PAPod 567 - Open Questions 2025: From Metrics to Monitors — Rethinking Safety

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Bob said the craziest thing last night at Meow Wolf, which I was actually really
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surprised you kind of liked Meow Wolf.
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I didn't put that in your category. We've got a hippie daughter. I know, I know.
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Bob was kind of in a contemplative mode after he got out of there.
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I know he's probably all freaked out by all the many stimuli.
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And he said, have you been thinking about your last day on Earth?
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And I said, well, not that much.
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Why do you ask? He says, I've been thinking about a lot. And I said,
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what do you think it's going to be like? And he said, it's going to be like
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every other day of my life, just shorter.
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Thanks, everyone. This was fun.
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Music.
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Hey, everybody. Welcome to the Pre-Accident Investigation Podcast.
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I'm Todd Conklin. How are you? So today is a big day.
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Well, it's kind of like any other day, really. But I think it's going to be
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a big day because, well, it's a big podcast. First of all, it's 45 minutes long. Sorry.
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But today's the day where we do the open and not open and closed.
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What's wrong with me? The open question and answers at the end of the conference
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we had this couple weeks ago in Santa Fe.
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And I always think this is interesting because it gives you guys,
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if you didn't get to go to the conference, first of all, we missed you. It was really fun.
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But if you didn't get to go, it gives you kind of a handle on what the topics
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were, what people were interested in.
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And I'm actually really encouraged by these questions.
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There's lots of really interesting questions that I would say are kind of the
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next level up questions. They're not the sort of how do I get my boss to listen,
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although that's an important question.
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But these are, you know, okay, we're learning.
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We've got some good ideas for corrective actions, but they're not defusing very
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well. That's a pretty good question.
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And you'll hear that. I mean, that's a big part of the conversation and a big
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part of what the podcast is all about. The conference was super fun.
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We had a whole lot of people. Everybody had a great time. No big dramas.
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Well, that's good. We did drag everyone to a place called Meow Wolf,
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which I don't know how to describe except kind of look it up if you get a chance to Google it.
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It's kind of this sort of hippie-centric, no, no, let's call it hippie-adjacent
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art installation that's large enough you can walk through.
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And it's pretty interesting. It was a fun thing to do.
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And people, for the most part, had a great time. So that worked beautifully.
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It was great. And then we had a great crowd of people and really good Mark Yeston
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presented and Martha Acosta, Jennifer Long, Andrea Baker.
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Bob Edwards, it was a really good crowd. And we talked about,
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we covered lots of ground. So it was fun. We missed you.
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You were missed. But you can feel included because you can listen to the questions and anything else.
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I mean, you know, everything's wide open and it's all yours.
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How are you doing? It has been crazy.
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It's hard to even understand where to talk about stuff.
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Because it's just, everything's crazy and super dramatic and bizarre and weird.
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Who knows? The only good news for me is that I'm going to go to the Bluegrass
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Festival in Winfield, Kansas.
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So I probably have some, I'm thinking I'm going to come back with some,
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you know, hot new bands that you should be listening to. I always try to do that.
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Oh, you know, that's good. That's where I found Seth James. And if you're not
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listening to Seth James, you should be, right?
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Years ago, I told you early on about Billy Strings. Now you're in.
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So let's enjoy the podcast because it is pretty long, but I think you'll find it really interesting.
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So basically, the presenters and some guests set up in the front of the room,
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and then people just ask questions.
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And we used one of those things where you could type them, and it immediately
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goes to the projection screen.
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But we also passed around a microphone. You'll hear both.
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And you'll kind of figure out who the folks are.
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There's a pretty interesting crowd. James Frederick is there. Charles Major is there.
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Britton Sutton's there. Andy, Bob, myself, Martha, Jenny.
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There's a good crowd. You'll kind of know who people are, but I think you'll
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find this pretty interesting.
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So without any further ado, here is the Open Questions 2025.
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So I'm curious about other things that we might be able to measure.
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We're all under immense pressure or pressure to measure things.
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And we've talked a lot about capacity, and we've got some ideas around that.
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And so I just wondered, with this group in front of us, if there are any ideas
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of value-added metrics that might benefit our organizations.
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So before we start to answer, and I'm super curious what the answer is,
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I would add to your thought chain the difference between the word metric and the word monitor.
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So, I think it's really significant to understand that when we talk about a
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metric in an engineering-centric organization, we're really talking about something we can measure.
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And so we know if we can measure it, that it's already happened.
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And so it's always going to be a historic referent of what has taken place.
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Metrics are pretty important.
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Who am I kidding? They're super important, and we've made them more and more
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important in our organizations.
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However, metrics have a very difficult time describing the present,
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and they suck at predicting the future.
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Fair enough? No arguments? Enter the word monitor.
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We really want to look at things we can monitor in real time and trend the ability to monitor.
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And the example I would use, just because it's one that resonates with me,
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is the gas gauge in your vehicle.
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So you don't really demand an accurate metric for how much fuel is in your vehicle,
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and yet you need to know how much fuel is in your vehicle.
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And so you monitor your vehicle's fuel by looking at a gauge that is not terribly
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mathematic, but in fact, incredibly visual.
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And so part of what I think we have to do with our organizations is help them
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understand the power of metrics for understanding what has happened and monitoring
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for understanding what is happening.
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It's how we do predict meetings, right? It's how we do predict meetings where
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we're monitoring for vibration and things like that, right? So you start to
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see it getting worse and worse and worse.
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It gives you an idea, hey, maybe we need to work on it. So you can monitor.
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Actually, a lot of things can be monitored.
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A good example, one organization we've been working with, we've moved to more
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of what we call a narrative-based or evaluative-based metric.
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And the example that they used
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was they were trying to move away from the traditional LTFR or TRIFAs.
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Data so they inversed it and they called it human reliability rate which basically
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we're not harming people this amount of the time rather than the other way around
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and then the third thing they looked at the second thing they looked at was
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their um critical critical control verification rate.
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And once again there was a number involved because it has to be a number but
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the evaluative component was more about which of the themes were repeating.
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Because leaders had this feeling that everything has to be 100%.
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Yet these guys were only ever getting to maybe 96, 97%. And by the way, that's amazing.
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To get to that number is truly amazing.
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But they're really interested in what were the themes that kept repeating in
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that space? Because that was more about the work and the design of work.
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And then the third thing they were presenting to those leaders as a metric were
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the themes that were coming through from all the 40 conversations at the front line.
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And not surprisingly, every month there might be 20 or 30 patterns or themes
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that were coming through.
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So the leadership is seeing reliability of humans.
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They're seeing the reliability of controls and huge adaption in the field and the work.
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And that made them curious. And the curiosity wasn't about how to reduce the
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adaption, but the curiosity was to understand how is the work creating that
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adaptive process that was going on?
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How do we shift our organization's thinking? And this is by someone who's not
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American because they use an S.
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How do we shift this? Todd.
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How do we shift this organization's thinking from managing risk to maintaining control?
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So the quick answer is leverage what your finance people do.
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They, that's how they think of risk. I mean, you're finance people,
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you have a whole group in your organization who doesn't see risk as a threat.
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They see it as an opportunity, right?
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So when Barry and Ben were talking about generating power and buying and selling
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power, risk to them is not a threat, it's an opportunity.
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So they really understand the whole process capability, the capacity idea.
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And so that's a pretty powerful thing. But that shift's a big shift.
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The exciting thing about it is that what it really does is give the leadership
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team something new to go out and look at.
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And that's a really powerful thing because we tell them all the time,
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if you want different answers, you have to ask different questions.
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And then they look at you and say, what questions do you want me to ask? Which is really fair.
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Part of what you do is you say the conversation changes when you don't go out
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and identify the sticky.
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You go out and talk about the controls.
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And what's interesting to us as leaders is not the presence of risk.
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That's pretty normal. The interesting thing to us as leaders is the absence of control.
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We really want to know where our processes are out of control.
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And so that becomes a really powerful new thing to look at. And because it's new, it's pretty novel.
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And what it does, it's a little bit self-fulfilling because when they go to
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the field and ask that question, They really do get different answers.
