#008 Corrie Pitzer | Resilience Engineering in Safety

Corrie Pitzer, guest · [06:28]I think it was an event that caused that. As the human resource manager, I had to go and give the news of the death on the mine, a fatal accident on the mine, to the family. And, the manager of this mine sent me to go and do it. He didn't wanna do it himself. And, it was quite a difficult situation to handle. You know, I was, I think I was twenty-four, twenty-five years old. I was never trained for A situation like that, and that probably led to the second event, because a few weeks later, there was another fatal accident, and the manager called me in again and said, you have to do this again, and I said to him, I will, but I think you should be there, because the family asked me the previous time, why were you not there to give the news yourself? And I convinced him to go with me. I think that was a life-changing event for both of us, in the sense of we gave the news to the mother, two little girls, six, seven years old. I think it was a experience that, we both suddenly realized there's something much more to life than just, you know, managing a mind, for him and for me. And, I watched how the mother tried to explain to these two little girls, they were twins, tried to explain to them that their father died in the accident, and they couldn't understand it. As they walked out of the room, because the mother said to them to go outside and play, because she didn't know how to handle the situation anymore. And they walked out of this little room, and they wouldn't look at us. They just walked straight past us into the backyard, and as we, me and this manager walked out, he stopped me, and before we got in the car, and he said to me, I'll never do this again. And I thought, you know, he's like just uncomfortable, and I was upset with him at the time, but he said to me, no, we're gonna stop killing people in my mind, because that lady and those two little girls did not deserve today. And that changed him dramatically. He became a very inspirational leader, and, he pulled me out of HR and put me into safety, and I was working for Gencor at the time, and, and that started my career in safety, and just went from there.

Corrie Pitzer, guest · [14:47]Well, if we can go back to that, manager, when he, him and I stood at this gate of this family, and he said, we're going to stop killing people on my mine, he actually said zero fatalities. So that concept, you know, there's no organization, no person cannot want zero fatality or zero harm. It is a moral imperative. You have to go for it. You have to state that and you have to, try to achieve that. And as a concept, it's probably the single most powerful change initiative in safety over decades now was this, yes, be going for zero. It had changed the world of safety, changed the thinking in safety dramatically, and drove down accidents, rates and things like that. So that's the one side of it. You have no other choice. It's a moral imperative. But as organizations started to embed this in your organization, it started driving the wrong behaviors. It started driving a number. And safety became very much the focus of the safety department and where they have their KPIs, and that KPI has got to look good. It has to be directed to zero all the time. As a result of that, you had some very, very negative behaviors that started to evolve in organizations. And those negative behaviors are the suppression of information, the fudging of data, the fudging of accidents, or the arguments, where is this really an accident? That's one side of it. The other side of it is that the workers, having been rewarded for not having accidents, for instance, because that was the next step to attach rewards to it. And obviously what workers were doing is they're going to give you what you want, because they also want the rewards. So there is still today a strong tendency for workers to try and avoid reporting as much as they possibly can, which brings about an improvement in safety numbers, but that's all false. So this is the downside of the zero focus. And unfortunately, it's part of business. I'm not sure we'll ever get it out. We're trying to propagate a concept that we term as beyond zero. What you're talking about is not an engineering concept, but when you talk about beyond zero, we talk about it in the sense of you're thinking into risk exposures, that this is the next level of safety focus in an organization where you don't measure, or if I can put it like this, where the measurement of safety is not necessarily an indication of the level of safety. That's beyond that now.

Petro du Pisani, host · [17:26]So you once told me about this concept of fake safety. Can you elaborate on that?

Corrie Pitzer, guest · [17:32]Yeah, fake safety is very much connected to this, whole idea of numbers and, and managing numbers in business. But there's also a lot of activity in the safety field. It's, the field of quality management in the eighties and nineties was a huge business on industry of its own. It had its own gurus, its own Methods and everything, and Deming was the father of that, but it soon became life of its own. And at this point in time, quality management, the quality movement, if I could call it like that, has disappeared. There is no such thing anymore, because its quality is integrated into the production process of organizations. They don't need these quality control systems at the back end of the business anymore. Now, safety is subject to that same kind of movement, cult-like appearance as what the quality movement was. So there's a lot of initiatives and, programs and very much, flavor of the month stuff, and it's much driven by consultants, the people that, you know, I am. And, there's very little work that I think that goes into the heart and soul of the organization, driving safety into the production processes, into the planning processes of the organization, into the operating model of that organization. It's always a add-on, and that's what I call fake safety, because it looks good, it looks busy, makes a lot of noise in the organization, people are happy to see it happen, and they're even connected to safety improvements if that happens, but it's not necessarily connected. That's fake, but it looks good, feels good.

