Black Box Thinking: What the Health and Safety Industry Should Learn from Aviation
Safety lessons learned from the aviation industry.
Books about achieving greater success are all too common these days, but one book certainly communicates a message that resonates with me that I think will strike a chord with you too.
I started reading Black Box Thinking: The Surprising Truth About Success because I saw its author, Matthew Syed, on TV talking about how incremental change can produce greater success. What I had not anticipated was just how poignant the content of Black Box Thinking would be from a health and safety management perspective.
There are a number of standout references in the book, the most easily explainable is perhaps the different mind-set towards learning within the aviation industry and the healthcare industry. The difference is stark. The aviation industry once was very dangerous, with many flights ending in disaster. However, through learning and an extreme focus on safety, flying is now the safest form of travel. Conversely, the healthcare industry remains responsible for the third biggest killer in the western world: preventable medical mistakes.
This is not to say that in healthcare personnel are less caring—their career choice alone indicates strong diligence and desire to do right. So, why is there such a difference in the safety performances of healthcare and aviation? Once boiled down, the difference is primarily fueled by attitude—mistakes are made over and over again whenever a profession stigmatizes error.
Syed talks about the paradox of success where the mistakes and often lives lost within the aviation industry have contributed to the safety of modern flying. This is partly down to appropriate feedback mechanisms being in place to ensure the industry learns from previous mistakes (for more on the importance of feedback, see Implementing a Safety Culture: Speak Up for Safety). If a pilot experiences a near-miss, a report is logged. In the health care industry where there is a significant presence of blame culture, or when a surgeon makes a mistake, it is not so openly addressed.
How, then, can those of us in health and safety learn from this? The clue is in the title: similar to an in-plane black box, we must record all critical data for investigations and, ultimately, improvements in safety. In order to learn from our mistakes, an appropriate system must be in place for capturing and reporting on all relevant information (learn about Using Rich Media to Enhance EHS Reporting).
Syed suggests organizations must “interrogate errors as part of their future strategy for success,” which is all too important in the modern landscape of health and safety management. Instead of viewing errors or near-misses as events that need blamed on someone, we should view them as opportunities for learning, and to improve the safety of our workplaces. We can do that by ensuring absolutely everything is recorded; analyzed; and, in turn, avoided in future.
Spanish philosopher George Santayana put it quite nicely when he said that “Those who do not remember the past are condemned to repeat it.” Reporting near-misses and incidents is extremely important, but how we deal with this information is even more integral. Below are some pointers on how you can add value to your EHS data:
Format data into understandable reports
The options for EHS software seem endless. To get the most out of your data, you need to be looking at a solution that has powerful reporting capabilities; can generate KPIs; and understandable, customizable information charts.
Spend time analyzing what went wrong
Putting the effort into investigating what caused an incident is paramount in improving your EHS performance. It’s all very well to produce a fancy report of the data, but what you do with that information is what makes the difference. Having an EHS program that can provide investigation workspaces will be useful in this process. Once you’ve joined the dots and determined the cause, steps can be taken to avoid the same problem in the future.
Monitor, move forward, and learn
The data’s been recorded, reports have been produced, investigations have discovered causes, and changes have been made—what now?
Monitor—an essential part of making changes is checking in on their impacts. Has altering that practice as a result of that incident prevented the same incident from reoccurring? Effective health and safety management should promote continual progress; without progress, words such as success, improvement, and achievement have little meaning (and if you’re big on quotes, you’ll have picked up the Franklin reference). This is essentially Syed’s message, but with an EHS spin: just like the aviation industry, we must treat failure as a learning experience in order to progress in solving problems and forming strategies for the future.
Anyone looking to promote near-miss, close call, and positive intervention within their business should add this book to their Christmas list. It’s full of facts, figures, studies and true insight into the possibility of improving the workplace and the wider world we live in by turning failure into success.