Session No.

513

What Works Best Doesnt Come Naturally: Leadership

Actions for Preventing Loss
Aubrey Daniels, Ph.D.
Founder
Aubrey Daniels International
Atlanta, GA
David Uhl
Senior Vice President
Aubrey Daniels International
Atlanta, GA

Introduction
Post-hoc assessments of the causes of severe injuries and fatalities in major industrial accidents
consistently uncover a break in the chain from leadership to the front-line. Gaps are discovered
between senior leaderships intent and its ultimate impact. This session will explore leadership
behaviors that unintentionally contribute to risk in the workplace. Leadership tips will be
provided for reducing injury severity and preventing catastrophic events.
Organizations often struggle with getting the right activity and demonstrated support for
safety from managers, senior leaders and executives. The leadership behaviors discussed in this
presentation represent best practices distilled from years of consulting with a wide variety of
organizations. We will discuss:

Behavioral lessons learned from major accident investigations

Unique role of senior leaders
Validating the safety of systems vs. auditing the compliance of employees
Proactively creating a culture of candor and trust
What the science of behavior teaches us about Firefighting vs. Fire Prevention
Senior Leader Tips: Must Dos and Must Avoids

Behavioral Lessons Learned

When organizations conduct post-hoc assessments of the causes of severe injuries or fatalities in
the workplace, they consistently uncover a break in the chain from the leadership to the front-line.
Publicly available documents like the Columbia Shuttle Accident Investigation Boards report or
the Chemical Safety Boards Texas City Refinery report demonstrate so. The truth is that
leadership, culture, and management practices have as much to do with major accidents as do the
technical issues we read about in these reports. Leaders, through their actions (and at times
inaction) either contribute to or detract from an effective safety culture.

One theme found in major accident investigations is that bad news doesnt readily travel
up the chain of command. Often, for quite some time people have concerns or theyve noticed
something wrong, but that information doesnt reach the senior leadership level. In fact, often the
front-line workers are well aware of potential calamity when people in leadership roles are not.
Insufficient attention to leading indicators for safety has proven problematic, as has overemphasis on infrequent, lagging safety indicators. Reports from the Deepwater Horizon Macondo
Well blowout investigation and the Texas City Refinery investigations show that company
leadership had been celebrating the absence of personal safety incidents the very day of both
explosions. We also learned that employees performing the work had expressed concerns about
process safety leading up to each tragedy. Underreporting is a symptom of a safety culture that is
consistent with negative reinforcement in the work environment.
Investigations also have shown that major industrial accidents share this common thread:
a whisper at the top of the organization becomes a shout at the front line. This means that
concerns expressed by senior leadership about expense control, for example, are often interpreted
as we cant spend any money on preventative maintenance or that production takes precedent
over safety. While in most instances during investigations, senior leadership would tell us this
was not their intent, it was the ultimate impact on front-line performers. So messages both up and
down the chain of commandwhether bad news traveling up or expectations traveling down
have proven to be critical factors in root cause analyses of major accidents.

Unique Role of Senior Leaders

Since these common factors have shown up again and again in similar investigations, its time
that senior leaders recognize the key role they play in preventing such events. While incidents
typically happen at the front line, it is an organizations senior leaders who establish the physical
and cultural setting within which the front line works.
The explicit role of senior leaders in safety has not always been well articulated. Phrases
such as living our safety values or making safety our #1 priority are vague and not
pinpointed, and therefore not very helpful. There are some straightforward behaviors that
managers and executives need to demonstrate to foster desired safety performance and build an
intentional safety culture. What leaders say about safety, how they prioritize safety both in words
and actions, and how quickly they deal with hazardous conditions are all fairly obvious examples.
But there are also more subtle leadership behaviors that impact safety that we will
explore. We will provide specific tips for senior leaders to employ that will increase the
likelihood that their impact is in line with their intent. These best practices have proven effective
in creating and sustaining world-class safety cultures across a range of high-hazard industries in
North America and beyond.

