We thought we had it covered. But here it is – that same pesky incident making another unwelcome appearance, commanding our attention yet again. But why, why, why? We’ve asked ourselves the same set of questions – over and over. Did we do a well-timed investigation? Yep. Did we learn what the root causes were? Absolutely. Did we share our learning – and, in doing so, update our systems and physical risks controls? We did – yes.
In fact, it’s very likely we’ve skilfully ticked off this set of questions. In our mind, the picture was crystal-clear – we’d taken care of everything. But, frustratingly, these recurring incidents continue to expose our colleagues to dangerous situations. So, what did we miss?
The answer’s straightforward.
We never actually checked that the improvements we were aiming for, were ever implemented. And, if they were, we never reviewed them to see if they genuinely made any difference at all. It’s this straightforwardness, that can leave people scratching their head – ‘surely, it can’t be that simple?’ When we have high loss or high potential incidents, there’s very often a determined surge of activity to investigate them, to openly and widely communicate and to update any measures we have in place. It’s a positive step forward. But then, all this ‘goodness’ can come grinding to a halt. Quite literally.
In my experience, a typical conversation can go something like this:
Me: I was curious to know what’s the impact of your new approach, after that high potential near-miss three months ago?
Manager: Really good actually, I think we’ve made real progress.
Me: That’s great news. What does real progress look like?
Manager: Well, we had a safety stand down, we updated our standard and improved some equipment.
Me: Sounds really positive. How consistently are the new risk controls being used?
Manager: Well, after the stand down and everything else, we assume that the work practice is actually a lot better.
Me: Okay, so does that mean you’re confident that the incident couldn’t be repeated today?
Manager: Erm, welI, it’s a good question. I’m not sure I could answer it at the moment.
Me: What do you think you could do to be in a better position to answer?
Manager: You’re making me think that we need to do some real-world checking.
Me: Sounds great, I’d be interested to know how you get on.
When we’re busy and rushed, we can sometimes forget to take a few moments to reflect on how well we’ve responded to incidents. Reflective practice is a healthy habit to get into. All it means is making a conscious effort to stop and think about something. So, instead of starting to ask ourselves ‘why, why, why’ – what we really need is to stop all this ‘do-do-doing’ – because it’s in these moments of reflection, when we develop some of our most invaluable insights.
One of the reasons we’ve grown and keep on growing, not just at home but overseas, is because of our business philosophy. It’s what we’ve built a solid global reputation around. And, because it’s delivering short-term and long-term results, our clients tell us it has a tangible value to their business. To find out more about how we’re transforming businesses, please get in touch.
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