Last 20th of May I’ve got the following e-mail from Pieter Jan Bots : “Thank you for submitting your proposal for the symposium: RISK AND SAFETY Different Perspectives , Amsterdam 11-12 November 2014. We are happy to announce that your presentation with the title: Fourth Paradigm in the Work Field has been approved for the symposium.
The next day Carsten Busch, with Pieter Jan and Nick Gardener the driving force behind the seminar, wrote me an extensive e-mail to congratulate me and to warn me: “We think that your presentation will be one of the most controversial of the seminar, therefor we have put it in the section ‘New Perspectives’. Since we understand that your presentation will be on the ‘edge of what most participants will expect’ (i.e. out of the comfort zone of most safety people), it will be important to keep it somehow concise. He went on: “The questions that I hope you’ll answer are: Why a new paradigm is needed in the work field? Which road should we take? And How?”
Since I will only have a twenty minutes to develop my thoughts (it looks like a TED talk!), I’ll really have to be ‘concise’, and that is not one of my Core Qualities! So to prepare myself I have written this blog.
A Paradigm… it’s 20 cents isn’t?
The paradigm concept was first coined by Thomas S. Kuhn is his book ‘The structure of scientific revolutions’[i]. A Paradigm is, according to Stephen R. Covey[ii], the way we ‘see’ the world – not in terms of our visual sense of sight, but in terms of perceiving, understanding, interpreting. As a metaphor, I like to compare our paradigms to the colored lenses in our glasses. What we see isn’t a completely accurate reflection of reality, it is shaped by our attitudes and perceptions.
Fig 1 Paradigm Metaphor ‘colored glasses’ (based on The Ladder of Inference of Chris Argyris[iii])
Paradigms are mental models, frames of reference, … that help us to see the reality and to solve our problems. Charlie Palmgren thought me to use the concept ‘mindset’[iv], a paradigm is a frame of reference for our body of thoughts, a model that we use in order to understand and to explain certain aspects of the reality.
The term paradigm shift was also introduced by Thomas Kuhn in the same book, The Structure of Scientific Revolutions. Kuhn shows how almost every significant breakthrough in the field of scientific endeavor is at first a break with tradition, with old ways of thinking, with old paradigms. A paradigm shift, then, is a change to a new game, a new set of rules. Each Paradigm Shift is more or less a reaction to a crisis. Sooner or later, every paradigm begins to develop a special set of problems that everyone in the field wants to be able to solve and no one has a clue as to how to do it. How are those special problems going to be solved? By changing paradigms, by a paradigm shift! In my ‘TED talk’ I’ll use the representation of a Paradigm and a Paradigm shift presented by Joel Barker in his book ‘Paradigms’[vi][v].
Figure 2 The presentation of a ‘Paradigm’: the Paradigm Curve
First let’s label the axes in Figure 1: the horizontal (or x axis) represents Time; so if we move to the right, time is passing; the vertical (or y axis) represents success or ‘Problems solved’ using the prevailing paradigm. So if we moving upwards more new problems are solved at a specific time. The process starts not at zero, because problems were solved in the past without a particular set of rules (or Paradigm). Note that there is a slight slope to the A phase: problems are solved in a slow way until we fully know and have refined the problem-solving rules of the actual Paradigm. If you are successful in this then Phase B follows. The dramatic change is the angle of the curve in Phase B indicates that you fully understands the paradigm. You have become efficient in identifying problems that can be solved using the paradigm and effective at applying the rules to discover solutions. You’ll notice a break in the B segment of the line. The more powerful the paradigm, the more problems it will solve over time. Let’s take a look at the C phase of the Paradigm shown in Figure 1. We see the rate of problem solving begin to slow down and the time between problems solved increases, our solutions breed new problems. As we climb higher on the curve, the problems remaining typically increase in their difficulty. The Paradigm Curve is a simple and useful way to depict the life span of a paradigm.
Why a paradigm shift is needed in the work field?
Simply because the actual way of dealing with work field problems doesn’t work anymore. Workers at best ignore the slogans of top management, at worst they play along. In most companies the safety philosophy remains naïve, mechanical, fallacious, shallow and .. a century old.
A great deal of the Work Field management remains stuck in the ideas of Fredericks Taylor ‘scientific management’. I know there have been paradigm shifts in the past, because I’ve lived through them: the ‘technical paradigm’ (I call it the Heinrich Paradigm) has been followed by the Organizational one (I call it the Frank E. Bird Jr. Paradigm), which has been followed by the Human Behavior one (I call it the ‘Dupont’ or ‘dr. Krauze’ Paradigm). Those present ‘safety organizations’, as some call them, seeks behavior manipulation or control and at the same time are killing innovation and preventing sound communication and successful ‘crucial dialogues’. Behaviorism is the ‘popular’ philosophy, unfortunately more and more problems are not solved by the actual ‘Human Behavior’ paradigm. “We can’t solve problems by using the same kind of thinking we used when we created them.” is a quote attributed to Albert Einstein and IMHO very true in this context.