Validating the Safety of Systems vs. Auditing the Compliance of

Employees
Senior leaders are responsible for creating and maintaining organizational systems and processes.
Organizational systems influence behavior just as much, sometimes more, than what leaders say
and do directly with the workforce. Policies, safety training programs, incentive systems, staffing
levels, reward and recognition programs, promotion and hiring practices, supplier and contractor
relationships, and quality programs all have potential impact on safety. Thus, leader behavior sets

the context for frontline behavior both directly and indirectly. Yet, the impact of many
organizational systems on safety is unknown and unplanned.
Interviews with employees in high-hazard environments reveal that a common perception
is shared about the involvement of senior leadership (either site management, or company
leadership from beyond the site). Their presence is most typically observed when something is
not working or has gone wrong. I only see them in our area when theres a problem or
something is broken, is a common refrain.
Furthermore, employee perceptions are that senior leadership involvement out where the
work is being performed most typically is some form of audit or inspection. Conversations with
those senior leaders tell us that may not be their intent, but often that is the impact they have on
front-line employees and contractors. A typical employee perception was once expressed, they
keep asking and probing and poking until they find a problem; and when they do, they take it
back to their office like its a shrunken skull.
This is not because senior leaders necessarily are negative people, but rather they are
likely to have long reinforcement histories for finding and fixing problems. In many plant
environments, leadership teams often are comprised of engineersformally trained problemsolvers. These highly-skilled, very successful problem-solvers have a tendency is to go directly to
a problem without even noticing all the things that are happening exactly as they want. This
phenomenon is not limited to engineers. For decades, our businesses, meetings and reports have
been set up for management by exception where we start first with whatever problem, deviation,
or exception has been identified and work tirelessly to remediate it.
Another practice that perpetuates this negative perception is how, when out in the
operation, senior leaders tend to point out exceptions to Personal Protective Equipment (PPE)
policy or deviations from other mandatory practices. They then are experienced as enforcers or
part of the disciplinary system rather than someone who is there to help or provide support. While
anyone should be empowered to stop an unsafe act, our recommendation is to leave the discipline
to the immediate manager and respect the chain of command.
Senior leaders are more likely to be experienced as helping and not inspecting or auditing
if they engage the workforce in dialogue about how the companys systems and processes are
working; asking what can be done to improve this system or that process? Asking these questions
will not only give senior leaders a sense of whats happening when their entourage is not present,
but also what they might be able to do given their role or authority level to make it easier for
employees to follow procedures or work in the safest manner possible.

Proactively Creating a Culture of Candor and Trust

Demonstrating a pattern of following through on suggestions from the workforce to make
systems and processes safer and more effective will increase their trust and credibility in the eyes
of the men and women doing the work. Some baseline level of trust is required to get people to
speak up and be candid about whats working and whats not, so follow-through on commitments
no matter how minor will be critical.
Remember, auditing and inspecting rarely says to the performers that leadership is trying
to help or that leadership is concerned about the workforces well-being or safety. Soliciting
feedback on how the companys policies and systems are impacting the work and then making

timely adjustments to maximize effectiveness will demonstrate that safety is your top value.
Organizations with world-class safety cultures feature rigorous follow-up and follow-through on
employee safety suggestions, and as such are more likely to hear what is working and what needs
improvement.
In order to be in the best position to help, senior leaders must build relationships,
demonstrate trustworthiness, and encourage truth-tellingeven when it pains them to hear.
Recognizing that part of your role is to help provide and arrange positive reinforcement for safe
behavior and resisting the urge to inspect and correct front line workers will create a solid
foundation for progress.

What the Science of Behavior Tells Us about Firefighting vs.

