A Releasing Your Unlimited Creativity discussion topic

Copyright 2008 by K. Ferlic,   All Rights Reserved

Although it may be an over generality but, unfortunately, humanity seems to require a blood sacrifice before individuals really pay attention to safety hazards and think about fixing problems. Someone must become injured if not die before actions is taken fix what can be seen as a potential problem. Of course, there is a balance point. Overly concerned about accidents or injury will limit what we do. Little consideration for the possibility of accident and injury will cause us to have a greater probably of an accident and injury. Here we have the benefit of looking at the lessons learned of others in similar operations. There are general rules which can a be followed to prevent accidents or injuries. The most important of which is to incorporate the lessons learned of others. The second is to continually look to improve operations at all levels. Look to see how any task can be done more cost efficiently, safely and in a quality fashion. High safety risk injuries such as the aircraft industry and nuclear industry have embraced this message and have greatly improved operation over time. The same can be done for any organization.

As discussed in the topic, "Accidents from the perspective of the awareness of the existence of the creative spirit," there is a chain of events for every accident or failure which occurs. These chains reveal there are accident precursors. That is, there are conditions which point to an accident. There are indicators or precursors for every unfortunate event which reveals where the system is breaking down in some way for some reason. When enough of these precursors exist, we end up with a failure of accident of some type. In knowing precursors exist, we can look for therm and correct them before the combine to create a accident. The question is, "How do we find the precursors?"

The answer, quite simply, is to look for them. But then, how do we know what to look for? The first place to look is to look for deterioration of designed systems, both hard and soft, in any way and making changes with out proper review. Hard designed systems are engineered system incorporated into physical structures. Soft systems and things that can be readily changed like the way a particular task is accomplished. Maintenance programs which restore systems and components to "as designed standards" and their associated surveillance programs go a long way to finding accident precursors.

Here it needs to be noted that when and if the maintenance and/or surveillance program find something unexpectedly deteriorated, like a component wearing out faster than expected or individuals neglecting to follow a procedure, other similar and related systems should be reviewed for similar deterioration. The key is an eternal vigilance always look to see what is changing and ensuring what is changing lies within expectations and deterioration of the protection and quality is not being lost.

Here we need to rely on the mindfulness and awareness of all employees. We cannot inspect safety or quality into any operation. Each individual must be aware of quality and safety requirement and perform their task in a way to ensure that quality and safety are met. If we rely on some type and kind of oversight to catch poor quality of lack of safety, we are asking to have an accident. Oversight should be a check and verification. It should not be what is used to identify problems.

In this regard, looking for accident precursors is also about becoming aware of individuals who seem to have lost their creative passion and/or their enthusiasm for the job and/or for life in general. These individuals tend to become less attentive to details, bored, frustrated and the like. The more we lose passion for what we do, the more likely errors will be made resulting in accidents or problems and the less likely we will see what is in front of us deteriorating. When individual are passionate and motivated about what they do they are mindful and aware of precursors. They will catch the precursors long before they become an accident or performance issue.

Whatever we see, we need to look at the pattern of what is occurring and do not focus on snap shots or isolated events. Accidents result from a chain of events. If we look at isolated finding, we will not see the chain that is being created. The key here it to ask ourselves what the isolated events are tell us about our operations. Are the events truly isolated and one of a kind or are the more events and if so, how are they connected. Seemingly totally unrelated events in different areas in the same facility may be pointing to an overall lack of management attention. If there are many events in unrelated areas in the same facility one can be assured there are more issues to be found. It is that they have just not yet been found for there is a common issue across operations. To look at the pattern to track the cause effect chain  someone must always be looking, being mindful and being aware as to what is needed.

To always be looking, being mindful and being aware of what is need is not about a real time inspection program. Rather it is about each individual within the team being mindful and aware of what is being required and they ensure the requirements are met. There are feedback loops that can be created for any aspect of an organization’s performance to ensure a health, safety, quality and efficient and effective performance. With motivated individuals such performance is a natural byproduct and there is no need to regulate it through a formalized program. But, each individual needs to be able to perform their job.

In looking an any out of normal event or occurrence, there is the need to ensure the root cause is identified and fixed rather than seeking some "quick fix" or inadequate fix that allows for the problem to return. To find someone not following a required procedure and making them follow the procedure does not fix the root cause. There is the need to pull the string to ask why the procedure was not followed. Was the individual inadequately trained, did they simply willfully discard the procedure, or maybe they were told they didn’t need the procedure? Each of this causes will have a different fix.

To look for precursors personnel need to be sufficient trained to understand there are precursors to accidents and we each need to be looking for them. If we know what is expected, we can then see what is outside expectations. Employee need to know their eyes and ears are the first line of defense in finding and identifying precursors. They are the ones in the workplace every day and will be the ones who most probably will find and identify the precursors - if they are looking.

Manager also need to trained on what is expected and the existence of precursors and know what to look for in both the workplace and in the employees in that workplace. Managers need to "walk the spaces" to ensure expectations are being met. It is not about manager doing inspections. Rather it is about being aware of the condition of the operations in all facets under their supervision.

In talking about ways and programs to find the precursors to accidents, it needs to be remember each organization is unique. Another’s approach cannot be applied and expected to effectively find our accident precursors. We need to eat and digest what another have done and understand why they do what they do. Then we to take what is appropriate discarding the remainder. If what we do does not effectively address our uniqueness and the way we do business, we will be asking to have an accident.

Related topics
Accidents from the perspective of the awareness of the existence of the creative spirit

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