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I mean, hugely different answers.
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Charles, build on that because you've thought about this a long time.
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Less than three seconds so far.
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So the risk. Yeah, so I really don't know what else to add to what Todd had
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to say is that change the way we look at risk as really important.
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Really more of an opportunity for something to go well or something to go wrong.
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And then for us to understand what can we proactively start doing,
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looking at different measures than we have in the past.
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I think it's somehow connected to the last question in my mind,
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is that what could we start monitoring that gives us an idea better about what
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risks are currently out there that we could do something about?
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I think this idea of opacity is really important as far as for leaders to be
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looking for places that things are opaque.
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Okay, being from a business school, and many of you have looked at these things,
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but the balanced scorecard for strategy is something that every executive knows something about.
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And one of the things that people miss in that balanced scorecard when they're
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trying to have measurements for all of these different areas,
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the financial ones are easy, is that they fall in love with a certain measurement.
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And really the way that it was designed was to keep changing the things that
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you're measuring to monitor how you're going in there because it's so easy to create blind spots.
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So part of your monitoring process should be, what are some of the things that
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we don't know that are opaque, that are, you know, that are ambiguous in the information?
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Where are some of the information missing?
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What are some of the unknowns that we might have?
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And that is actually much better information than where have we succeeded and
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where have we failed, because the success and the failure have already given you information.
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The thing that you should be afraid of are the unknown unknowns.
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So again, related to that last question about what to look at in monitoring and measuring,
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I think there are a number of things in your safety and health management systems
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that you can look at much more efficiently to monitor how are we doing? Are we getting better?
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Are we seeing things happening in a positive direction?
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Think about things like an occupational health. Think about things like the
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whole HOP implementation and just try to look at those as part of that system.
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There's a number of things on that. I put together a little piece that was in
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one of the trade publications a couple of months ago about kind of eight habits
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of highly effective management systems.
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And, you know, there's some interesting things to talk.
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Further question about moving from looking at things through the lens of risk to control.
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There's been a couple groups that I've gotten to speak with fairly recently
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where that was a really, really tough switch.
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And in most things, the proof is in the pudding. So a lot of the times when
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we think about control for a senior leader level, part of what they're thinking
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about in terms of control is whatever that they've historically labeled as critical
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rule or a lifesaving rule.
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And so when we start talking about how important controls are,
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I would just ask them about the health of the control.
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Hey, can you teach me about the health of your control?
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Usually that would bring up quite a few questions of what we meant by health of the control.
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And so I say, well, if you went out right now in the field, how many exceptions
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do you have to your life critical rules?
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And the answer is usually none. And I say, well, there's none on paper,
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but how many exceptions in real life do you have to your life critical rules?
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Because if that's what we're saying our control is and we have exceptions to
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it, then the health of that control, it's probably not very strong or we need
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to do some change around it.
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And then in a little bit of conversation, people in the room would be able to
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say, well, there probably are quite a few exceptions. Actually,
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we know that there are exceptions.
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And then the next question is, well, what are we doing about it?
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And that's usually where people get stuck.
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And that's a bit of the conversation of shifting the thought process from focus
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on risk to focus on control, because if you can pick something that people know
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that they're trying to use as control today and you can show quite quickly and clearly that,
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hey, it's probably the health of it isn't as strong as you think it is,
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maybe we should go learn about that and make that better as a place to start.
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It gives people a tangible place to start thinking about control differently.
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So that's just an example of how you might do it. Andy just said and asked you
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guys, how many of you guys have a pretty solid control validation and verification process?
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So one, thank God you raised your hand or had a bit of pretty quiet.
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I'd be like, oh, I'll wait.
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But I think this is so interesting because, so I come from a world where we
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would talk about this as really like, are your controls efficacious,
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right? But I've been told I can't use the word efficacious.
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So I'm supposed to replace it with, are your controls in place and functioning,
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which I would suggest is also efficacious, but we can talk about that.
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I mean, the idea that people, that we don't validate controls is really an important
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thing for us to be thinking about as an organization, because that's really
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a monitoring. I mean, Andy just said it.
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That's a really important monitoring, and it's actually relatively easy to verify
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and validate in the field.
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Verification and validation of controls is not an audit, it's not an inspection,
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but it is going out and testing the controls that are in place.
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It's also an incredible opportunity to have this conversation that Annie's talking about.
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And really, what I would suggest to you guys is that's an area of growth on
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your operations side that simply is not optional.
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I can't think of a reason why you wouldn't do it.
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You want to know if your controls are fine. You want to test your controls.
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And you want to test your controls before something happens.
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So you need to know before that, before you fall off the clip with that rope
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catching. Right. Exactly. And if you think about mountaineering, that's a great example.
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The one I'm thinking about is Bob and I, and I think you were there,
00:16:54.829 --> 00:16:59.449
Andy, we were at a paper plant and the general manager of the paper plant said,
00:16:59.849 --> 00:17:03.909
we had a fire last week and he's really upset about it.
00:17:04.269 --> 00:17:13.009
We evacuated the plant with no injuries in 15 minutes and the fire team responded
00:17:13.009 --> 00:17:19.069
and he said it like it's a bad thing, like look how much we suck.
00:17:19.329 --> 00:17:23.489
And Bob said, I'm having a hard time making that a bad story.
00:17:24.189 --> 00:17:28.929
That's the best verification and validation you could have of your emergency
00:17:28.929 --> 00:17:30.729
response system at this facility.
00:17:30.949 --> 00:17:34.149
And that little comment that Bob made, do you remember this at all?
00:17:34.349 --> 00:17:37.489
Yeah, yeah. It was someplace in, I remember it was stinky. Yeah,
00:17:37.629 --> 00:17:39.389
right, because of paper mill. Yeah, there are.
00:17:40.200 --> 00:17:45.360
But that little comment that Bob made changed the entire trip for us because
00:17:45.360 --> 00:17:50.640
it went from a we're one banana peel away from dead to when you test your system
00:17:50.640 --> 00:17:54.560
and it functions, you should be celebrating that and learning from it.
00:17:54.720 --> 00:17:57.820
And that's where those drills and stuff come in, too, like Crowley out there.
00:17:57.900 --> 00:17:59.200
And we got to spend some time with them.
00:17:59.380 --> 00:18:02.600
And they were testing their emergency response by actually getting the light
00:18:02.600 --> 00:18:06.320
boats out and ready to go and all that stuff. And one of them hung up and did not work well at all.
00:18:06.800 --> 00:18:10.480
Nobody lost their crap about that at all. They're like, glad we did the drill
00:18:10.480 --> 00:18:13.160
because now we know that thing can hang up and it was corroding.
00:18:13.260 --> 00:18:16.760
We didn't know it. And so some of this stuff is we don't know until it's too
00:18:16.760 --> 00:18:17.840
late and then it's not working.
00:18:18.240 --> 00:18:21.920
That's not okay. I test my fire extinguishers and check them on a regular basis
00:18:21.920 --> 00:18:23.280
because Caden uses them.
00:18:23.820 --> 00:18:26.500
He catches stuff on fire and he knows how to put a fire on. He's been able to
00:18:26.500 --> 00:18:27.220
do this since he was three.
00:18:28.000 --> 00:18:31.240
I'm either raising a special forces ninja guy or a terrorist.
00:18:31.700 --> 00:18:33.600
I believe the word is arsonist. Yeah.
00:18:34.760 --> 00:18:38.420
Well, he blew up my neighbor's mailbox. Still fits in arson.
00:18:40.180 --> 00:18:42.740
So Andy says this about controls. I think it's really smart.
00:18:42.960 --> 00:18:46.100
If we have controls in place that really try to control the human,
00:18:46.340 --> 00:18:48.340
what do humans tend to do when you try to control them?
00:18:48.820 --> 00:18:51.680
Oh, man, it's like squeezing Play-Doh, right? I mean, when you try to control
00:18:51.680 --> 00:18:54.580
me, you ask me, I'll go to the ends of the earth for you.
00:18:54.720 --> 00:18:57.420
You tell me, I'll die first, right?
