Its good to talk – does your system?

In my last post I spoke about the dangers of focusing on a single root cause when investigating accidents.

However, while there is no doubt that accidents are caused by multiple contributing factors, one key element does continue to rear its ugly head in our research. This element is common across accidents, as well as across different types of causal factors in the same accident.

So what is this ubiquitous contributory factor?

Communication. In most accidents, there are often numerous communications issues or failures across all levels of the work system.

Critically, communication issues often occur within and across levels of the system. Within levels, for example, these issues are often evident when participants do not understand or misinterpret instructions from activity leaders. Across levels, field managers might provide overly complex instructions about risks and hazards to activity leaders. Inexperienced activity leaders might not ask their field manager the right questions about what to do in an emergency. Parents might misinterpret the questions on consent forms, or misunderstand the risks communicated about the activity. Schools might fail to communicate with the activity centre about behavioural issues. Communications issue are often present at the highest levels of the system; for example when government and regulatory bodies are not on the same page.

Importantly, it’s not only about people not talking to one another or telling each other the wrong thing; often it is poor communication within documentation, policy and procedures, training programs, risk management and incident reporting systems, and equipment. For example, an incident reporting system might contain information about recurring hazards. However, for whatever reason this information in not communicated to the people who need this information most. The end result is a system that is not aware of its own hazards.

So whilst the contributory factors themselves may be different in terms of their source, often they centre on safety-critical communication. Communication, it seems, has a lot to answer for when disaster strikes.

The important messages here are that it is it is good (for every ‘thing’ in the system) to talk (about everything that is important) to the right people: it is important to make sure that your system “talks”. Make sure you have processes in place that allow all the people within your system (participants, leaders, field managers, risk managers, admin staff, parents etc.) to talk about the important issues, to communicate the right information to the right people, and to monitor understanding. It’s not enough just to “send” the information, you have to know it has been heard.

Let’s repeat that. It is good for everything in the system to talk about everything that is important to the right people. Sounds simple doesn’t it? Unfortunately it is often not achieved across the safety critical domains, as evidenced by recent tragic events in other areas. The Air France 447 tragedy in which an Airbus A330 dropped into the Atlantic Ocean killing all on-board effectively happened because the aeroplanes systems couldn’t communicate with one another, the cockpit displays couldn’t tell the pilots what was going on, and the aircrew didn’t communicate particularly well about what they were doing in response to the situation. The Kerang rail level crossing tragedy of 2007 happened because the rail level crossing did not effectively communicate to the truck driver that a train was approaching. Moreover, the hazards around the crossing were not effectively communicated across the system.

How should organisations deal with this? The wrong approach is to send a memo around your organisation telling people to talk more often to one another. This will fix nothing much really, other than people might be chattier over lunch for a week or so. But it’s not safety critical information and remember it’s not just people that are the problem – it is ‘things’ too. The right approach instead is to work out what needs to be communicated to ensure safety, who needs to know it, and what or whom should be communicating the information. Only then can you identify where these ‘communication’ issues exist and fix them. Revise the policies, risk management programs, procedures, increase the communications channels, incorporate regular reporting into incident reporting systems etc. Get the system talking. It might just be the fundamental change it needs to supercharge safety.

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Posted in Systems thinking
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