Implementing Safety Systems and Protocols

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Moving Past the Safety Performance Plateau in Maintenance and Operations

Grid operators are increasingly implementing an array of safety systems and protocols, including risk, stakeholder and safety management systems, along with robust human capital management programs. In many cases, however, safety performance is still plateauing and safety metrics, including perception surveys, injury frequency and severity rates, are indicting a lack of forward progress.

To better understand this lack of forward progress, it’s important to understand the three distinct phases of the utility industry safety journey, each with different strategies and unique characteristics. In simplistic terms, the three major phases include:

1. Eliminating intrinsically unsafe conditions

Utilities should focus on physical conditions, tools and equipment, and look for opportunities to engineer out of existence unsafe conditions.

2. Developing safe work procedures and safety management systems

Utilities should develop specific procedures and systems to reduce the potential for harm when employees are dealing with hazards that can’t be eliminated.

3. Error reduction and human performance

Utilities should create an environment in which the likelihood of errors, including the potential for harm from human errors, is reduced.

The challenge for most organizations lies in the overlapping nature of these three phases, each requiring different types of management effort for success. In companies that excel in safety, the principles involved in all three phases are well understood and, as such, the organization can apply the most appropriate response for the conditions present.

To explain why management’s approach must change between the three phases, it is useful to look at the commitment needed to achieve success in each phase. In phases 1 and 2, the typical approach to continuous improvement is through risk analysis, action plan development and commitment to completing the required actions. Management can insist on an audit of pinch points and have guards manufactured (phase 1). Similarly, management can insist on safe work procedures being written or a monthly safety audit being done, then hold people accountable to the completion of the activities (phase 2). Phases 1 and 2 respond well to a commitment to informed activity. In phase 3, however, management cannot stand in front of the workforce and seek employees’ commitment to making no errors in the coming year. This highlights that management must think differently through the various phases of the safety journey.

Duncan KERR
is a seasoned operations executive and managing partner with The Engine Room Consulting Group with more than 28 years’ experience. He has spent half his career working in industry leadership roles spanning operations, engineering, asset management, supply chain, general management and capital projects.

Organizations have typically been successful at achieving success in phases 1 and 2 of the safety journey; however, phase 3 is where safety performance typically stalls. The third phase of the safety improvement journey, error reduction and human performance, involves reducing the frequency and impact of normal lapses in mental focus and memory. True success in this phase involves strategies designed to positively influence the workplace and to reduce employees’ potential for human error.

is a managing partner at the Engine Room Consulting Group. He has worked within multiple industries supporting leaders’ abilities to execute and sustain behavioral changes and operational performance improvements. His wide-ranging experience encompasses strategy development, safety, leadership acceleration, process excellence and frontline execution. Learn more about The Engine Room Consulting Group Ltd. at or by emailing at

Common examples include using a pre-flight checklist on an aircraft to reduce the potential for well-trained pilots to make errors arising from the complexity of their tasks, or embedding specific safe work habits, such as applying lock-out/tag-out procedures and keeping personal workspaces free from clutter.

The Cognitive Disconnect

Reducing the number of errors made by otherwise well-intentioned employees and the harm that results requires an understanding of the way human minds work. The principles arise from cognitive psychology and the relationship between conscious, subconscious and unconscious minds. The conscious mind processes active thoughts and things a person must remember to do. The subconscious mind allows a person to do things such as walking to a destination without consciously thinking about each step. The unconscious mind takes care of activities like breathing while walking. With respect to cognitive psychology, the major implications impacting industrial safety performance are the limits of thoughts our conscious minds can hold and the inability to keep our minds from wandering.

There is an upper limit on the number of thoughts we can maintain in our conscious minds at a single point in time. At work, exceeding that upper limit puts us at risk of an error created by complexity in the workplace.

Everyone experiences their minds wandering at times. In the workplace, no one can maintain perfect mental focus over extended periods of time. This effects how complacency in the workplace is viewed and addressed.

To understand why humans’ minds work the way they do, it’s helpful to know that conscious processing in the brain requires more energy than subconscious or unconscious processing. Conscious processing even burns more calories. As a result, the human brain is hard-wired to move functions that don’t need conscious processing to the subconscious or unconscious levels. Studies indicate that the average person can maintain four to seven discrete thoughts at a single point in time, but even that requires a concentrated effort. When a person is forced to consider a new thought, one of the previous thoughts is “squeezed out” of the conscious mind. In addition, if there is no reason to be concentrating on something, the brain is conditioned, through millions of years of evolution, to stop thinking about it and move to a less calorie-consuming state of mind.