00:18:57.640 --> 00:19:03.500
But when you put in place controls that help people be successful and save them, right?
00:19:03.700 --> 00:19:08.120
Not if, but when something happens that actually keeps them from dying or having a really bad day,
00:19:08.120 --> 00:19:10.820
those are controls and some of those like auto braking you don't even know you
00:19:10.820 --> 00:19:14.180
have until it kicks in because you fail to stop i don't think we do enough of
00:19:14.180 --> 00:19:16.700
that in industry i think the automotive world's done some pretty good work in
00:19:16.700 --> 00:19:20.380
that space i think we need more auto braking things that'll kick in when me
00:19:20.380 --> 00:19:23.760
the human because i don't think humans are reliable i think we're adaptive and
00:19:23.760 --> 00:19:27.680
resilient i mean storm rolls through we get up clean stuff up get back on track
00:19:28.060 --> 00:19:32.660
adaptive we're always adapting we're not very reliable i mean i'm two sigma
00:19:32.660 --> 00:19:37.460
maybe on a good day And so the reality is humans are incredible,
00:19:37.520 --> 00:19:41.560
but we count on them to get it right all the time. So controls need to help us.
00:19:41.940 --> 00:19:45.200
And I love what Todd said about, let's go check them out. Let's test them.
00:19:45.260 --> 00:19:48.240
Let's see if they're actually going to hold up when things go bad.
00:19:48.700 --> 00:19:52.260
So there's two questions I ask because I like to ask questions that are storytelling based.
00:19:52.460 --> 00:19:57.320
And one question is, with this control, can you share a story with me when it
00:19:57.320 --> 00:19:59.380
supported work to go well?
00:20:00.140 --> 00:20:05.180
And then can you share a story with me when the control hindered the work and
00:20:05.180 --> 00:20:10.260
you see a whole different picture because the function is one part of it.
00:20:11.951 --> 00:20:14.571
The help or hinder component, which is standing on what you're saying,
00:20:14.751 --> 00:20:15.931
is equally as important.
00:20:16.111 --> 00:20:22.311
But by starting with the help, it gives you much better context when you move to the hinder.
00:20:22.871 --> 00:20:27.051
So from a psychosocial perspective, I know which is a bit of an unusual word
00:20:27.051 --> 00:20:31.291
to use here around psychosocial risk, if you start with how it supports you,
00:20:31.431 --> 00:20:33.151
you'll get better on the other side.
00:20:33.711 --> 00:20:37.271
I just wanted to get us back to the kind of the questions.
00:20:37.491 --> 00:20:44.191
I thought we were done. Well, no, but I saw a few questions that seemed to kind of ask the same thing,
00:20:44.391 --> 00:20:50.091
which is when you have two companies that are working together and one is strong
00:20:50.091 --> 00:20:54.651
and heavy kind of in their hop journey and the other is not,
00:20:54.651 --> 00:20:58.311
how do you help one another?
00:20:58.551 --> 00:21:02.031
How do you help kind of bring them along on the journey with you?
00:21:02.251 --> 00:21:07.751
Or even maybe you're both on the same HOP journey, but you're in different spots.
00:21:08.311 --> 00:21:10.651
How do you kind of bridge that gap?
00:21:11.231 --> 00:21:13.751
There's been a few organizations that I think have done this pretty well.
00:21:14.291 --> 00:21:18.211
I don't think ours was one of them because we weren't far enough along. We don't exist anymore.
00:21:18.691 --> 00:21:24.751
But, I mean, the first thing that they did was invite them to any training that they had, right?
00:21:24.811 --> 00:21:27.191
So if you're working with someone and you realize that, hey,
00:21:27.331 --> 00:21:30.451
in order for us to be really successful, we're going to have to be on the same
00:21:30.451 --> 00:21:32.731
page, they intentionally invited them.
00:21:32.831 --> 00:21:37.131
There was one organization that actually created training for all of the folks that worked with them.
00:21:38.711 --> 00:21:42.011
I honestly think from the stories that they've said, it's just a lot of patience
00:21:42.011 --> 00:21:45.571
and the willingness to teach them as though they were part of their own organization.
00:21:46.071 --> 00:21:49.251
But at the leadership level, the place where it seems to matter the most and
00:21:49.251 --> 00:21:53.011
where you can have a pretty, I would think, succinct conversation without having
00:21:53.011 --> 00:21:58.531
to go into the whole detail and philosophy is when you have one group of folks reporting to another.
00:21:58.691 --> 00:22:03.211
So picture like a contractor, subcontractor situation and the folks that are
00:22:03.211 --> 00:22:07.211
subcontracting or the folks that are contracting the subcontractors,
00:22:07.311 --> 00:22:09.551
if they don't want the subcontractor to, for example,
00:22:09.751 --> 00:22:12.411
remove somebody from the job site because they're on this hop journey,
00:22:12.471 --> 00:22:14.371
we're like, hey, that's not the response that you have to have.
00:22:14.591 --> 00:22:19.011
They had to be very explicit with what they wanted the contract team to do or
00:22:19.011 --> 00:22:22.091
the subcontract team to do when something went wrong, like very explicit.
00:22:22.471 --> 00:22:26.371
And say that we know historically we've asked you to remove somebody from the
00:22:26.371 --> 00:22:27.391
job site when this happens.
00:22:27.531 --> 00:22:30.711
We are asking you very specifically not to do that this time.
00:22:30.711 --> 00:22:31.831
We're going to respond differently.
00:22:32.011 --> 00:22:36.391
And they had to have that meeting up front in their contract piece of it.
00:22:37.291 --> 00:22:43.071
When it's the opposite, it's really, really hard because obviously the dynamic is quite different.
00:22:43.331 --> 00:22:46.291
And I can tell you the practical things of what people do.
00:22:46.371 --> 00:22:50.211
I don't know a good solution to it, but I can tell you practically the stories
00:22:50.211 --> 00:22:54.151
that I've been told is when you really don't feel as though you have the authority
00:22:54.151 --> 00:22:58.751
to sort of push back on the response that somebody's had. What they do is...
00:22:59.510 --> 00:23:04.330
They remove the person, right, as requested, and then they go operationally
00:23:04.330 --> 00:23:09.270
learn themselves within their own space and time to make sure that the next
00:23:09.270 --> 00:23:11.630
time that they face this, they can set themselves up for success.
00:23:11.970 --> 00:23:18.950
But they haven't pushed as hard back as they historically would maybe have wanted
00:23:18.950 --> 00:23:21.890
to because they didn't feel that the power dynamic was there,
00:23:22.010 --> 00:23:25.390
where they basically brought the person back into the fold of their organization
00:23:25.390 --> 00:23:26.350
when something went wrong,
00:23:26.510 --> 00:23:28.790
said, hey, we're going to operationally learn amongst ourselves.
00:23:28.790 --> 00:23:32.190
We're going to share the information, but their response was very similar to
00:23:32.190 --> 00:23:33.050
how it was historically.
00:23:33.550 --> 00:23:38.430
And Helen, that's a lot what I see sometimes the inverse. But we hire contractors
00:23:38.430 --> 00:23:42.430
and something goes wrong, especially around lotto, and we'll get on a learning
00:23:42.430 --> 00:23:45.650
call and they'll talk about what happened.
00:23:45.690 --> 00:23:48.990
And then we might ask about the worker and say, oh, don't worry, we got rid of the worker.
00:23:49.210 --> 00:23:52.650
Now, what that actually means is that they're just removed from our site, right?
00:23:52.790 --> 00:23:54.930
They say they fired them, but they really moved them somewhere else.
00:23:54.930 --> 00:23:59.570
It's really not that draconian, but it's still sending the entire wrong message around learning.
00:24:00.410 --> 00:24:04.470
So what happens is we get on a learning call with these events and if you're
00:24:04.470 --> 00:24:08.250
in our gate, you're our people, man. We care about you. We train you just like we would our people.
00:24:08.610 --> 00:24:12.170
And we want to learn with you just like you're our people. So when it comes
00:24:12.170 --> 00:24:16.990
to this learning call and they say, oh, don't worry, we fired or removed this guy.
