It is increasingly recognised that leadership is a key, if not primary, contributor to effective WHS risk management. Leadership is commonly seen as the 1st element in a WHS management system. Research has identified that leadership may be a greater contributor to reducing accidents than hazard management systems or safety consciousness.
Considerable effort in ‘process safety’ has taken place in the oil & gas, mining, aviation, shipping and other industries that are characterised by a potentially higher innate risk of a major incident. What may not be clearly evident is the success to date of these initiatives in reducing the incidence of catastrophic events.
Conclusions of investigations into recent catastrophic events indicates that there are multiple factors at play that in combination lead to the event, e.g. ‘…a whole sequence of events of poor decisions with unfortunate consequences when put together.’ Don Boesch, Member of Presidential Commission, BP Deepwater Horizon Oil Spill and Offshore drilling.
Overall, , the conclusion of the Presidential Commission into the BP Deepwater disaster was that the blowout was avoidable. ‘This disaster likely would not have happened had the companies involved been guided by an unrelenting commitment to safety first.’ (our italics), Bob Graham, Commission Co-Chairman.
A review of the conclusions from the enquiries that inevitably follow catastrophic events, from the Titanic, through to those in more recent memory such as Challenger, BP Texas City Oil Refinery, and Deepwater Horizon (Macondo Well) tell us there are a relatively small group of common indicators that are present as interdependent causal factors, including:
- High management turnover resulting in: the loss of institutional knowledge; changed expectations, agenda or focus areas; different management and leadership styles; trust levels needing time to develop.
- Recent significant organisational change, such as a re-structure or staffing cuts, resulting in: uncertainty over new roles and accountabilities; higher workloads; new work relationships and networks to develop.
- Significant / ongoing budget cuts, e.g. cut in maintenance schedules, resulting in: implied if not explicit understanding that safety is negotiable
- Reward systems dominated by (short-term) production-budget targets, resulting in: sub-conscious if not conscious decisions to promote production that enhances (significant) risk
- Level of risk oversight not at the highest level in the organisation, resulting in: less optimal risk data and understanding at the governance level where overall strategic direction and priorities are set
- Record of previous warnings not being heeded, resulting in: failure to learn and the implementation of required remedial action
- Previously agreed safety performance strategies not or only partially implemented, resulting in: risk level not reduced and therefore remains susceptible to the unwanted event occurring
- Recent incidents not reported and/or relevant learning shared, resulting in: institutional ignorance to risk and/or risk level
- Audits/inspections infrequently conducted and/or subsequent recommendations not implemented, resulting in: risk and/or risk level not known or existing controls verified as appropriate and/or effective
In Michael Quinlan’s recently published book ‘Ten Pathways to Death and Disaster: Learning from Fatal Incidents in Mines and Other High Hazard Workplaces’ (2014), he lists 10 factors that most incidents had evidence of at least three and many exhibited five or more. Here are four of the ten pattern causes identified by Quinlan:
- Failure to heed warning signs
- Economic / reward pressures compromising safety
- Worker/supervisor concerns that were ignored
- Poor worker/management communication and trust
It is our view these four clearly suggest a ‘failure of leadership’ that we can see clearly in the recent Deepwater Horizon disaster:
“At the time of the Macondo blowout, BP’s corporate culture remained one that was embedded in risk-taking and cost-cutting – it was like that in 2005 (Texas City), in 2006 (Alaska North Slope Spill), and in 2010 (“The Spill”). Perhaps there is no clear-cut “evidence” that someone in BP or in the other organizations in the Macondo well project made a conscious decision to put costs before safety; nevertheless, that misses the point. It is the underlying “unconscious mind” that governs the actions of an organization and its personnel. Cultural influences that permeate an organization and an industry and manifest in actions that can either promote and nurture a high reliability organization with high reliability systems, or actions reflective of complacency, excessive risk-taking, and a loss of situational awareness.”
Final Report on the Investigation of the Macondo Well Blowout - Deepwater Horizon Study Group, March 1, 2011, Center for Catastrophic Risk Management.