In the utility sector, however, it is rare to see considerations made to address and mitigate complacency traps. Instead, common responses to incidents involving “complacency” include: blaming the individual, warning the rest of the crew about complacency, reminding people to keep their mind on task or assuming it’s a training problem and re-training. Many of these strategies are, however, flawed. Blaming an individual who becomes complacent or warning them to never be complacent are unrealistic. Complacency will happen—it’s in our DNA! Furthermore, retraining does not address the complacency trap as it is not a skill gap that needs to be addressed in the first place.

Mitigating Complacency and Complexity

That said, there are actions management can and should take so that complacency does not create a safety hazard. Viable and effective strategies that can mitigate the complacency trap include:

1. Engineering out the complacency trap, such as ensuring a stairwell has consistent stair heights.

2. Developing alarms that “alert” people to a higher point of focus.

3. Creating methods of checking things that are easy to overlook; for example, staged checklists.

4. Building defensive safe work habits, such as doing a field level risk assessment before every job, even if it’s not documented.

On the opposite end of the spectrum, complexity in the workplace arises from several sources, including performing inherently complex tasks, information overload which creates mental complexity, and cluttered workplaces or environments which can create situational complexity. Regardless of source, complexity leads to errors and hazardous situations in different ways. It can be simple omissions leading to potentially devastating incidents, information overload preventing critical steps of a process from being retained, or working in a cluttered space so people fail to see developing hazards.

Like complacency, there are specific actions management can and should take to mitigate the various sources of complexity. Viable and effective strategies that can mitigate the complexity trap include:

1. Breaking complex tasks into components with prompts to remind operators about easy-to-miss steps. A good example would be implementing phased checklists, such as in the aviation and medical industries.

2. Aligning information transfer with the needs of the audience and not the preferences of the provider. This would include task training, onboarding and safety meetings.

3. Designing the workplace to reduce situational complexity, like implementing programs, such as 5S workplace organization methodologies.

4. Building defensive work habits. Good examples of this include the way carpenters arrange their tools or the way operators test respiratory and rescue equipment before use in confined space entry.

Building Safe Work Habits

One effective strategy to reduce the loss of focus caused by complacency or omissions due to mental complexity is to build safe work habits. In industry, however, leaders at all levels often are either reluctant to try to build safe work habits or at a loss on how to coach employees to establish safe work habits. Companies often focus more on cardinal rules and writing procedures that cover every eventuality. Ironically, some of these additional rules and procedures add to the complexity challenge and increase the chance that employees will make mistakes and miss things.

Conversely, many of the best companies and industries identify the specific habits they expect to see exhibited all the time. They then strive to build and anchor those habits so they become second nature. These are coached and reinforced by every level of leadership to the degree that the ingrained habit is not only exhibited at the workplace, but in almost all aspects of an employee’s life.

This concept of intentionally building positive safe work habits requires more front-end effort than the typical approach taken by most companies. Too many companies assume that “telling” a person to do something or providing information in a computer-based training module creates the knowledge leading to desired habits, but it rarely does. Most people develop safe habits over time through reinforcement, coaching and feedback. It’s not as straightforward as putting on a training seminar. Once a new habit is established, however, it becomes the new normal practice that requires little effort to sustain. If the time and dedication needed to anchor good behaviors are considered, coaching to establish safe work habits is less effort than training, retraining, threatening and discipline.

Companies that excel in safety performance understand it is incumbent to go beyond telling an employee to do something in training. Behaviors must be repeated at a high enough frequency over time to become a habit.

This means that the coaching process always extends beyond most companies’ initial training programs. As a result, the employee’s supervisors must play a role in the safe work habit-forming process. On a positive note, there are only four prerequisite coaching requirements essential for supervisors to anchor safety behaviours and create the right habits. Front-line supervision must:

1. Be able to spend time in the field

2. Position themselves to observe and know what to look for

3. Have courage to speak up and act on their observations

4. Communicate in a way that helps the person being coached

It is crucial to coach foremen and supervisors to get to a level where they understand their safety role and have skills and confidence needed to move the needle forward on safety every day. Managers and senior leaders, on the other hand, would benefit from having a clear understanding of the pros, cons and limitations of default tactics—specifically, safety messaging and formal discipline. As much as senior management may take the lead on safety strategy, front-line supervision have the largest impact on safety culture, standards and performance.

By setting clear expectations, holding people accountable, observing what is going on and acting on observations, employees’ behavior can be changed. Furthermore, front-line supervisors have a specific role in error reduction through leveraging their observations and knowledge of good vs. bad habits, and having the courage required to establish and change work habits.

Editor’s note: For the full article on Safety, Error Reduction and Human Performance visit

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