00:24:17.390 --> 00:24:20.550
Well, we can't direct their work, right? There's legal reasons.
00:24:20.670 --> 00:24:24.130
We say, hey, I know I can't tell you how to treat your workers and exactly what to do there.
00:24:24.130 --> 00:24:30.710
But next time something like this happens, I would really love to hear and learn
00:24:30.710 --> 00:24:35.070
from the worker about the context and then see a plan that you have about why
00:24:35.070 --> 00:24:39.890
we're going to change the way we do the work so it doesn't happen a second time.
00:24:40.330 --> 00:24:45.150
And Barry Boswell on this call says, why did you fire the guy?
00:24:45.490 --> 00:24:49.030
They say, because I thought that's what you would want us to do.
00:24:49.410 --> 00:24:52.810
Right. Because that's the natural, normal response is people want to see strong
00:24:52.810 --> 00:24:56.150
action in this some way. And we say we want to see strong learning.
00:24:56.410 --> 00:24:59.830
In the beginning, when we're setting up an outage, so we go from like 300 people
00:24:59.830 --> 00:25:02.170
on site to 1,800 people or 2,000 people on site.
00:25:02.370 --> 00:25:05.790
We get the leadership teams, all those guys together. We tell them about our
00:25:05.790 --> 00:25:09.710
learning versus blame culture and that we want you to be part of that.
00:25:10.310 --> 00:25:15.250
We cover some of the principles with those guys and we say we want to learn and hear from you.
00:25:15.670 --> 00:25:20.770
And then we actively go out and we talk about these hot principles at breaks
00:25:20.770 --> 00:25:23.310
and those kind of things with them. So they receive some training up front,
00:25:23.310 --> 00:25:27.290
but then we reinforce it all the way through the cycle because we know things will go wrong.
00:25:27.350 --> 00:25:30.170
But the less we know, the more things will go wrong.
00:25:31.252 --> 00:25:35.532
The only thing I would add to this equation is that I actually think this is a symptom.
00:25:35.752 --> 00:25:39.032
I mean, it feels like a problem to us in this room because it is a problem,
00:25:39.032 --> 00:25:44.212
but it's actually a symptom of the relationship both informal and formal we
00:25:44.212 --> 00:25:45.632
have made with our contractors.
00:25:46.112 --> 00:25:49.872
And I think we really have to think about that relationship changing.
00:25:50.312 --> 00:25:55.132
So part of what I would suggest is that we probably should talk about how we're
00:25:55.132 --> 00:25:59.932
going to respond to an event as a drill before we actually respond to an event.
00:26:00.532 --> 00:26:07.612
So one of my favorite stories, it's the rubber glove potato salad story, is in Calgary.
00:26:08.292 --> 00:26:12.552
What's that fancy Fairmont? That fancy, fancy place. Is it the Fairmont?
00:26:12.852 --> 00:26:18.612
I mean, it's swanky McPancy fancy. I mean, shirts and shoes required kind of place, right?
00:26:18.992 --> 00:26:23.072
So there was a big oil sands company that was about to flip a switch,
00:26:23.072 --> 00:26:26.812
and they were going to go from 300 employees to, like, seriously,
00:26:27.092 --> 00:26:31.692
6,000 employees on a weekend. And they'd prepared for it. They had man camps,
00:26:31.852 --> 00:26:32.852
I'm sorry, people camps.
00:26:33.092 --> 00:26:37.852
They had more toilets, bigger sewer ponds. I mean, they were ready for this to happen.
00:26:38.272 --> 00:26:41.732
But before it happened, the senior executive of the company that was about to
00:26:41.732 --> 00:26:46.872
grow brought in all his contract leadership, all the personnel representations,
00:26:46.872 --> 00:26:49.392
and they brought him to this fancy fairmont.
00:26:49.392 --> 00:26:54.212
And it was pretty remarkable because the entire agenda for that meeting was
00:26:54.212 --> 00:26:56.732
one item. We will have an accident.
00:26:57.272 --> 00:27:02.432
Something will happen. And when it does, how are we as a collective leadership
00:27:02.432 --> 00:27:05.652
team going to respond to it? It was remarkable.
00:27:05.892 --> 00:27:09.272
And what's interesting is they did have an accident.
00:27:09.612 --> 00:27:14.072
Something happened, of course. And because they'd done that rehearsal,
00:27:14.452 --> 00:27:20.392
they'd really played out the accountability that they had to each other as the company.
00:27:20.532 --> 00:27:23.692
And they had the contract people and the lawyers in that room.
00:27:23.872 --> 00:27:27.112
So that conversation is a really important conversation.
00:27:28.480 --> 00:27:31.580
We're growing into a problem that we didn't know. Well, I think we always knew
00:27:31.580 --> 00:27:33.680
we had this, but now it's becoming more profound.
00:27:34.100 --> 00:27:37.660
We're going to have to really look at how we have those relationships with our
00:27:37.660 --> 00:27:39.920
contractors. Because Charles is right.
00:27:40.300 --> 00:27:42.720
If they're on your site, they're your people.
00:27:43.520 --> 00:27:48.140
It's pretty painful when a contractor dies, just like it is when a worker dies.
00:27:48.420 --> 00:27:51.500
And so that's a really important thing to think about. Okay,
00:27:51.560 --> 00:27:52.680
you want to hear the rubber glove story?
00:27:53.440 --> 00:27:58.140
So we're at this fancy fair. I mean, this place is like, they got a guy that hands out the tea.
00:27:58.460 --> 00:28:02.900
I mean, it's fancy. And they bring this meal out for lunch, and I'm sitting
00:28:02.900 --> 00:28:06.020
next to the CEO guy because they made me. That's not my style.
00:28:06.480 --> 00:28:09.800
And they bring out this potato salad, and I love potato salad.
00:28:10.120 --> 00:28:14.620
And I'm eating it, eating it, eating it, and there's something that just won't break down.
00:28:15.840 --> 00:28:18.920
At first, you know, you kind of think it's celery because celery is a tricky
00:28:18.920 --> 00:28:23.780
vegetable, you know, stringy, and there's a lot going on. And so I take my napkin
00:28:23.780 --> 00:28:26.940
real subtly because I'm sitting next to the CEO guy, and it's pretty snooty.
00:28:27.200 --> 00:28:30.520
And I just go like this when no one's looking, and it's a rubber glove.
00:28:30.880 --> 00:28:35.980
Now, I don't know what your recipe for potato salad is, but mine doesn't have a rubber glove in it.
00:28:36.060 --> 00:28:40.280
And so when the waiter came by, because there's a million waiters at this place,
00:28:40.440 --> 00:28:46.640
I just handed him my napkin, and I said, tell the chef this ingredient is not in my recipe.
00:28:47.260 --> 00:28:50.200
And he took the napkin and walked away because that's the kind of place they
00:28:50.200 --> 00:28:51.440
are. I mean, they're like, yes, sir.
00:28:51.960 --> 00:28:55.540
And pretty soon i could
00:28:55.540 --> 00:28:59.600
see heads looking around the corner but i
00:28:59.600 --> 00:29:04.340
don't know why you guys had that been a hair or a band-aid i think i would have
00:29:04.340 --> 00:29:09.420
probably just puked right there but i i don't know why the rubber glove it didn't
00:29:09.420 --> 00:29:15.080
it i don't know it just didn't seem that bad to me i was the weird yeah i mean
00:29:15.080 --> 00:29:19.040
it's a kind of and so i didn't think a thing about it and the meeting went on.
00:29:19.220 --> 00:29:23.500
They did come out later in the afternoon and they have their own kind of tea they serve.
00:29:23.780 --> 00:29:28.120
And they said, we'd like to give you a box of this tea to say thank you.
00:29:28.480 --> 00:29:32.780
And I said, well, okay. I mean, I just wasn't a big deal to me.
00:29:33.180 --> 00:29:37.240
Then we had the nightly dinner. Have you ever been to one of these where all
00:29:37.240 --> 00:29:41.740
the senior executives go and there's like six kinds of wine and they're celebrating
00:29:41.740 --> 00:29:43.500
this meeting? And it really was a good meeting.