The fact that these events continue suggests that we maynot understand and accept that these interdependent causal factors were repeated time after time. Therefore we may not have taken the necessary steps to ensure that it does not happen in our organisations.
Temptation may exist for executives and managers in less high risk industries to dismiss the lessons to be learned from these disasters as being at best only tangentially relevant to their industry, or at worst irrelevant and only applicable to those high risk industries. Ideally, reflection will lead to a more direct, high level connection, helping any organisation identify opportunities to improve their risk management process.
THE CRITICAL CONTROL MANAGEMENT PROCESS
Another inevitable learning from major losses involves the absence or failure of the controls that should have been in place to prevent or at least reduce the consequences of the event. Controls can be as complex as a technological system to monitor hydrocarbons or as simple as a seat belt.
In addition to effective leadership, the management of critical controls is increasingly seen as the way forward. Though not developed in the mining industry, the global industry body, International Council of Mining and Metals (ICMM) distributed a brief process guideline2 in mid-2015 that has been adopted by the vast majority of industry companies as the target for the future.
Called Critical Control Management (CCM), it focuses on the specific, most important controls to prevent or minimise an event that would have a very high consequence to the specific company. These priority events are called Material Unwanted Events or MUEs. The CCM approach defines and establishes practical actions that verify the status of critical controls.
Please refer to ‘An Introduction to Critical Control Management’ for more detail.
Recent advances in WHS risk management suggest that moving to a critical control-focussed operation will result in better performance. However, CCM is not an overnight adjustment to the business. Companies have developed multi-year plans to move toward the goal of effective CCM. CCM involves major changes in mindsets, as well as activities.2 As a result, the move to CCM requires effective leadership for CCM planning and successful embedding Without committed and involved leadership the opportunity of focussing the business on the critical few to avoid disaster will fail.
However, the Leadership critical acts for an effective change are not well defined. There is a need to look at Leadership itself as a critical control and understand the specific leadership acts that contribute to a successful change to a critical control focused WHS management system.
Leadership as a Critical Control Research Project
GSI, as a global leader in helping develop effective Leadership, is sponsoring a research project designed to gather and analyse data about the quality of Leadership Acts related to critical control-focused WHS management in order to identify their effectiveness and the relationship to successful change. Also, this study would demonstrate the value of measuring critical control acts and sharing related learnings.
CCM defines ownership for events and controls at several levels in the organization. An example of fully implemented CCM Leadership is suggested below. These levels of leadership provide a reporting conduit that captures the real status of critical controls, providing an opportunity to act or investigate should a critical control be failing.
- The overall leadership of the CCM initiative
- The leadership of the assigned MUE owner,
- The leadership of the assigned Critical Control owner for the MUE, and possibly
- The leadership of the assigned verification information gathering for each Critical Control
The proposed research project will examine the respective, critical-few Leadership Acts required at each level, establish and test a process for the capturing and recording these acts to gain insight into any required corrective actions at the achieve the most effective Leadership approach.
Initial workshop outputs involving organisations currently implementing CCM suggest that there are six critical acts of CCM Leaders.
Engage with Leaders about the their CCM roles
Set clear expectations for the CCM Leaders
Ensure the CCM Leaders have required CCM knowledge & skills for their roles
Provide feedback on data or observations about the Leaders role execution
Encourage all CCM initiative issues to be reported
Act decisively when a CCM initiative concern is raised
This approach to considering selected critical Leadership Acts to be the focus of developing and measuring Leadership is not only relevant to CCM but any major change in an organisation. Good understanding of this approach should be a priority for reducing risks to the business. Therefore, GSI is establishing a multi-company approach to investigate Critical Leadership Acts and invites your participation in this seminal research.
Please refer to the ‘Leadership as a Critical Control’ Research Program 2016-2107 for more details.
1 R.B.M. de Koster, D. Stam and B.M. Balk, Accidents happen: The influence of safety-specific transformational leadership, safety consciousness, and hazard reducing systems on warehouse accidents, Journal of Operations Management, Nov 2011
2 International Council on Mining and Metals (ICMM), Health and safety critical control management good practice guide. London, UK:2015