Recently I was studying Google’s management philosophy where I was struck by one of their principles: “make mistakes well”. On initial presentation, this would seem to be counter intuitive, yet it is hard to dismiss when examining the success of the Google enterprise. Surely, “making mistakes well”, is an oxymoron?

Google has been a disruptive technology, that has not been constrained by rules. Its technology and business methods have underpinned a complete change of state for the business and advertising models prevailing for the past century. The enterprise’s success has, at its heart, a commitment to its willingness to invest resources in business concepts with no proven deliverable. This practice is a derivative of Google’s “make mistakes well” concept.

Another organisation that is disruptive and thrives on embracing risk is Uber. Here is a business that intentionally breaks the rules, yet is achieving extraordinary market success. Uber is succeeding by focussing its business model on the customer experience, and disregarding the regulatory framework that its competitors operate within. Through the safety prism, it is breaking the golden rule of regulatory compliance. We could therefore draw the conclusion that either the regulatory framework is flawed and has outlasted its purpose, or that Uber is creating a business that is in breach of the community social and ethical constraints which should be subjected to intervention and punishment. Eventually these opposing forces will result in a state shift for the regulatory system or the failure of the enterprise. I am willing to venture that is the disruptive enterprise that will prevail.

The business management literature is clear in that failure to evolve is a path to extinction. There is a wealth of examples, Wang Computers, Kodak, My Space, Ansett, Pan Am, Palm Pilot, and the list goes on. If a business in the new millenium is to sustain success and growth, it must constantly evolve and, by definition, embrace failure as a feature of finding new pathways.

In the practice of safety, we have built a view of success that may be self serving and ultimatley destructive to the organisation it serves. Over the past two decades we have defined safety success as Zero Harm, and subsequently interpreted zero harm as the absence of incidents, generally expressed through total recordable incident frequency rate. Is this a true measure of success, or is it simply a convenient way for safety professionals to define success in a self regulated safety bubble where we manage a statistic in isolation from the business it serves?

At the heart of the predominant safety paradigm and Zero Harm, is capital C Compliance. Compliance to rules, behaviors, procedures is rigorously pursued, and those that stray are sought out and punished. We, the safety professionals,  need to challenge this paradigm’s assumption of system improvement in a constrained management environment.  It is essential that we are partnered in the delivery of sustained success for the organisations that we serve.

In posing this challenge, I am not suggesting that using proven methodologies should be disregarded, rather that the punitive compliance model embeds dissentive to innovate or to communicate variation. If we understand anything about organisational resilience, we know that it is dependent on continual incremental improvement and a state of continual cognitive dissatisfaction with the current state.

Are there industry examples where non compliance is a feature of system improvement. Medicine is one such professional practice to study the concept of rule breaking. Ever since the regulation of therapeutic drugs, there has been a practice of “Off Label Prescription”. When a drug is approved, it has clearly defined therapeutic application, which is regulated by Therapeutic Drugs Administration (TGA). The Off Label process is where the drug is used for a therapy that was not included in the TGA approval. Cancer treatment has long used this concept to develop new treatments essentially through therapy trial and error. The outcome of this practice has seen significant advances in treatment that would not have eventuated if the treatment was limited to the approved therapy. This process is not without cost, but is carefully managed within an agreed risk tolerance framework, and the principle of “making mistakes well”.

Conversely, safety has become constrained by a quality management overlay, driven by prescription and subjugation. I would venture to suggest that his model has led to increasing the probability for catastrophic failure in complex system due to damping down active feedback mechanisms for system divergence. This paradigm constrains incremental and constant improvement. Whilst we may cling to the belief that incident reporting and risk assessment tools have, as their purpose improvement, I would contend that this is not what practice and experience critically examined demonstrate. In any organisation functioning under a prescriptive safety paradigm, the safety management team will regularly note the repetition of the same types incident events transacting through their organisation on an ongoing basis. What we tend to experience in the constrained safety paradigm is reporting avoidance, supported by incentives not to have incidents registered.

