Nigel Heaton looks at his work with the UK’s Highways England and discusses how they’ve been helping the improve the organisation’s safety
We all know that if we keep doing the same thing we keep getting the same results. Yet it is not just the English FA who has failed to take this lesson to heart. Many organisations have reached a point where their reactive data relating to safety remains stubbornly constant. It appears that they have reached an asymptote. Risk assessments, safe systems of work and competent personnel still fail to deliver the next step change.
For the last two years Highways England has been working towards making the next change. They produced a 5-year plan that mapped out a range of initiatives that will make the Strategic Road Network a safer place for employees, contractors and all road users. The plan has five golden threads:
- Leadership and Culture
- Competent People
- Managing Risks
- Measuring Performance
- Engaging Stakeholders
The overarching theme of the plan is that everyone will go home safe every day. Plans to deliver one of the golden threads, leadership and culture, are starting to be rolled out within the organisation. This article briefly explains what is happening and what is starting to be delivered within the organisation.
Just Culture is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them, which are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated (1). Highways England is committed to delivering a Just Culture throughout the organisation. Leaders are being trained so that they all have a basic understanding of why people make mistakes. We recognise that few people come to work to deliberately hurt themselves or colleagues. We recognise that systemic failures are by far the most significant cause of errors. So when leaders are involved in determining what happened to provoke an error, they are being provided with a simple decision tree based on a Just Culture. This allows them to understand why an accident occurred and how it can be prevented in the future. Leaders are provided with a collection of tools that enables them to explore the full range of underlying causes of accidents. They are encouraged to ask not just why an accident occurred but how it happened. They use Conklin’s idea of infinite hows(2) to challenge assumptions about causation and to apply a Just decision making process.
We know that waiting for accidents to occur is too late. So leaders are also provided tools to support change within the organisation before accidents happen. We are rolling out Michie’s COM-B(3) as a tool for managers to apply when they wish to promote or change a behaviour. COM-B recognises that behaviour requires people to be Capable of exhibiting the behaviour, that they have the Opportunity to behave as we need them to and that they are Motivated to behave in the desired way. The approach can be used to challenge perception and thinking about why people behave in certain ways and to develop more effective systems to support safe behaviours.
We also encourage leaders to engage in site tours which allow them to experience work at the coalface. We want leaders to understand the jobs that their colleagues undertake and to explore the challenges of work. We encourage them to ask questions that allow colleagues to express their concerns. We provide them with a sample of Conklin’s pre-accident questions:
- What went as planned?
- What surprised you?
- What did we miss?
- What did you have to adapt or change
We also ask them to identify “killer questions” that go to the heart of the job, such as:
- What scares you?
- What keeps you up at night?
- What job do you find very difficult to undertake?
The aim is to empower leaders with the ability to capture issues before they become accidents.
Committing to improvement
We are rolling out a 3-day training programme, with a six week gap between days 2 and 3. At the end of day 2 all delegates have to describe a specific commitment to act. This was written down, shared with their colleagues and captured. The idea was to encourage all delegates to undertake action that could then be explored on day 3. Using a simple commitment based on an if… then construct, delegates were encouraged to identify a temptation where they might exhibit an unwanted behaviour and to replace it with a desired behaviour.
For example, if I am tempted to ignore an unsafe act, I will always challenge it and use COM-B to explore the behaviour.
The idea was to base the action on an implementation intention(4), which has been shown to be an effective way to delivering behaviour change.
The programme was extensively piloted in the first half of 2016. Delegates were asked to identify the strengths and weaknesses of the course and how to improve it. By the end of summer 2016 the course was rolled out as a series of 3-day workshops.
We followed up all delegates 3-4 weeks after they had completed day 2 of each session. We talked about their plan, what actions they had managed to take and what additional support they required.
They then returned for day 3 and each delegate shared their actions, and as teams undertook a simple SWOT analysis to work out how to improve. A small number of additional tools were delivered, including a practical way to use Just Culture to dynamic situations and how the management of wellbeing can be improved.
To date, more than 100 delegates have been through the programme. Whilst we recognise that the time taken to change culture is typically measured in years, the majority of delegates report some success in applying the tools and changing the behaviours of their teams. Whilst we have emphasised the long-term nature of the programme and the emphasis on lead rather than lag indicators, we are surprised to see a fall in accidents and an increase in near miss reporting in the main trial area.
It is too early to report the programme as a complete success. However, by providing leaders with lots of simple tools to deliver change and supporting them to implement the programme, we appear to be moving towards a safer organisation. Other work is looking at the safety maturity of the organisation and we believe that we will see a significant change in the safety maturity of the organisation at the end of 2017.
Looking for your own Just Culture? Speak to our safety consultants for information on how we can transform your organisation.
This article appeared in the Winter/Spring edition of Cardinus Connect, Stand Up for Your Life.
- Eurocontrol (2015), https://www.eurocontrol.int/articles/just-culture
- Pre-Accident Investigations (2012) Todd Conklin
- The Behaviour Change Wheel (Behavior Change Wheel) – A Guide To Designing Intervention
- Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493-503.