00:29:43.760 --> 00:29:47.300
And they had a three choice menu the
00:29:47.300 --> 00:29:51.020
first choice was triple a alberta beef with
00:29:51.020 --> 00:29:54.460
like asparagus or brussel sprouts something
00:29:54.460 --> 00:29:57.420
icky right the second one was chicken
00:29:57.420 --> 00:30:01.440
and the third one was fish i'd like
00:30:01.440 --> 00:30:05.720
to point to someone in the audience i won't say her name but generally when
00:30:05.720 --> 00:30:11.340
you're in places like santa fe or calgary fish should not be your first choice
00:30:11.340 --> 00:30:16.420
okay just just check it in with you okay right So who's going to get,
00:30:16.520 --> 00:30:17.880
what meal are you going to order?
00:30:18.020 --> 00:30:21.020
AAA, Alberta, I mean, there's not even a question.
00:30:21.380 --> 00:30:25.640
The problem is, is that the dumb fish course had crab cakes.
00:30:27.499 --> 00:30:31.679
And I really wanted crab cake. So I asked the waiter that evening,
00:30:31.879 --> 00:30:37.679
can I get the AAA Alberta beef, but can I substitute the crab cakes?
00:30:37.819 --> 00:30:39.919
And the waiter said, no.
00:30:40.479 --> 00:30:44.139
And I said, okay. And he says, you know, there's just a certain amount of food
00:30:44.139 --> 00:30:47.399
we've prepared and the meals are prepared. And so we just don't have enough
00:30:47.399 --> 00:30:48.899
extra food to substitute.
00:30:49.119 --> 00:30:52.359
And I said, no problem at all. I said, if you don't mind, though,
00:30:52.419 --> 00:30:58.259
would you tell the chef I'm the potato salad guy from lunch?
00:30:58.879 --> 00:31:04.079
That's all I said. They bring out the meals. And I had a pile of crab cakes.
00:31:05.679 --> 00:31:09.379
And the CEO turns to me and he said, how did you do that?
00:31:09.799 --> 00:31:12.899
I said, well, I need to tell you a little story about lunch.
00:31:13.079 --> 00:31:14.819
I've been kind of keeping it a secret. it.
00:31:15.559 --> 00:31:20.239
If we choose not to investigate or focus on minor events, cuts,
00:31:20.879 --> 00:31:25.819
slips, trips, falls, etc., and only on events that result in critical injury
00:31:25.819 --> 00:31:31.159
or fatality, can it be seen as not caring about hurting people?
00:31:31.459 --> 00:31:32.739
Can I take a look at it and shut up?
00:31:33.079 --> 00:31:36.519
So I think that's the wrong way to look at it. And I think that sends the wrong
00:31:36.519 --> 00:31:37.739
message out to your organization.
00:31:37.939 --> 00:31:41.079
I think what you want to tell your organization is that you really want to look
00:31:41.079 --> 00:31:46.879
at high information events more than you look at low information events.
00:31:47.259 --> 00:31:51.439
And so help the organization understand that we're not looking at events based
00:31:51.439 --> 00:31:53.579
upon consequence or possible consequence.
00:31:53.839 --> 00:31:58.499
We're actually looking at events based upon the context of the event.
00:31:58.639 --> 00:32:04.399
Because you all know in this room that there are big accidents that have very little to teach us.
00:32:04.699 --> 00:32:09.359
I mean, there's just not much to teach. Something vibrated off the top of the
00:32:09.359 --> 00:32:11.399
rig. It fell. It hit hard.
00:32:11.839 --> 00:32:14.839
I mean, I'm not sure. I mean, we can learn from it for sure.
00:32:16.021 --> 00:32:20.141
There are also little accidents that can teach us much. And so I would really
00:32:20.141 --> 00:32:25.701
encourage you guys to rethink how you prioritize your potential to learn and
00:32:25.701 --> 00:32:27.161
really look at events and say,
00:32:27.161 --> 00:32:31.221
is there much to teach us here or is there not much to teach us here?
00:32:31.361 --> 00:32:34.701
Now, that means you're going to have to do some kind of learning around the event early.
00:32:34.981 --> 00:32:40.061
But if you're not doing event critiquing right now, I'd be really shocked and surprised.
00:32:40.921 --> 00:32:46.421
Was that a no or yes? I think that's good. I mean, and just one thing is like,
00:32:46.521 --> 00:32:53.041
if investigations is how people feel cared for, you got a lot of other problems.
00:32:53.661 --> 00:32:59.521
I mean, there's got, you know, thinking about if really the goal is to help
00:32:59.521 --> 00:33:04.321
people feel cared for, think about ways to give people more voice,
00:33:04.581 --> 00:33:06.901
you know, not through surveys, please.
00:33:07.701 --> 00:33:13.781
And, you know, sort of other opportunities to share their experiences and their
00:33:13.781 --> 00:33:18.561
concerns and their fears than waiting until something bad happens.
00:33:18.941 --> 00:33:22.401
Yeah, we had a lady that was about my age, mid-30s and, sorry,
00:33:22.541 --> 00:33:26.181
mid-60s, and she tripped on flat concrete, broke her kneecap in half.
00:33:26.681 --> 00:33:29.501
Lost time accident. I was the first responder on that call. Where are my firefighters
00:33:29.501 --> 00:33:33.161
at? It was like, oh my word, I don't know that I've seen somebody in that much pain before.
00:33:33.621 --> 00:33:36.341
We got her out of there got her taken care of it was hard to even get her out
00:33:36.341 --> 00:33:39.761
in the hospital I mean in the ambulance she served so much it was a lost time
00:33:39.761 --> 00:33:40.141
accident it was a lost time accident,
00:33:40.868 --> 00:33:44.808
what do you think we did? Took care of her knee. Back in the day,
00:33:44.908 --> 00:33:46.588
it would be like, oh no, that's lost time. You got to do something.
00:33:46.688 --> 00:33:48.708
We got to start inspecting everybody's shoes when they come into work.
00:33:48.748 --> 00:33:51.088
And we got to paint everything yellow and put a little sign up that says,
00:33:51.208 --> 00:33:53.148
know where your toes goes and write all this crap.
00:33:53.408 --> 00:33:55.848
And we didn't do any of that. We just took care of her knee.
00:33:56.268 --> 00:34:00.128
We had a magnetic die clamp failed and dropped a 20,000 pound top plate in a
00:34:00.128 --> 00:34:02.388
die set right next to a guy's arm during setup.
00:34:03.048 --> 00:34:06.308
Okay, that could have killed him. Didn't even hurt him. It was a new technology
00:34:06.308 --> 00:34:08.248
we're moving to, the magnetic die clamps.
00:34:08.928 --> 00:34:12.888
We did deep, deep, deep operational learning. And we found out we are not process
00:34:12.888 --> 00:34:14.468
capable of managing that technology.
00:34:15.128 --> 00:34:19.428
Nobody even got hurt. He was fine. He was cleared by a few inches.
00:34:19.568 --> 00:34:22.808
But that's the difference. There's contextually rich, tons to learn.
00:34:23.088 --> 00:34:26.128
The ladies tripped on the flat concrete. I just think you take care of, Renee.
00:34:27.108 --> 00:34:31.128
And actually, someone before this had a question, because right now they're
00:34:31.128 --> 00:34:34.788
doing like learning teams on seemingly everything, like any event that's happening
00:34:34.788 --> 00:34:35.968
and people are getting burned out.
00:34:37.288 --> 00:34:40.588
And what we were talking about is that the place that you want to spend all
00:34:40.588 --> 00:34:43.068
your time and energy is a place that there's something to gain from spending
00:34:43.068 --> 00:34:47.008
all your time and energy, which means that there has to be something to learn,
00:34:47.148 --> 00:34:48.568
which is usually there's a lot of moving pieces,
00:34:48.728 --> 00:34:52.408
a lot of moving parts that you want to understand. So we would call it high complexity.
00:34:52.548 --> 00:34:55.088
But I like the – what term did you just say, Todd?
00:34:55.488 --> 00:34:58.568
High learning? What did – Oh, high potential learning. High potential learning?
