#9 Competence, complacency and fatal injuries – The counter-intuitive nature of serious incidents and fatalities.

This surprising pattern (similar findings were also just released in the UK) brought to mind the words of a long-serving occupational safety professional from over 30 years ago: “Larry, the young guys get hurt more than the old guys, but it’s the old guys who die”. At the time, Larry didn’t understand why this should be so, but he recognised a phenomenon that needed proper understanding.

Unfortunately, the age dimension remains just as relevant today as it was back then, which is exactly why he invited eight more panellists to discuss competency, complacency and serious incidents and fatalities (SIFs) during this series of SafeConnection Webinars.

At the outset, Larry canvassed the panel to see if they too recognised this tendency in their workplaces: across the board, the answer was Yes:

• With 20 years of experience, complacency will set in,” says Ravindra Dhapola (Head Corporate SHE, CSR & Sustainability, Tata Coffee). “Then one day something happens and there is a serious incident”.
• Indeed it might be that “multiple things go wrong”, explains Alex Carnevale (President, Dynacast International). “It’s an ‘and-and’ problem”. In other words, a worker’s eyes or mind were off task – and there was deviation from the procedure, PPE requirements, and so on.
• Larry agrees: “The number of reports I read where a fall arrest harness was five feet away from the guy with a perfectly good anchor point right there…”

The fact is that our brains are hardwired to become complacent, and the psychology that overlays that physiology plays an equally decisive role:

• “Incidents don’t always happen because of at-risk conditions”, points out Shankar Rajagopalan (Head Safety, Quality, Systems, Sustainability, Process Improvements & Business Excellence – Sterling & Wilson Middle East Solar Energy). When you do something for long enough you become ‘unconsciously competent’ – but sometimes you aren’t doing the job 100 percent correctly, so there will also be times when you are ‘unconsciously incompetent’ and you aren’t even aware of any deviation from proper procedure.
• Our brains use so much energy, evolution has caused us to try to conserve blood glucose. Therefore, “when the task is routine, the brain doesn’t need to think about it”, adds Jim Spigener (Chief Client Officer, DEKRA). “Serious events often happen during routine operations. This is why someone with so much experience can end up making a potentially fatal mistake”.

Given these challenges, what can be done by way of prevention or mitigation? How can we reduce the disproportionately high level of serious incidents and fatalities amongst workers in their fifties and older? The answer lies in leadership mentality and in process preparation:

• “Management can put processes in place to avoid this type of complacency”, explains Dr Waddah Ghanem (Senior Director, ENOC; Fellow, GCC Board Directors Institute). “If you have someone who is very good at their job, they will fall into their routine. So, you want to get them doing something else to switch up their routine.”
• Alex Carnevale recommends that managers and organisational leaders stay catastrophe aware at all times: “We have to assume that there could be non-compliance or something going wrong on a personal level. Very rarely was it the first time that it almost happened”. As Alex says, a lot of the time you will hear ‘oh, yeah, I almost did that once’ or ‘I almost forgot that once’. You want to make sure people aren’t punished for coming forward with those near-misses”.
• Another panellist shares that they will have non-safety or employees from non-operational departments walk through the plant and see what makes them feel uncomfortable, because those are the things that an operations specialist might take for granted. He shares that they also ask employees this question: “if your child was working in this facility, where would you not want them working and why?”

As this tragic instance makes clear, the issue of competence and complacency can become even more difficult with external contractors: “How do you build a culture of resilience with contractors?” Larry asks the panels:

• “It’s very challenging,” says Hari Kumar (Director Group EHS Assurance, Emirates National Oil Company). Hari points out that it is no secret that contractors are often the weakest link, and at ENOC they see a higher incident rate within the contractors than permanent employees. “When it comes to preventing SIFs, we cannot distinguish between the two, but priority usually is with your own people when you have limited resources and time”.
• To balance this natural tendency, they have put more resources into monitoring the contractors at his workplace, going from three to 11 safety officers who are there to refresh the contractors on procedures, and make sure they are competent.
• Ravi also emphasises the importance of building the capability of the managers who are working closely in the field and operations to monitor the workers’ behaviour. “We cannot just say ‘we have trained them, it’s their responsibility now”, he concludes. We have to go out there and make sure they are doing it.

While on the surface the nature of fatal injuries seems counter-intuitive, examining the drivers reveals that experience breeds complacency: the combination of the latter with the unexpected means that everyday situations have the potential to escalate even a minor error such as a loss of balance to a SIF.

The last word on this vital topic goes to SafeStart Author and SafeConnection moderator Larry Wilson: “While human error is inevitable or unpredictable, the states that cause them are not. You know when you are likely going to be tired every day, and you’re probably going to be right within 5-10 minutes. You know when you will likely be rushing. You know who or what makes you frustrated, and you can also predict, fairly accurately, when you will probably become complacent or go on autopilot. So now all you need to do is think about the four states, especially complacency, since you can’t notice it – in the moment – and just ask yourself, on a scale from 1-10: ‘how complacent am I with this job or task?’ In other words, we can beat complacency, but we have to put the tools to do it in the worker’s hands. It’s not going to happen just by putting up signs that say, ‘Think Safety’”.