Fire Prevention in High Hazard Environments
Applying the science of behavior enables us to understand why we tend toward reactive
management practices when we know that proactive approaches are superior. Senior leaders play
a crucial role in setting expectations and more importantly what they reinforce that contributes to
this cultural norm.
If leaders understand the ABC Model of behavior (Antecedent-Behavior-Consequence)
and the follow-up/follow-through elements (Consequences) have more impact than the up-front
elements (Antecedents), then they can better plan their time and invest their efforts to ensure they
are having the desired impact on safety performance and safety culture. A scientific
understanding of behavior will enable leaders at all levels to be more effective. Evidence-based
tools and methods will be demonstrated to understand:

Why are we so reactive? Why do we struggle to be more proactive?

Organizations are perfect systems Performance we are getting today is perfectly aligned
with the consequences in place in the environment
Sustained behavior is a function of its consequences
Consequences that are Immediate and Certain to the performer are more powerful than those
that are Future and Uncertain to the performer
PICNIC Analysis example of Firefighting in an industrial setting

Senior Leader Tips: Must Dos and Must Avoids

In order to derive the most benefit from the behavioral lessons learned from catastrophic event
investigations, senior leaders must make adjustments to their current repertoire of interactions in
the workplace. Understanding these learnings and applying best practices consistent with what
behavioral science tells us will result in strengthened safety performance and culture. Many
leaders tell us that making slight adjustments in their daily routine not only has a positive impact
on industrial and process safety and severity, but makes each day more rewarding as well.
Validating the safety of the system more than auditing the compliance of employees will
have a stronger benefit. Consistent demonstration of best practice leader behaviors will accelerate
the creation of a culture of candor and trust. Using the science of behavior to understand common
practices and develop sustainable solutions will lead to better decisions, policies, systems and
impact.

Here is a summary of effective behaviors to do more and ineffective behaviors to

eliminate, in order to improve safety in high-hazard settings:

Must Do
1.
2.
3.
4.
5.
6.

Show up when things are working/going well

Celebrate successes, no matter how small
Observe behaviors, looking for good examples of safe actions to reinforce
Demonstrate an interest through the questions that you ask
Ask about leading indicators and safe behaviors
Objectively observe the impact of your actions, decisions, and policies

Must Avoid
1.
2.
3.
4.
5.

Auditing/Inspecting
Get directly involved in disciplinary mattersbest addressed through the chain of command
Keep probing/asking until you find a problem
Reacting negatively to bad news
Over-emphasizing lagging indicators

Bibliography
BP. Deepwater Horizon Accident Investigation Report. 2010.
(http://www.bp.com/content/dam/bp/pdf/gulf-ofmexico/Deepwater_Horizon_Accident_Investigation_Report.pdf)
Columbia Accident Investigation Board. Report, Volume 1. 2003.
(http://www.nasa.gov/columbia/home/CAIB_Vol1.html)
National Academy of Engineering and National Research Council. 2011. Macondo Well
Deepwater Horizon Blowout: Lessons for Improving Offshore Drilling Safety. Washington,
DC: The National Academies Press.
National Commission on the BP Deepwater Horizon Spill and Offshore Drilling. 2011. Deep
Water: The Gulf Oil Disaster and the Future of Offshore Drilling Report to the President.
(http://www.gpo.gov/fdsys/pkg/GPO-OILCOMMISSION/content-detail.html)
U.S. Chemical Safety Board (CSB). 2012. CSB Investigation: At the Time of 2010 Gulf Blowout,
Transocean, BP, Industry Associations, and Government Offshore Regulators Had Not
Effectively Learned Critical Lessons from 2005 BP Refinery Explosion in Implementing
Safety Performance Indicators. (retrieved March 6, 2014) (http://www.csb.gov/csbinvestigation-at-the-time-of-2010-gulf-blowout-transocean-bp-industry-associations-andgovernment-offshore-regulators-had-not-effectively-learned-critical-lessons-from-2005-bprefinery-explosion-in-implementing-safety-performance-indicators/)
U.S. Chemical Safety Board (CSB). 2007. Final Investigation Report: Refinery Explosion and
Fire. (Report No. 2005-04-1-TX) (http://www.csb.gov/bp-america-refinery-explosion/)