00:34:58.648 --> 00:34:59.988
That or before, after potato salad.
00:35:00.448 --> 00:35:03.208
High information. We call them high information events, right?
00:35:03.248 --> 00:35:06.068
High information. Yeah, that's probably an easier way of thinking about it.
00:35:06.188 --> 00:35:09.048
And you can tell the difference because when you go to talk to somebody who
00:35:09.048 --> 00:35:12.028
is involved in a low-information event, they don't even want to talk about it.
00:35:12.248 --> 00:35:13.028
Well, there's not much to talk about.
00:35:13.328 --> 00:35:18.888
Well, this happened. But when Mark told that story about sometimes his friend
00:35:18.888 --> 00:35:23.088
Brian who fell and they were doing an investigation on him and he said sometimes
00:35:23.088 --> 00:35:25.268
people fall and then the instructor fell.
00:35:25.888 --> 00:35:28.968
I mean, that's a really good example of a low-information event.
00:35:28.968 --> 00:35:32.528
To me, and you guys all have to help me with this one, I really struggle with
00:35:32.528 --> 00:35:34.248
the whole idea of potential SIF.
00:35:34.888 --> 00:35:38.888
I mean, I just do. And the reason I do is because any accident,
00:35:38.888 --> 00:35:41.568
if the controls fail, can kill a person.
00:35:41.908 --> 00:35:46.208
It's probably the majority of fatality. Not the majority, but I've done an awful
00:35:46.208 --> 00:35:49.528
lot of fatality investigations in stairwells.
00:35:49.908 --> 00:35:55.188
But most stairwells on your hazard assessments don't really hit the deck as
00:35:55.188 --> 00:36:00.208
potential SIFs because they're stairwells. I mean, so I don't know how I feel about that.
00:36:00.348 --> 00:36:03.848
I really struggle with that. I don't have an answer because we have to have
00:36:03.848 --> 00:36:06.568
a way to look for significant events that we could learn from.
00:36:07.008 --> 00:36:12.948
But I think a potential SIF, I don't know, it seems like if I was given the
00:36:12.948 --> 00:36:17.588
opportunity and didn't have a lot of time, I could talk the organization out
00:36:17.588 --> 00:36:19.168
of that being a potential SIF.
00:36:19.668 --> 00:36:23.888
So I don't know. I mean, I'm torn on it. What do you think? What do you think?
00:36:24.781 --> 00:36:28.581
Well, yeah, but I don't want to because really the reward of talking them into
00:36:28.581 --> 00:36:30.141
doing stuff is that I have to do stuff.
00:36:31.021 --> 00:36:36.021
Next question. Do you want to read it? When considering how to apply post-incident
00:36:36.021 --> 00:36:39.321
learning teams, what's the best way to determine when the organization should use them?
00:36:39.481 --> 00:36:43.761
I'm concerned that without some definition that they may not be used consistently.
00:36:44.161 --> 00:36:46.761
Initially, I thought about creating a flowchart to guide that decision.
00:36:47.581 --> 00:36:48.661
I'm going to hand this to you.
00:36:50.281 --> 00:36:54.101
So we made we live this one. And the way we did it was in our production meeting
00:36:54.101 --> 00:36:57.741
in the morning, we just would look at the situation and go, that's worth learning about.
00:36:58.421 --> 00:37:01.481
Another bee sting, another bug bite that turned into a recordable. Yeah.
00:37:02.281 --> 00:37:05.181
So we just, our boundaries around it were pretty straightforward.
00:37:05.181 --> 00:37:07.321
We just said, let's talk about it as a leadership team.
00:37:07.501 --> 00:37:10.381
If it's contextually rich or we don't really understand how it happened,
00:37:10.401 --> 00:37:12.541
or there's maybe a lot of stuff we can learn here.
00:37:12.781 --> 00:37:16.981
If it's a bug bite, we had 30 bug bites one year, seven of them recordable.
00:37:17.201 --> 00:37:20.261
You know what I stopped talking about? Damn bug bites, right?
00:37:20.261 --> 00:37:23.281
We had a honey farm across the street from us. And I know you don't want to
00:37:23.281 --> 00:37:24.641
kill honey bees. I saw the Bee Movie.
00:37:24.881 --> 00:37:28.261
And so we just quit talking about it. It was recordable. I don't care.
00:37:28.681 --> 00:37:31.481
But in a conversation and production meeting, that's what we use.
00:37:31.601 --> 00:37:33.961
Now, different companies have actually written parameters.
00:37:34.241 --> 00:37:37.361
I think it's fine. Nothing wrong with that. But I also think it's okay to just,
00:37:37.521 --> 00:37:41.581
as leaders and frontline leaders, say, whew, that's worth learning about.
00:37:41.761 --> 00:37:44.121
I think that'd be worth digging into a little deeper.
00:37:44.621 --> 00:37:48.921
Not a very scientific answer, but it sure works. Post-learning team.
00:37:49.561 --> 00:37:53.621
How do you recommend sharing what the team recommends to the leadership team?
00:37:53.901 --> 00:37:59.061
There are times where we have a learning team, but then do not see the results afterwards.
00:37:59.953 --> 00:38:03.033
Yeah, don't create more bureaucracy. If you're short on bureaucracy,
00:38:03.273 --> 00:38:06.893
call me. I still have a box left over from GE. You can have it for free.
00:38:07.553 --> 00:38:12.453
But, you know, Carmen, you used a lot of systems that you had in place already
00:38:12.453 --> 00:38:15.053
with your equipment, improvement things and all that, right?
00:38:15.233 --> 00:38:18.993
So she's used that to track this stuff through. But she also says something really important.
00:38:19.293 --> 00:38:22.493
If we don't get stuff done, then people will be like, okay, well, don't ask me again.
00:38:22.833 --> 00:38:26.353
So it goes also back to what's in my circle of control. Let's do something.
00:38:26.873 --> 00:38:30.653
We had one where the guy just needed a locking carabiner. Said, can anybody help?
00:38:30.933 --> 00:38:34.313
Right? We had one where they just needed a buggy whip to be able to identify
00:38:34.313 --> 00:38:35.813
how close they were getting to the piece of equipment.
00:38:36.073 --> 00:38:39.333
We had one where they needed a piece of tape on the ground. Oh, no. That was terrible.
00:38:40.533 --> 00:38:43.673
So, three different work groups there could not get along.
00:38:43.873 --> 00:38:46.773
It was amazing. So, Andy and I led this one. And they needed a piece of tape
00:38:46.773 --> 00:38:49.073
nice and straight on the ground to line the components up.
00:38:49.213 --> 00:38:52.273
They could not figure out how to put the tape on it. That's your job.
00:38:52.373 --> 00:38:53.073
Nuh-uh. That's facility.
00:38:53.213 --> 00:38:55.813
Maintenance could do that. They were arguing about it. I wanted to say,
00:38:56.073 --> 00:38:57.953
give me the damn roll. I'll put the tape down.
00:38:58.393 --> 00:39:01.553
Andy and I decided we're not going to put the tape down. Our goal,
00:39:01.693 --> 00:39:03.293
it may sound ridiculous. This is what happens.
00:39:03.513 --> 00:39:08.813
Our goal was to help them work through that problem of who's putting the tape on the ground.
00:39:09.153 --> 00:39:13.113
That sounds silly and trivial, except that's how dysfunctional they were at
00:39:13.113 --> 00:39:14.353
that site. Go where they're at.
00:39:14.813 --> 00:39:18.633
So one point from Tuesday of the first day, we were talking a lot about transparency.
00:39:18.633 --> 00:39:24.373
And I know of multiple workplaces that have kind of adopted a learning team
00:39:24.373 --> 00:39:29.493
process, but have serious situations where they have to sign confidentiality
00:39:29.493 --> 00:39:32.473
agreements, the people on the teams, that's not the way to do it.
00:39:33.711 --> 00:39:37.211
Let's start there and then work backwards towards how to make this all transparent.
00:39:37.731 --> 00:39:41.271
I'm personally a fan. We do a lot of storyboarding of the learning team afterwards.
