance.
New Research on Decision Making in Safety
Extensive research in psychology over the past few decades has deepened our understanding of how our brains work and how people make decisions. We discovered that humans are not perfectly rational decision-makers; we don’t always make decisions that serve our best interests. Two psychologists, Daniel Kahneman and Amos Tversky, showed that human decision making is subject to error and thanks to them, we are now able to anticipate and even quantify natural failures in our thought processes[i]. Despite successful applications of their work to economics, law, marketing, and public policy, we are only now starting to understand how this decision-making research applies to safety.
In 2015, Krause Bell Group sponsored collaborative research to explore the very broad question, “What is the role of decision-making in serious injury and fatality prevention? Our Safe Decision Making (SDM) Innovation Group enlisted thought leaders from ORCHSE and six major corporations representing different industries. We pooled data, experience, and expertise in an attempt to answer questions like,
- Who makes safety related decisions?
- Which decisions are most important?
- Which cognitive biases affect which kinds of decisions?
- And can we improve safety by improving decision making skills and knowledge?
Participating companies contributed information from 60 SIF events. From these, we carefully extracted and analyzed over 600 decisions, and were rewarded with powerful insights.
Key Finding: Whose Decisions Matter?
It seems intuitive that everyone’s decisions matter. But one of the most pronounced findings of the study was that decisions made above the front line play a bigger role that we expected. Of the over 600 decisions found to have influenced the 60 SIF events, two-thirds were made by individuals in management positions. Additionally, the clear majority of those were made by site level managers. Front-line workers made fewer than 20% of the decisions leading up to a serious or fatal injury.
The extent to which site-level leaders’ decisions impact safety is not fully appreciated in today’s organizations. Managers know that they need to make sound decisions because ultimately, “a company’s value is no more (and no less) than the sum of the decisions it makes and executes.”[ii] Yet, this understanding has not carried over into the safety arena to the extent it should.
The Shortest Distance to Zero
Until leaders at every level understand this aspect of how safety improvement works, efforts to prevent injuries will continue to focus on front line workers, and we will miss opportunities to have a long-lasting, far-reaching, game-changing impact on our exposure.
It is critical that this not be misconstrued as blaming the manager, any more than it makes sense to blame the worker. What this suggests instead is that leaders are positioned to have a greater influence over safety than previously recognized, and by creating the right context for their decisions, equipping them with appropriate and timely information, and strengthening their skills in safe decision making, they could provide the greatest opportunity in safety improvement.
The shortest distance to a zero-injury rate may be through a direct focus on decision making within site management. As the data are telling us today, these are the leaders who make critical operational decisions every day, decisions that have direct impact on safety. These decisions involve scheduling, work assignments, purchasing of new equipment, hiring, etc.
In Part 2 of this series, we will dig deeper into the types of decisions that played a role in the 60 SIF events. We will explore how those decisions break down and whether it is possible to improve safe decision making. In the process we will suggest practical steps towards even more effective safety leadership.
References
[i] Kahneman, D., Slovic, P., & Tversky, A. (Eds.). (1982). Judgment under Uncertainty: Heuristics and Biases. Cambridge: Cambridge University Press. doi:10.1017/CBO9780511809477
[ii] Blenko, M. W., Mankins, M., & Rogers, P. (2010, June). Harvard Business Review. Retrieved from https://hbr.org/2010/06/the-decision-driven-organization.
Acknowledgements
Christina Thielst contributed to the skillful writing and editing of this article.
Hi, I’m a frontline supervisor (open cut examiner) in an open cut coal mine. I find this article interesting and totally agree with what is being put forward. Point 4 under decision making in safety: I would make at least 20 of these decisions every shift and having the knowledge of task objectives, procedures/ legislative compliance, worker capabilities and attitudes can mean the correct decision is made. At times I watch workers go about their task(s) knowing that they have the skill and ability to perform however could make a small error and create a safety concern without being aware. After providing the worker with the relevant safety knowledge or background it is evident that relevant info is crucial in making safety conscious decisions. I could ramble all night about this topic but I’ll leave there until part 2 of this series is out. I enjoyed the read! ?
Thanks, Scott!
Nice article , in fact we have just developed and indeed I am currently in Asia delivering some training for our leadership teams at each factory. This training is designed to encourage them to learn to see with a different perspective , understanding what is happening on the “shop floor” and coaching them with the things I see and the rationale for it along with the legal duties / ramifications or possible outcomes. Also we encourage intervention and engagement with the workers to gain their perspectives and ideas driving two way communication .. so far feedback is positive the ultimate goal is to reduce incidents.
I would agree that the basic tenor for safety (or EHS as a field) of an organization starts at the top and flows downs. Leading by example has a profound effect on workplace safety. From the Titanic to today’s modern high-speed warehouses, safety will only ever be as good as the person at the helm, who dictates the course and priorities of the organization. Also accurate information (even “bad news”) must flow up to the senior management ranks so effective decision making can be made. Short feedback loops are essential for improving the effectiveness of any program.
Thanks, Rob! Much appreciated.
Thank you Kristen for this article. James reason apportioned concern that organisational failure was significant in the causal chain for incident and accident as far back as the early 1990s. Both from the perspective of strategic safety decision making and tactical safety decisions in the work space. It is essential that organisations train and empower every employee as a safety leader to create generative safety outcomes and move towards zero injury rates. This will require investment in human capital for training in risk assessment and the need for managers to promote and encourage suggestions for safety improvement by those that do the unsafe work.
It’s an interesting study. I fully agree with findings. I am eagerly waiting for part 2.
I found this article interesting. It amazes me that some top level managers don’t get it; that if safety isn’t in their mind at all times, walking the talk, their direct reports and those reporting to them will follow by example. Where I am employed, our top executive walks the talk. Expectations are high and I have seen the culture change accordingly. A gentleman named Paul O’Neill once wrote, “Safety should never be a priority. It should be a precondition.” That is everyone’s expectation where I work. We care for each other and want quality of life after employment for all who walk through these does. What matters outside of work should always be on our minds. What matters to you?
Hello Kristen, it’s been a very long time. I used to attend the BST Users Conferences. I’m still associate with your current and former colleagues. This is an excellent article. I’ve investigated many SIF incidents in my career and always look for that point in which the outcome could have changed. I find in most SIF incidents there is an initial “Cause” many years before the incident and quite often it’s a technical or organizational change. Closer to the incident though the incorrect decisions are often taken by the immediate line management or unfortunately the person who sustains the SIF injury. If possible, can you mail or upload a full version of the article. Kind regards, Neil
It’s great to hear from you Neil! Yes, it’s a dilemma we’re working hard to solve: How do you improve safe decision making when the full impact on safety isn’t felt for months or years, if at all?
Exceptional article Kristen.
Thank you for the insight, something I’ll certainly be sharing this amongst my peers.
Kindest,
Clayton.
Thank you, Clayton!