Reasons why shit happens

Following on from our first piece on the “10 reasons why shit happens”, here’s a deep dive into the top reason why shit happens and some additional insight that you may find helpful when managing change (both strategic and operational). Management of change aims to protect workers from harm before and during the implementation of changes. It ensures that change is evaluated for safety prior to the change occurring.

Breaking it Down

Strategic and operational change are the two types of change that cause serious incidents/accidents in our experience. These are bought about by various factors, and we will explain these below.
What is very important to understand, if your workplace adopts a strong culture of Take-5s and Job Safety Analysis by workers and work groups, you will have a much better chance of eliminating accidents caused by change. That is, assess what you are going to do before you do it and put the right controls in place beforehand.

Strategic Change

Strategic change includes factors that occur well before any work is completed. It occurs at the safety in design stage, i.e. design of facilities, equipment, or processes. At its core, it is about assessing risk (likelihood and consequence).
Here are some of the areas we see are important contributing factors to serious incidents concerning strategic change:

  • Alignment & Assessment: A key feature of managing strategic change is to get the right people around the table to align objectives and to nut out what the risks and resulting controls might be. Our experience tells us that when serious incidents occur, alignment and assessment is not completed or achieved, and this sets up the escalation sequence at the very start of the change process. Assessments must be completed with the correct people in the room with the right experience and with the right facilitation.
  • Strategic Engagement & Communication: Using a learning teams’ approach, where you get the right heads in the room, with the right facilitation, including the correct scope, normally gets the job done. A quick point to note, the people who get the work done need to be in the room. Even for strategic planning, worker experience needs to be included. For high-risk equipment/processes, this is extremely important as there are many ways for safety devices to be defeated and operators pretty much know then all! Communicating the change and bringing the team along on the change journey is key, involve workers early and often. Isolate your workforce in any strategic change at your peril as they are key to your success, especially concerning strategic change.
  • Change Readiness and Impacts Assessments: Assessing the change on the organisation is critical. This sets up requirements for additional training and risk controls, and any changes to organisational design (R&Rs, reporting lines, team dynamics etc.). Never underestimate the amount of work that may have to be done in cultural alignment/development and training and awareness space – the success of change (apart from assessing the risk correctly) will primarily depend on this. Culture is everything, make sure culture underpins your effort.

Typical Strategic Change Scenarios

Here are some strategic change scenarios that we come across; with some questions we suggest you ask yourself. These are not exhaustive but do give an idea of what can induce serious incidents/accidents!

    1. We are expanding our site, what additional risks will this introduce?
      • Reduced space
      • increased traffic/traffic management risks
      • less outside storage space,\
      • changed wind patterns around our storage stacks and the building leading to stack instability
      • increased water runoff leading to increased risks of flooding
      • increased shared user interface (man vs machine risks) etc. etc.?
      • Note: there is one key area that is often overlooked in any kind of expansion (whether it be organisational or site level), and that is increased production pressure. Although this might not typically be considered change, change in itself can induce this, and therefore it is important to identify, acknowledge and plan for it. Production pressure takes many different forms; however, it induces behaviours such as rushing which is a common causal factor we see in serious incidents. These pressures can also ebb and flow during the day in certain industries when peak periods occur so therefore being aware of this is important to assigning resources at the right times of the day/night to reduce this pressure. Production pressures whether real or imagined are a real risk and one that needs to be identified and controlled.
    2. We are acquiring another company, what additional risks will this introduce?
      • Mismatch of existing procedures,
      • different skill sets,
      • different equipment,
      • different HR and Safety processes
      • mismatch/misalignment of risk perceptions & safety cultures etc. etc.?

Operational Change

Operational change is a change experienced at a worksite level and is normally of a dynamic / acute nature (i.e. occurs in a short timeframe over minutes or hours).
There are many different factors that can induce operational change. and we will mention these below and these are not exhaustive, however in our experience can induce serious incidents and accidents:

The Number 1 Reason Operational Change Causes Incidents

Mother Nature!!!
A change in the weather can significantly increase risk factors – workers, supervisors and managers need to understand this. Wind and rain are probably the biggest environmental factors that induce incidents in our experience.

  • The key question is = do we understand our triggers for safe work (GO > GO WITH CAUTION > NO GO)? As an example, this could be wind limits (measured and visual cues). It could also include predictive weather forecasts of these events to shape forward planning.
  • Mother nature risks and understanding of triggers were sadly highlighted by the Whakaari | White Island tragedy. Were there clearly understood triggers for GO > GO WITH CAUTION > NO GO? Know your triggers. If you are completing any activity with mother nature (including weather risks), make sure you clearly understand these. If you don’t, you have some work to do and quick smart.
  • Mother Nature is particularly challenging for those working in high risk AF8 areas regarding the likelihood of the earthquake event (which is ever decreasing) and the impacts resulting. There is a lot of work going on in this space and rightly so. This is also one of the few examples of an operational change risk that is also a strategic change risk. Risks that experience both types of change should certainly receive priority for planning and control/response.

The Number 2 Reason Operational Change Causes Incidents

How many people have worked later because the job went longer than planned? Me!! Fatigue is a killer. Whether it be driving or a lapse when working on high-risk machinery, understanding and assessing fatigue is really important.

  • Driving is in the top 2 risks of most companies we do work for. Driving is a key risk factor concerning fatigue, lots of controls are required in this risk bucket (including fatigue) and more on this in future blogs. If you were going to load resources into any one risk area, driving would be it if you do a lot of driving.
  • If fatigue is a risk, ensure an approval process is in place for work over hours, and ensure that fatigue is cumulatively tracked, including travel to and from work.
  • Make sure your workers know the specific risks around driving while tired. Could they identify what the telltale signs are if their mate was driving? Document this training, and make sure workers are actually implementing the controls that have been put in place and trained. See this case for a recent example of the importance of this.
  • Have procedures in place for pre-planned accommodation to allow sufficient rest if traveling/driving is involved and make sure this is followed. A lot of companies have a policy like this but how many actually apply it? Don’t push past the point of exhaustion.

The Number 3 Reason Operational Change Causes Incidents

You move away from a site and then come back to it several weeks later. Are the above and below ground conditions the same? Are utilities still live, have these been re-tested again to ensure they are not? Never assume the site is in the same condition as you left it; do so at your peril.
Things get delayed and all of a sudden you are time poor, and you have to rush to complete the job. Understand rushing can cause incidents. Don’t be tempted to rush before planning and completing the job safely. It’s still takes less time than that spent on an incident investigation and more importantly everyone gets home safe.

Wrapping Up

To reduce the safety clutter, this is the end 😊.
In summary, try to avoid the top reason for incidents occurring, that is, managing change and you should be able to avoid the top reason why “shit happens”. At Intesafety, because we drive a lot, mother nature and fatigue / driving are critical risks, and we wrap a lot of stuff/controls around this. Our question is, do you?

Good luck.

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