What are the kind of problems that are created by the actual paradigm in the work field? Let’s keep it ‘concise’ and only look at one prevailing element of the actual paradigm: the ‘zero’ mindset. The actual buzzwords in that mindset are ‘zero accident’, ‘zero preventable accidents’, ‘zero injuries’ … and finally ‘zero harm’.
This ‘zero harm’ is indeed one of the last convulsions of the actual safety ‘frame of reference’. There is no possible way in the world for any organization to ever meet that ‘zero’ goal. The believers of the zero mindset are basically setting themselves and their subordinates ‘from the outside-in’ up to all sorts of issues to obtain ‘on paper’ what cannot be obtained in reality by using that slogan. Most CEOs and managers of the ‘zero mindset’ companies that are charged with achieving ‘zero harm’ have become like the fabled emperor with no clothes on. He was sold ‘invisible’ clothes by a persuasive consultant, and the people lied to the emperor to avoid shaming him (and to have to bear the consequences of their ‘authentic interacting’).
There are at least two guaranteed strategies for achieving a ‘zero accident goal’ in this paradigm: 1) creative use of statistics and definitions (classification of accidents!) and 2) a massive dose of good luck over an extended period of time. Being who I am, I won’t recommend either one to you, even though the first has ‘success guaranteed’ after implementation. It’s all about whether you want to like yourself upon seeing your reflection in the mirror. I do like myself, and I’d like to keep things that way.
There is this third method that may get you close, eventually, but it costs a lot of hard work, disappointment and patience: good safety management. And without a certain dose of luck it won’t bring you down to ‘zero’ and keep you there. Because you simply cannot control everything, and “entropy will get us in the end”, so accidents do happen, no matter how good you are.
My experience has taught me that the “zero” talk leads to under reporting and misleading information about the safety reality. Zero harm is a great vision. But is it necessary to say this? The purpose of safety is in line with the core purpose of every human being (Play the ‘Purpose Game’ and you’ll find out if you don’t know it by now). The focus should be not on the end result but on what is being done to prevent accidents. What proactive measures are in place? Are they working? Are we focusing on the right things (looking solely at the human behavior and not at all the causes why incidents are occurring)? And more important: ‘are those measures lived from the inside-out, because people believe in them or are they just doing it – or worse making the right ‘movements’ – because we have to do it, from the ‘outside-in’.
I have always received the same comment from ‘zero harm’ disciples from many industries: “They believe that if you don’t buy into the zero mindset that you advocate or endorse incidents and injuries!” Or, you are willing to accept less than zero. Accepting that someone may come to harm is a different thing from planning to have someone harmed. I think it’s very transparent if you manage to communicate that you cannot provide 100% safety, even if you would like to. There is of course a major nuance between not endorsing a “zero goal” and “planning to injure”. My response has always been this – wanting something and getting something are two different things. A plan to improve the process is the only logical way I know I can influence the probability of incidents occurring. If I have a zero injury goal but do nothing different, how can I expect different or improved results?
The desire that everyone in a company does their work without injury and goes home in the same state of health as they came to work in is NOT the same as a Zero Injury target. The longer I thought about it, the more disgusting the whole idea of ‘Zero Accidents’ became. It’s not only a thing that involves mostly fear, blaming or statistical lying. One of the worst things about it is that the concept of risk acceptance, which is an essential part of safety management, is neglected or even denied by it. Don’t get me wrong, by far most accidents can be prevented, and in hindsight probably all of them. But in reality not everything can be prevented. Firstly because we’re never capable of controlling all the variables. Secondly because we don’t even want to reduce risk to ‘zero’, and thirdly, if we wanted to we, – like the ‘zero mindset’ CEO’s – don’t have the resources to do so.
So we badly need the fourth paradigm in Safety!
Which road should we take?
As in the poem of Frost[vi] ‘the road not taken’! Until now we’ve taken the ‘outside-in’ road. The working population were forced to have continuous improvement from the ‘outside-in’. The had to perform safely and follow the procedures, instructions, rules and regulations, if they believed in them or not.
In order to take the road less travelled, first of all our safety slogans need to be focused more toward the everyday working population so that they accept the basic principles (be safe, think smart, be alert, do dialogue, etc.) from the ‘inside-out’.
