I am a proponent of accountability in safety; however, I also believe that accountability is necessary at all levels of the organization. We tend to be very quick in identifying the ACTIVE failures by those who made the error, mistake, or violation, and a negative consequence was the result (vs. all those times, the outcome was positive). Heck, in today's world, we may even have caught it all on camera for everyone to see. And if that ACTIVE failure was an EXCEPTIONAL violation (vs. a routine or situational violation), then we can consider holding those who performed that act accountable.
But why are we so slow to hold managers accountable for their violations of Management System expectations? Examples include failure to certify SOPs, utilizing the MOC tool on changes, "pencil whipping" permits and safety checklists, failure to manage corrective action plans, etc. These failures are called LATENT ORGANIZATIONAL failures, and although they may be farther away from the ACTIVE FAILURES we see in the videos of accidents, they "set the stage" for many of the ACTIVE FAILURES we may eventually see in future videos of accidents.
This discrepancy in who we hold accountable for safety can drive a massive wedge between the men and women doing the dirty and dangerous work closest to the risks and management who sets the tone and expectations of how the business (and, more specifically, the daily tasks) will operate. Remember, disciplining workers closest to the risks will never change a culture (or their behaviors), but a culture may never change without proper discipline. This applies to ALL LEVELS of the organization: those closest to the risks and those removed from the risks. EVERYONE plays a role, and therefore, "accountability" needs to be applied at ALL levels that influence the ACTIVE FAILURES.
Discipline alone will NOT improve behaviors or attitudes; it may be necessary but NEVER rely on it to fix all the failures in an accident.
I had a couple of bosses who understood this all too well. When an accident was found to have been in part caused by either a ROUTINE or SITUATIONAL violation of a policy, procedure, or program, we would specifically look to understand how those behaviors slipped through the cracks in our BBS Observation process, our SWP audits and inspections, training programs, etc. This is when my eyes were opened to how we humans fail on a daily basis.
I lost count of the number of times we would have audits/inspections and dozens (if not hundreds) of BBS observations on a task, only to discover that the behavior was SO COMMON that we failed to identify them as deviations from written SOPs/SWPs and training. This is where I learned that 2nd and 3rd Party Data Validation is CRITICAL to managing our safety data! Workers who do the job the same way as those they are observing can/will fail to identify a deviation from a SOP/SWP since they are observing the task being performed in the same deviant manner they perform it. This is a LATENT ORGANIZATIONAL failure in that our SMS/Safeguards failed to identify "deviations" from our SOPs/SWPs. You know, those "controls/Safeguards" we are expecting to control our risks!
So when an accident happens, and that accident involves the FAILURE to follow an SOP/SWP, I can assure you there is a lot more at stake than the behaviors we can witness on the videotape. Simply thinking we can discipline those we see violating the SOP/SWP and all will be well is just foolish. We need to understand what motivated those behaviors and HOW those deviant behaviors were never identified in our SMS activities BEFORE the undesired consequence occurred. Remember, ROUTINE violations are those that have become the "norm," and management's failure to identify and intervene BEFORE the accident should be baseline SMS expectation. We need to analyze the ORGANIZATIONAL FAILURES that set the stage for that deviant behavior to become the "norm." We need to look no further than our management system failures.
