achieve magazine recently spoke to Rosa Carrillo, an internationally recognised specialist in transformational culture change and leadership development.
achieve – Many organisations struggle with communicating that safety is a priority over production. Why is it so difficult to prevent critical loss events and what can we bring to the management of our systems and people to improve resilience?
Rosa Carrillo – It is very difficult to maintain safety as a priority in people’s minds because of the multiple demands on them – financial goals, deadlines and stockholders demanding share value. These are the primary concerns of the highest levels of management, but the communication where the work is actually done is completely different. People are mostly concerned with meeting the demands of getting the job done in the most expedient way possible. I’ve found that management tends to communicate about safety in safety meetings through policy and procedure and these methods are not getting us the results that we want. Complexity management, complexity theory and relationship psychology show that the environment is constantly changing, so static policies and procedures are simply not going to be adequate.
achieve – How does complexity theory contribute to the way safety should be managed?
Rosa Carrillo – We’re not able to make good decisions and take correct action unless we’re aware of what is truly going on around us. And one of the things we’ve learned through cognitive psychology is that we tend to see what we expect to see. No matter how well trained we are, or how well intentioned we are, when we walk into a situation we are missing a lot of the important data that can inform us that something is unravelling, or that "drift" is taking place. Complexity management trains managers to prevent failure by remaining constantly aware and then to develop that in other employees and associates, so that everyone is contributing to gathering the necessary data.
achieve – Almost like adopting a mindset to be vigilant, or to expect the worst?
Rosa Carrillo – Yes. Karl Weick, one of the thought leaders in highly reliable organisations (HROs), has written several books on mindfulness and another called Managing the Unexpected1. His theory to prevent disaster is always to expect the unexpected. A manager can’t do that alone; they must engage all employees in the same mindset.
achieve – You advocate for transformational leadership in safety. Can you explain what that is and how it works?
Rosa Carrillo – A transformational leader is able to influence change in individuals and social organisations. And the primary tool for that change is to raise consciousness or raise awareness. As a leader you have to first become aware of your own feelings and the way that you tend to interpret reality so that you can open your mind to accept information that may be non-conforming to what you believe to be true.
Transformational leaders must change themselves first before they are able to influence and motivate employees to begin taking the same approach. Transformational leadership is the focus on values and working with the people around you to help them see and articulate what’s really important and of value to them, so that when you try to get buy-in into the shared goals of the organisation, you’re tapping into those values.
achieve – It’s been widely proposed that safety leadership is about managing the behaviour of workers to work safely. Is behaviour-based safety the key to achieving high reliability organisations?
Rosa Carrillo – My entire career has been based on culture and transformational leadership. Behaviour-based safety has not proven a viable alternative for me or my colleagues who think along the lines that I think, because it tends to focus on people’s responses to external stimuli. People who are primarily behaviourists talk about the fact that they focus on behaviour because it’s visible and it’s measureable, and that you really can’t tell what a person’s thinking so how can you control or manage that? I agree that you cannot control what people are thinking.
Complexity management theory actually emphasises that once a manager communicates a thought or an idea, he or she has no control over how it will be interpreted or communicated to others. It’s almost like each person communicates it in their own way and adds their own meaning to that statement.
I think it’s imperative that we keep looking for further solutions and further answers, which many of us have found in complexity management and relationship psychology. It helps to explain why we try to make things so explicit and so orderly. We have the rules and procedures, so why don’t people follow them? It’s because people take the initial thought and idea and then, in conversation and in interaction with other individuals, it changes. What we sometimes call error or not following procedure is not even noticed by individuals because it is natural for human beings to take an original way of doing things and keep adapting it. The problem arises when the adaptation or change to the rule or procedure produces an error, accident or failure.
achieve – What are early warning communication systems and what benefit can they bring to the safety management process?
Rosa Carrillo – Early warning communication systems encourage and engage employees to bring forward changes as they are taking place or deviances in procedure. Even that word deviance has a negative connotation, because by deviating from procedure there’s a fear of punishment or reprisal. So we have to look at our language, the natural human process of adaption and the changing of the procedures as something that can be talked about openly without fear. And that brings me to the importance of trust and open communication in creating a safe work environment. Without trust there can be no open communication, and without communication there’s failure.
Structure, policy and procedure will not create the kind of open communication that we need, it falls upon leadership to do this. An open communication system has to do with the leader’s ability to listen and to encourage people’s disagreement and extract and highlight opposing points of view. This is something that is sorely lacking in our training of management – the ability and importance of listening, and the ability to solicit this contradictory information. Early warning communication systems consist of specific conversational forums where people are encouraged to have this type of dialogue.
achieve – While some companies focus on the value of continuous improvement, you’ve proposed a concept of perpetual assessment. Can you describe its method and its benefits?
Rosa Carrillo – The idea of perpetual assessment comes from perpetual awareness. If you accept that the environment is constantly changing and people are always adapting and changing their approach to the work, then perpetual assessment is necessary. Current systems are audited by regulators who come in now and then to make sporadic assessments, even if they take place on a regular basis. We need to inculcate the notion that we are all responsible for constant awareness and constant observation in the workplace to spot the changes and correct them in a timely manner before they lead to failure.
achieve – Drift into failure is a concept you've suggested organisations need to engage with. Can you explain the relevance and importance of recognising drift and what organisations need to do to address this?
Rosa Carrillo – Drift is a concept where a procedure originally put in place is changed over a period of time by operators who find that if they skip a step in the procedure, nothing happens. After a while those steps are forgotten and unfortunately when those systems become tightly coupled, disaster occurs. This is because suddenly the procedure or element that was once so important but has since been forgotten was the one that would have prevented the disaster. And if we skip a step or a procedure and nothing happens, we then assume that skipping that step is actually saving us effort. Unfortunately in safety, when people don’t understand the underlying reasons why these procedures exist, failure can happen. And my recommendation has been, in terms of the early communication systems, to develop processes in your organisation that encourage people to discuss and bring forward changes in the processes and procedures that they’ve observed, or that they think would improve the process. By bringing them up in open dialogue they can then be examined and addressed and either adopted or discarded.
achieve – That sounds like a perfect segue to your relationship-based change model for safety.
Rosa Carrillo – Managers who are highly trained in management competencies, strategy and financial control typically have very little expertise in relationship management, which is where things really happen in an organisation. It’s the relationship between the manager and the employees that creates open communication, allowing information to surface and to be shared. There are many, many subcultures in our organisations, with different levels of management and different occupations. For example, engineers and operators don’t speak the same language, nor do they see the world in the same way. We need to create organisational structures that encourage communication across these subcultures.
1 Weick, Karl E., Sutcliffe, Kathleen M., Managing the unexpected: assuring high performance in an age of complexity, Jossey-Bass (2001).