00:39:41.611 --> 00:39:45.811
And the purpose of the storyboard is to tell the story. And the story is not about people.
00:39:46.391 --> 00:39:50.691
The story is about the work. The story is about how the work was supported, what hindered the work.
00:39:51.071 --> 00:39:56.111
But what's most important is that that story is written in a way that whether
00:39:56.111 --> 00:40:02.051
another worker reads it or a board member reads it, they can see themselves in the story.
00:40:02.691 --> 00:40:08.731
Yeah. And they can see the potential of other deeper systemic things that could exist in their areas.
00:40:08.911 --> 00:40:13.311
And that's what drives it. It's about, you know, that sharing and extending out further.
00:40:13.851 --> 00:40:18.671
And I think you should also recognize that sometimes certain solutions that
00:40:18.671 --> 00:40:22.011
are produced don't work. And that's okay.
00:40:22.511 --> 00:40:25.991
And you just need to know when you need to go into a much better process.
00:40:26.231 --> 00:40:29.811
Bob mentioned earlier that, you know, there are biases in these.
00:40:29.811 --> 00:40:35.991
But in many cases, you go to the people who are doing the work and they absolutely
00:40:35.991 --> 00:40:38.591
know what the solution they need is.
00:40:38.731 --> 00:40:43.191
Some problems are hairier that actually require innovation.
00:40:43.191 --> 00:40:49.711
And that's when you need to go into a deeper innovation type process where you
00:40:49.711 --> 00:40:53.651
do some more critical thinking, where you spend more time.
00:40:53.651 --> 00:40:59.231
You know, instead of producing multiple solution sets, you first produce multiple
00:40:59.231 --> 00:41:03.371
problem sets and you question those, the assumptions of the problem sets.
00:41:03.531 --> 00:41:09.171
And then that's when you get to an innovative solution that no one had ever thought of before.
00:41:09.411 --> 00:41:15.751
And so there might be some cases where your learning uncovers that you need
00:41:15.751 --> 00:41:17.771
to do more. Not in most cases.
00:41:17.951 --> 00:41:22.311
I think in most cases, the people doing the work know what they need to do.
00:41:22.411 --> 00:41:31.911
But if it is a really hard, hairy problem, then you need to add some more rigor. Yeah.
00:41:32.784 --> 00:41:36.464
And I think that's a totally fair statement that oftentimes people will say,
00:41:36.924 --> 00:41:40.964
well, we defined the problem, but then like nobody knew how to solve it.
00:41:41.064 --> 00:41:43.464
And then when we ask what the problem is, it's a problem that people have had
00:41:43.464 --> 00:41:48.304
for like 30 years that requires like a cross-functional group from multiple
00:41:48.304 --> 00:41:52.564
different activities to come together to come to some sort of consensus about that.
00:41:52.744 --> 00:41:55.864
And you're like, well, yeah, that's not fair to have six people that you sat
00:41:55.864 --> 00:41:59.124
in a room for two hours be the only people that are there to solve the problem.
00:41:59.264 --> 00:42:03.244
That is just not a fair way of doing it. Now you can crowdsource solution sets.
00:42:03.304 --> 00:42:06.244
You can get into an innovation space. You can create a sub team that's going
00:42:06.244 --> 00:42:08.744
to go take a look at that and they can go through a cross function.
00:42:08.884 --> 00:42:10.744
There's so many different ways of addressing it.
00:42:11.104 --> 00:42:15.204
And for people who are asking, how is AI helping in this situation?
00:42:15.204 --> 00:42:19.484
I can tell you, we recently did a learning team, came across a problem that
00:42:19.484 --> 00:42:22.684
had been a problem for, I don't know, Matt, do you remember how many years?
00:42:23.904 --> 00:42:26.904
Decades? Many, many, many years. They had not solved it yet.
00:42:27.064 --> 00:42:30.804
We defined the problem really well. It was a technical problem in terms of being
00:42:30.804 --> 00:42:34.004
able to center something while another piece of material was rotating.
00:42:34.324 --> 00:42:40.884
And they used ChatGPT to crowdsource a solution for it from all of the Internet
00:42:40.884 --> 00:42:44.924
and found within like a 20-minute search, they found a tool that they could
00:42:44.924 --> 00:42:48.044
purchase for like $200 to solve the problem. I don't lose hands.
00:42:49.824 --> 00:42:54.444
Nailed it. I'm going to read the next question. As a hub community,
00:42:54.744 --> 00:43:00.484
do you think we can move away from the terms like accountability and responsibility
00:43:00.484 --> 00:43:02.544
and only talk about ownership?
00:43:03.084 --> 00:43:07.624
It feels like we are spending a lot of time trying to redefine a word that is
00:43:07.624 --> 00:43:13.124
no longer holding that meaning in our present day society. I would say 100%
00:43:13.124 --> 00:43:17.724
I think you can move away from the word accountability and call it a practice of ownership.
00:43:17.964 --> 00:43:23.464
But you first have to create the mindset shift away from accountability and
00:43:23.464 --> 00:43:25.824
discipline because there are so many ways.
00:43:27.248 --> 00:43:31.768
It's a baggage-heavy word. And in the redefining and the moving away,
00:43:32.008 --> 00:43:36.868
you have to own what accountability really is to be able to move into ownership.
00:43:37.308 --> 00:43:40.128
Can I add just one thing? Yes, please add. So I love that answer.
00:43:40.148 --> 00:43:43.688
And I think that it's very dependent upon your organization of where you might
00:43:43.688 --> 00:43:45.688
be able to do that and some organizations might not.
00:43:45.848 --> 00:43:50.448
So it'd be wonderful to see a couple folks from this room right now come back
00:43:50.448 --> 00:43:54.328
and say, look at this really good success story and then share it with others
00:43:54.328 --> 00:43:58.108
who are struggling with those questions to show PAC at work what can happen
00:43:58.108 --> 00:43:59.528
when you move away from those terms.
00:44:00.068 --> 00:44:03.468
I think there's a question that somebody wants you to... Yeah,
00:44:03.828 --> 00:44:04.968
I think you keep pushing that down.
00:44:06.368 --> 00:44:09.208
I don't think I need to read it. I know that the question is,
00:44:09.468 --> 00:44:15.188
some regulators like OSHA seem to push things like accountability and discipline
00:44:15.188 --> 00:44:18.148
around some of the things within their work.
00:44:18.168 --> 00:44:22.008
How do we deal with that or something like that? I don't agree on this color OSHA.
00:44:24.068 --> 00:44:30.228
So where I think the couple of places this really lies at OSHA is in the employee
00:44:30.228 --> 00:44:34.748
misconduct affirmative defense part of after a citation is issued and you're
00:44:34.748 --> 00:44:37.868
trying to say, well, Jim screwed up and that's why we got cited.
00:44:38.108 --> 00:44:43.068
So don't cite us or remove the citation, withdraw the citation.
00:44:43.308 --> 00:44:47.968
The other place that I think it shows up is within some of the programs like lockout,
00:44:48.728 --> 00:44:54.368
or part industrial vehicles where you're trying to demonstrate deviations in
00:44:54.368 --> 00:44:59.268
operations to show that you've done things like retraining when you've had that,
00:44:59.368 --> 00:45:01.688
that there is a process in place for that.
00:45:01.888 --> 00:45:08.008
I know that this has been, over the years, really been spun up to say OSHA requires
00:45:08.008 --> 00:45:09.748
us to have a disciplinary program.
00:45:10.918 --> 00:45:14.678
That's the case. I think that in those, you know, a couple of specific examples,
00:45:14.678 --> 00:45:18.738
I'm sure there's some others, that there is something that says when somebody has done,
00:45:19.178 --> 00:45:23.718
you know, drives the fork truck into the I-beam, we probably should make sure
00:45:23.718 --> 00:45:26.098
they know how to drive the fork truck again.
00:45:26.298 --> 00:45:30.598
That seems like a good logical step. For the affirmative defense stuff after
00:45:30.598 --> 00:45:34.038
the citation, that gets into, you know, we've been really good in these three
00:45:34.038 --> 00:45:38.278
days of the term lawyer has only come up a couple of times, but that really comes into the,
00:45:38.538 --> 00:45:42.678
you know, what the lawyers have done to the practice of health and safety, in my opinion.