I recently read Tony Hsieh, the CEO of Zappos, book Delivering Happiness. I would recommend reading this book to anyone desiring to understand culture, the nature of organisational success, the importance of cultural engagement with the success of the organisation, and the need to adapt and change to ensure the longevity of an organisation. Hsieh contends that Zappos success is underpinned by the partnering of his business with his people, and encouraging them to constantly challenge the way things are done. By applying this principle his business has been a disruptive force in retailing.

Safety can only thrive when it is an active partner with the objectives and success of the organisation as a whole. Unless we embrace organisational goals in the holistic sense, then we as safety professionals contribute to the failure of the organisation, rather than its ability to thrive and regenerate.

In this sense we need to revisit our concepts of success and failure. How can we have safety success where there is no incentive and significant barriers to trying new methods of achieving the work and therefore the organisational outcome. An alert should flag when any improvement is crushed by the constraint of a rule, procedure or regulation.

There was a video posted on youtube of a truck unloading a load of thatch. View this video(embedded below) and note your conclusions within the compliance paradigm. The method used to unload the truck clearly breaches the safety norms we have come to embrace. If we take a step back, and look again, there could be merit in embracing error. The method used eliminated the need for workers to mount the tray and manually unload the vehicle. Our current paradigm would dictate that an incident report is prepared together with an investigation. I would propose the outcome to be a safe work procedure, training program and disciplinary process for the worker involved, and where it was a contractor, their dismissal. The truck would be successfully unloaded in a much slower time, with significant cost in labour. It is also likely that a workers will experience manual handling related injury through repetitive performance of the task.

Watch video

It is foreseeable that our competitor uses the non-compliant process, wins the business and from the compliant one. Therefore the safe business is no longer in business and the safety program has contributed to the organization’s failure.

Conversely if our business was able to constructively engage with the “innovation” of the driver and adapt it to a sustainable method, for example the modification of the truck to have a tilt tray, the safety and organisational goals would be more closely aligned. If the driver is unable to communicate his method due to a punishment regime attached to compliance, the business is deprived of the opportunity to engage with the variation in order to transform it to a sustainable practice.

The Australian government reviews of productivity indicate that mining and construction productivity is falling well behind the USA in the last 10 years. Safety management proclaims that safety management improves business productivity, roles out the mantra of the iceberg and the cost of incidents, but where is the data that tests our practices, productivity costs of the labour intensive rules driven systems and their delivery on producity? If safety management underpins productivity we should be seeing the evidence of productivity leadership against the US in peer industries.

As safety professionals are we engaged in the productivity management for our organisations, and equally are we active in the dialogue of innovation and incremental improvement. Experience would suggest to me that we are not, and that we are blissfully unaware of the productivity performance of our organisations and industries.

As with the medical method for “Off Label” we need to embrace and encourage management and workers to challenge and change the way work is performed, build real trust and “Just Culture” to allow people to share their failures as well as their successes.  Hollnagel and Dekkers work challenge us to engage with a success model, rather than a failure driven model. Integrating safety with innovation and organisational resilience is not only a desirable idea, it is fundamental to the relevance of the safety profession in the disruptive business environment. If we are not to be part of making our organisations Safely Extinct, we must abandon methods and measures than constrain and re-engineer our safety paradigm to that of one that enables organisational success where we can make mistakes well.

 

Works Cited

Best Way To Unload a Truck!” YouTube. YouTube. Web. 06 Sept. 2014.

International Comparison of Industry Productivity.” International Comparison of Industry Productivity. Web. 06 Sept. 2014.

Off-label Use of Medicines: Consensus Recommendations for Evaluating Appropriateness.”Medical Journal of Australia. Web. 06 Sept. 2014.

Regulate This! A New Freakonomics Radio Podcast.” Freakonomics RSS. Web. 06 Sept. 2014.

Tony Hsieh | Delivering Happiness.” Delivering Happiness. Web. 06 Sept. 2014.

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