Safety consists of a plan and a process. The plan is usually your policies, procedures, activities, etc. that will prevent accidents (What you have to do). The safety process is how the plan is implemented and run (How this is done). Better than a ‘zero’ mindset, I believe the focus should be on how to improve the process in the fourth paradigm in the work field. The process should be observed, audited, and scrutinized from the ‘inside-out’ to find where expectation and reality have gaps. The wider the gap and the bigger the risk, the more focus and resources should be brought to bear to fix it.
During my life I understood an inherent issue with the human condition: we want to take risk but not acknowledge the taking of risk. We act in an unsafe manner but we justify it in many ways. Most of all, we prefer ignorance of the risk over uncovering and addressing the issue. Until we can change the acceptance that risk is out there and must be controlled from the ‘inside-out’, we can’t move forward. This is not easy. Because you can’t control risk if you can’t acknowledge it!
In the actual paradigm many in our business claim to know and live by continuous improvement cycles and the lessons learned by quality management and then ignore Deming’s 14 points. Outcome measurements alone won’t get us to 100% safety, they need to be linked to input measures. Measure and react to the inputs and the resulting outputs will take care of themselves. Process Control holds the secret not reclassifying the true information for a statistical lie .
In the new paradigm we will move the zero accident target to a vision. Then the whole community, including workers, put together strategies and plans (that include actions) on how accidents can be prevented from the ‘inside-out’. In the new paradigm the positive inputs (conditions, behaviors, activities) will be controlled by all from the ‘inside-out’ to ensure they are both being done and they are helping to actually prevent accidents from happening. I can guarantee if you do this, the outputs (accidents) will be reduced over time. As you make gains, fine tune your approach until your current state meets your ‘end’ state (or at least a state that contains an acceptable amount of risk, level that will be lowered over time).
And how will we take that road?
We need a (safety) culture change that allows the ‘inside-out’ control at all levels of the input measures. That, in my opinion, is a huge issue and one that must be addressed in order to allow the flow of information. And for this trust and openness are everything. The companies that live in the fourth paradigm – I call them Creative Interchange companies – certainly have an easier time of managing EHS issues. So the answer is very simply. We have to re-install the Creative Interchange Process in the Work Field.
I’m working with clients to help them to create the needed paradigm shift. We start with building trust and openness and learning to have ‘crucial dialogues’ (which are based on that natural transformation process, called Creative Interchange) about issues. Not only safety issues since we’re working on a culture change in the work-field, not only in the safety-field. This culture change is in fact a paradigm shift. The challenge in the new paradigm is to consistently demonstrate that the truth is valued… even when it’s not good news. In this new culture, the ‘Emperor has no clothes’ story becomes real: everybody is empowered to tell everybody (including the CEO and the managers) they aren’t doing a good job. In the present paradigm employees aren’t really empowered to do that and sometimes a consultant is (more often than not, at the cost of his contract – since the paradigm shift has not taken place yet).
A “zero vision” is not the same as a “zero target”. A ‘zero vision’ is what you really, really, want. But you know that you’re not there yet and that it will cost you a lot to get there. If you get there at all. But to me, it is the journey that is important, not the destination. You are convinced that it is worthwhile to strive for it. In order to get there you’ll probably have to put some shorter term goals – milestones – (realistic and motivating) where you’ll have to get first. The real discussion should be about lowering risk, prevention of incidents and to what lengths we are prepared to go to achieve these things, from the ‘inside-out’. And as James Reason once said “Safety is a guerrilla war that you will probably lose (since entropy gets us all in the end), but you can still do the best you can.”
Re-installing the Creative Interchange process will Drive out fear, so that everyone may work effectively for the company. (See Ch. 3 of “Out of the Crisis”[vii] W. Edwards Deming). Why because the energy of that transformation will slow down the ‘Vicious Circle’[viii]. In the actual paradigm the Vicious Circle is very much alive which lead to Organizational Mediocrity
[i] Kuhn, Thomas S. The structure of scientific revolutions. Chicago: University of Chicago Press, 1970.
[ii] Covey, Stephen R. The seven habits of highly effective people. New York: Fireside (Simon & Schuster), 1990
[iii] Argyris, Chris. Overcoming Organizational Defenses. Needham, Mass.: Allyn and Bacon, 1990
[iv] Palmgren, Charles L. Oral statement, Stone Mountain, Ga, Summer 1994
[v] Barker, Joel A. Paradigms. The Business of Discovering the Future. New York: HarperCollins Publishers, 1993
[vii] Deming, W. Edwards. Out of the crisis. Cambridge, Mass. Cambridge University Press, 14th printing, 1991
[viii] Stacie Hagan and Charlie Palmgren, The Chicken Conspiracy. Breaking the cycle of Personal Stress and Organizational Mediocrity. Recovery Communications, Inc. Baltimore, Maryland 1999