About 4 years ago, I embarked on a project of repairing a Permit to Work system because it was clearly broken.
I had been arguing the case for some time within the specific line of business I was working, but was not getting heard. When I moved into a central safety role, again, I started speaking out to generate interest in repairing the system after reviewing incidents and found two almost identical at the same location in almost identical circumstances.
In both incidents, contractors touched live electrical cables while excavating. Neither were significantly injured, but both received a "jolt." In the first incident, the power was supposed to have been turned off and the cables de-energized. In the second, a contractor was digging just 12 inches from where the cables were supposed to be laying.
Then last week, I received a call from a friend who had just investigated an incident at a retail fuel site where there had been an incident. He shut the site down and investigated the causes. He was still doing this when pressure to get people back to work resulted in the site having another absolutely identical incident. In neither incident was anyone hurt, but they could have been killed in both incidents.
Airports are inherently hazardous environments. The reason most people can go home at the end of each day is because the hazards are generally managed so that people don’t get hurt. But it is very rare when an incident occurs that we have never seen before.
As a result, we end up unnecessarily hurting another individual and family because the industry had the knowledge to prevent the incident, but failed to adequately control it. So I ask myself why we cannot effectively share information so that we all benefit from one misfortune and have an opportunity to refine our processes and procedures to prevent an incident from happening again.
We have the knowledge as an industry; but individually or organizationally, we may not. Why?
Information sharing in the right form and environment is vital, but the lawyers get panicky about this. They have a real and proven fear of litigation. Providing information on the causes of an incident may lead to legal action. Or someone may misinterpret the information and apply a process incorrectly so we do not share. Holistically, this results in us accepting that people will be injured – just not our people! But even that is not correct as you can see by the incident I talked about at the beginning of this article where in the same organisation and even the same line of business we had the potential to hurt people because they did not understand the risks and control them adequately.
'JUST CULTURE'
Consider the following:
- Incidents and near misses must be reported so they can be recorded without fear of retribution. Where people are fearful of reporting, people get unnecessarily hurt. There still has to be consequences for some actions, but this needs to be viewed within the ‘Just Culture’ model so that an honest mistake or a lapse is not treated the same as a willing and negligent act.
- Causes must be understood, which means that all incidents and those near missed with significant potential consequences must be investigated to determine the root cause and the contributing factors.
- People must be engaged. The incident learnings and causes must be communicated widely throughout the organisation in a way that makes sense to people, in a way they can relate to, in language they understand and can discuss with their workmates. Managers need to facilitate the discussions within the workgroups to see how this type of incident could occur in their part of the business with their activities or similar (it is this ‘or similar’ activity or situation that is often misses in the discussion). Managers should facilitate discussion not preach. The group generally know more about the activities and the relationship between the incident being discussed and their work activities than the manager will and can relate the information to their circumstances IF it is well explained.
- Processes must be reviewed to determine whether the same of similar consequences can occur in similar or different circumstances. You need to think broadly and engage the experts in the activities to test and challenge the assumptions to know what and how the established processes can fail so you have the opportunity to identify the hazard if it has not been considered previously in the controls and procedures, to check that the controls will work when called upon and that people understand the controls to be able to apply them correctly.
- People must be instructed and tested and supervised to ensure their understanding of modified processes so they can apply them correctly.
Let’s take a near miss as an example where a worker at Airport A was nearly crushed when reaching under a belt loader to retrieve a bag that no one else saw while his mate was lowering the belt preparing to move it away from the aircraft. The investigation will determine the following causes:
- Root Cause: The bag was placed inappropriately on the belt.
- Contributing Factors: Worker did not recognize the hazard, no training on how to recover bags in this area, time pressure to turn the aircraft around, no advise to co-worker that the worker was going to get the bag, etc.
The fact-finding process should not overly focus on the detailed specifics of the incident other than to provide a brief overview. The facilitator should focus the group discussion on the crush risk and where in their workplace with their activities and those of others and then ask what controls are in place to prevent these. After that, there will generally be procedures that need to change and people to be trained in the altered procedures.
Remember, the best control is to eliminate the hazards or work down the hierarchy of controls findings the strongest controls you can to prevent the incident occurring.
When you have found gaps in procedures, training or behaviors and corrected them, tell other companies on the airport through the Airport Safety Committees and ask the safety representatives or managers to tell other locations because effective and timely communication is the key to stopping others getting hurt…even if the lawyers find it hard to bare their souls!
Aviation regulators have a real role in this process and hopefully, will take this need on board to create an effective communication conduit to incident learnings even for ground staff.