Petro du Pisani, host · [19:09]Yeah, the definition you gave me is that fake safety is when managers pretend that they're serious about safety, and the employees pretend to believe them.

Corrie Pitzer, guest · [22:56]Well, that's exactly, one of the deeper concerns I have about our models in safety. Safety is a, is probably one of the most complex processes in organization, but it's very much an engineering approach, a mechanical approach, where if something goes wrong, we're looking for the cause, the holes in the Swiss cheese, and we're looking backwards, looking at all the linear causation of it. And it all makes sense when you add it all up, but an accident is a very complex event, and it has not got only one singular Causation. It has got multiple causation. It is a complex interaction of situations randomly happening as well that created this unique circumstance for a mishap to happen, if I can put it like that. And yet when we analyze it and looking backwards, we can find one single line very easily. Now that gives us the impression that safety is a simple process. All we have to do is find those causes, come to the root cause, and then eliminate the root cause and things will go better. We've done that successfully for many years, but as organizations grow and mature and become far more complex than what they were sixty, seventy years ago, those models don't apply anymore. They simply don't explain accidents anymore. And so to the point where I've made the statement the other, there are no root causes anymore. They are all embedded in the organization, there are many root causes, they're all multiple, and they interact at the same time. And so therefore our analytical tools is not linked to the realities of what we have, the chaotic situation, not complex situation that we have to deal with today.

Corrie Pitzer, guest · [31:24]Yeah, I think the, the concept of a near miss is, to me, is almost the same as an accident. it's a rare event, and it's also too late. It's happened. It just didn't have the final confluence at that time to cause the failure in physical terms. So to me, it's past information as well. I'd like to use a term, and we started using this term very recently, we call, it doesn't make sense like that, and we call that the far miss. It is so far away from happening, but it's a risk exposure, and that tells you a lot more, and it comes back to this thing about where do we spend our time as an organization, searching out, risk exposures in the organization. And when you start doing that, when you actually start searching out these kind of exposures, you realize they are incredibly random, they change all the time. You go into an organization or to a mine site at one point, and you go around, you look for, say, serious risks, you find them. If you go there the next day or three days later, you'll find different ones. And so any one of those could have resulted in a fatal accident. So you gotta be, have a system inside the organization, you have to have the process inside the organization to constantly look forward and constantly look dynamically forward. That's a key thing for me. We shouldn't have standard systems to capture risk with, because risk is not like that.

Petro du Pisani, host · [39:11]Now, changing the culture of an organization is normally quite complex, and it's quite difficult, and it takes years. It doesn't, it's not something that can happen quickly. So I'm always interested to know how do we do it? So what steps do you take? So what is step one? What is step two? And how do we know once we've got to that place that we wanted to get to?

Corrie Pitzer, guest · [39:30]Well, that step one is that change the definition of intent in the organization to what it should be. Step two is to create the capability and understanding at the executive levels in the organization, because we find it so readily that organizations have the slogan or whatever they have, And yet there is no real common understanding and acceptance in the top team of the organization, and, they, they all talk about it like parrots, and I'm not saying this in a, in a detrimental way, it's how it happens. But when you start testing the thinking and the, the actual believing in it, it starts to differ. So when you create that belief around it at top level, you have to create that belief right throughout the organization to the front-end employee that they all actually believe the same thing. Sounds simple, but that's how it is. So our change process starts with that. It then involves the, the change of belief, thinking, and actions of the leadership group, right to supervisor level. Once you've done that, you also have to look at your, the systems in your organization, because you can have systems directed away from your, your intent, and, you have to then re-engineer your process in your organization. Once you've got those two in place, You then have behavioral adaptation happening to what that original intent shift was. And culture is then, in the end, culture is that behavioral shift that happens.

Petro du Pisani, host · [40:55]You want to move away, away from a place where people are scared to report stuff and to highlight risk the entire time and hide their numbers and fudge them to a place where people feel completely open about being able to raise risks and look after each other as they generally care about each other.

Corrie Pitzer, guest · [41:12]And, and that's one aspect of that culture is the, and James Reason actually defined it like that, calling it, you know, a reporting culture. But you also must have a just culture, and that just culture refers to the systems. You have to have systems that support that reporting. If people are being blamed for accidents, they're not going to report them. It's a very simple equation. So your disciplinary process, your consequence management must be in tune with that objective to have a reporting culture. But then a series of things have to happen after that. You have to have a flexible culture too. A mistake can be interpreted in so many ways. You have to have that understanding in the organization and adapt to that. And then finally, you must have a learning culture where the organization can learn from these information flows that they get, the people talking about this. That is the final piece in the whole cultural shift.