00:45:42.878 --> 00:45:47.818
And it's something that I think there's a lot of room to show that there is
00:45:47.818 --> 00:45:52.918
retraining, counseling, other things that have been in place that discipline
00:45:52.918 --> 00:45:54.958
is not necessarily the only out.
00:45:55.138 --> 00:45:58.358
And again, what we've been saying all week, there are some things that are HR
00:45:58.358 --> 00:46:01.618
issues and should be handled like HR issues, and those aren't safety.
00:46:01.898 --> 00:46:07.538
In newly implemented initiatives or controls or processes that are intended
00:46:07.538 --> 00:46:12.558
to create capacity, but they're not getting put into place by the workers in the field.
00:46:12.878 --> 00:46:18.058
Should we as leadership revisit these, or is this a more of a neglect issue
00:46:18.058 --> 00:46:21.158
for the employees not managing these controls?
00:46:21.398 --> 00:46:25.238
I think one thing that we've done at Quantite, and when you think about this,
00:46:25.518 --> 00:46:30.118
when you start to put controls in place, what we do is we really identify the
00:46:30.118 --> 00:46:33.158
top three stickies, right, from the workers, giving us, hey,
00:46:33.238 --> 00:46:35.058
tell us what your top three stickies are, Right.
00:46:35.798 --> 00:46:39.298
Then we pull them in and we say, now, let's go over some barriers that if put
00:46:39.298 --> 00:46:42.298
in place, we'll never we will never see this fatality again. Right.
00:46:42.738 --> 00:46:47.698
And so they're making their own controls for that task. Then they're more willing
00:46:47.698 --> 00:46:48.998
to do it because they had a voice.
00:46:49.438 --> 00:46:54.378
So if you're doing what we like to say is let's do capacity with the worker, not to the worker.
00:46:54.658 --> 00:46:58.518
So I think that's what we have to think about is we're doing capacity with the
00:46:58.518 --> 00:46:59.978
worker, not to the workforce.
00:47:01.034 --> 00:47:04.274
Kind of Tayloristic if we're doing it for them or to them, right?
00:47:04.534 --> 00:47:08.414
But doing it with them is that back to that getting rid of that parent-child dynamic. So I like it.
00:47:08.814 --> 00:47:11.494
Yes. So we're doing it with them. We're pulling them in, right?
00:47:11.634 --> 00:47:15.334
We're, hey man, tell me what the top three things are that can kill you if you
00:47:15.334 --> 00:47:16.374
go out there and do this task.
00:47:16.754 --> 00:47:19.914
Now let's talk about what are some barriers that we could put in place that
00:47:19.914 --> 00:47:22.634
would be easy for you to do. Cause if it's easy, they're going to do it, right?
00:47:23.094 --> 00:47:26.114
And that would absolutely, if the release of energy does happen,
00:47:26.314 --> 00:47:27.894
would save you from being hurt.
00:47:28.174 --> 00:47:30.694
And then they put it together and we stack hands. We say, okay,
00:47:30.774 --> 00:47:35.014
guys, now you're, you told me, so now you're telling me now that we'll never
00:47:35.014 --> 00:47:37.034
have this event happen again that it hurts somebody.
00:47:37.454 --> 00:47:40.954
I think I would add, I would just say, I mean, I'll just scream into the microphone,
00:47:41.394 --> 00:47:45.174
that if the workers aren't using the controls, you stopped analysis too early
00:47:45.174 --> 00:47:48.834
and whoever made the controls wasn't close enough to the problem.
00:47:49.014 --> 00:47:52.814
I mean, I've never seen this as a problem because mostly I'm like you.
00:47:53.034 --> 00:47:55.534
I let the workers tell me what they want.
00:47:55.774 --> 00:47:59.974
Bob, When we did that tree trimmer thing, we had no idea what the control is.
00:48:00.154 --> 00:48:02.494
But it's very funny because all the senior leadership was there.
00:48:03.214 --> 00:48:08.534
And like I said, I'd really like a second climbing line. I said, today is your lucky day.
00:48:08.754 --> 00:48:13.334
You see all these new high-vis vests over here that have never been worn before?
00:48:13.994 --> 00:48:18.294
That's the senior leadership team. If you want the rope with gold strings and
00:48:18.294 --> 00:48:20.614
a diamond knot, you're going to get it today.
00:48:20.874 --> 00:48:26.954
Just ask for it. If our company is heavy hop, but is trending toward focusing
00:48:26.954 --> 00:48:32.694
on accident rates, how do we as middle management get it back on track?
00:48:36.074 --> 00:48:43.634
I guess the question is why? Why is it trending towards focusing on incident rates?
00:48:43.674 --> 00:48:45.874
That's the first thing you need to find out.
00:48:46.964 --> 00:48:52.124
So, is it customer pressure or like board pressure? Okay, so this is happening
00:48:52.124 --> 00:48:53.284
because of customer pressure.
00:48:53.724 --> 00:48:58.924
I mean, it's really interesting because the part that I think really is important
00:48:58.924 --> 00:49:04.644
here is the realization that there are opposing goals that exist simultaneously in your organization.
00:49:04.644 --> 00:49:09.024
And that some of the tracking and trending they're doing on incident rates are
00:49:09.024 --> 00:49:13.084
important for customer interface or for regulatory interface,
00:49:13.424 --> 00:49:17.604
order of director's interface, but not terribly important for the workforce itself.
00:49:17.964 --> 00:49:22.284
And so you may actually be keeping data that you show externally,
00:49:22.284 --> 00:49:24.904
but don't really spend a lot of time showing internally.
00:49:25.264 --> 00:49:30.624
But I would, if this were my organization, I'd be super interested in learning
00:49:30.624 --> 00:49:34.264
what's going on. because once you know what's going on, then you're in a little
00:49:34.264 --> 00:49:36.424
better place to just kind of tackle this problem.
00:49:36.804 --> 00:49:41.744
So, because the bottom line is, at least with this, the most important middle
00:49:41.744 --> 00:49:47.144
management question you can ask is, what do we want our workforce to do with this data?
00:49:47.764 --> 00:49:52.684
Because my entire career at Los Alamos, jump in, Michelle, I mean, you were there.
00:49:53.044 --> 00:49:58.624
They would show us those TRC and DAR rates. I had not the vaguest clue what
00:49:58.624 --> 00:50:01.904
to do with that data. I mean, I think they wanted me to change history,
00:50:01.904 --> 00:50:07.644
but I don't have that power because if I did, I would have bought Apple really early.
00:50:08.704 --> 00:50:13.664
So I have a quote to read from my former boss, but longtime friend,
00:50:13.784 --> 00:50:17.044
Doug Parker, who was the assistant secretary at OSHA in the last administration.
00:50:17.304 --> 00:50:22.664
This was a quote from the ASSP conference, I guess last year's ASSP conference.
00:50:22.884 --> 00:50:27.604
I was recently asked at a conference why we, OSHA, care so much about total
00:50:27.604 --> 00:50:32.304
incident rates, TRIR. My response to the audience, I really think it's that
00:50:32.304 --> 00:50:37.104
you care more about that, about the total incident rates, not us, OSHA.
00:50:40.244 --> 00:50:43.804
There were a couple other questions, but I thought that is the place to end.
00:50:44.184 --> 00:50:50.324
With the quote from the OSHA administrator on you're more freaked out by total reportables than I am.
00:50:50.944 --> 00:50:55.184
Always something to chew on. Well, that was it. That was open Q&A for 2025.
00:50:55.644 --> 00:50:59.524
I'm glad you came along. bong. If you stayed this whole time, I'm proud of you.
00:50:59.844 --> 00:51:02.604
Until then, learn something new every single day. Have as much fun as you possibly
00:51:02.604 --> 00:51:05.664
can. Be good to each other. Be kind to each other. And for goodness sakes, you guys.
00:51:06.480 --> 00:51:18.292
Music.