Updated: May 8
Lesson 1 - Identify The Risk - Don't miss the Elephant.
In this first edition of a series of Five Risk Management Lessons, we can learn from Elephants; I am exploring risk Identification.
I recently read the book RISK - A User's Guide by General Stanley McChrystal; it's a brilliant book, but this blog isn't about that. I searched for elephant-related risk topics, and the first chapter of Risk captioned this.
"They couldn't hit an elephant at this distance." Famous Last Words of Major general John Sedgewick before being shot by a sharpshooter during the Battle of Spotsylvania Court House on May 9, 1864.
Intrigued by this, I reached out to Rodger Hollins, a Health and Safety Advisor from The Waikato, and asked him, "when does managing risk become risk-taking? Is risk-taking a choice rather than a fate?" Rodger Explains;
As I look in the bathroom mirror every morning, preparing for my day, the number of visible grey hairs seems to be on the rise. I'm thankful that I am not old enough to have known Major General John Sedgwick personally. Therefore I can only speculate on the circumstances of his unfortunate and unexpected demise. Perhaps, after all the years in the military, being exposed to multiple conflicts, he became desensitised to the risks and didn't perceive his current situation as a significant threat compared to full combat? Perhaps, if he ducked like some of the others did, he'd add to the fear that everyone was experiencing at the time, reducing morale and compromising the imminent battle? Perhaps, he assumed that given that there were "only a few" bullets whizzing past, he felt that the odds were in his favour? Or maybe it's a combination of all of the reasons mentioned? Who knows? This story, however, is a good example that highlights the fact that the seemingly impossible happens, with significant consequences, way more often than we'd like to admit.
Fast forward 150 or so years, and the context of this article changes quite a bit. We are no longer referring to war, it is no longer the 1800's, and business leaders have substantial legal responsibilities to look after people in their employ. One thing that every business has in common is the ability to cause serious harm or death. The reality is that each business has its way of doing this, so it is essential to take the time to understand the work that is being done, no matter what or where it is, to determine how things can go wrong. But, what are the chances of an accident that causes serious harm or death actually happening? How likely was Major General John Sedgwick to be struck under the eye by a random bullet passing by from 1000 yards away by a rifle that was barely known to shoot that far? What are the chances that an I-beam being carried over people's heads on a construction site falls and crushes someone? In reality, retrospectively, once someone has been seriously hurt, the odds of it happening were high, but before the event, who actually knows?
"I'd start focussing on the real stuff, the stuff that matters."
A few years back, I had the privilege of watching a presentation by a well-respected investigator. After a thought-provoking presentation, we all went to lunch, and I ended up seated next to him at the dining table. I could not miss the opportunity to ask a few questions, so I made polite conversation and asked if I could proceed with one simple question. He agreed. "If there was one thing that you could change in Health & Safety tomorrow, what would it be?" I asked. Smiling, he politely responded and said, "I'd start focussing on the real stuff, the stuff that matters." He gave an example of an event that he had investigated, where everyone on site had completed induction, everyone was wearing the required PPE. In short, most of the expected health & safety controls were in place. This site was regarded as having high health & safety standards, yet someone was still seriously hurt, crushed by a crane mast that had collapsed. The main contributing factors were poor planning, incorrect lift calculations and lack of experience with this type of complex lift. Of course, I cannot comment further on the details, but yet again, perhaps an illustration of how sometimes we "sweat the small stuff" and forget to focus on the real stuff, the stuff that matters.
So, in the context of identifying hazards prior to the job, what's your real stuff, and how do you and your team ensure that you maintain focus on the stuff that matters? At face value, it sounds simple. Identify your hazards, understand the associated risks, and put controls in place that either eliminate the Risk by removing the hazard or minimising the Risk through reliable controls. However, is there enough focus on critical risks? How well are they understood, and most importantly, do workers perceive them to be critical or not?
Critical risks are recognised as those risks arising from hazards that are more likely to have severe consequences if people are exposed to them. They are the things that can kill, maim, or cause serious health conditions, soon or in the long term. Given the subjectivity of the "likelihood" assessments in the common qualitative or semi-qualitative approaches, some may agree that critical risks should receive suitable focus irrespective of the likelihood assessment, as it is often underestimated, as perhaps it was, in John Sedgewick's case? There is no doubt that there are various reasons why critical risks are not identified or perceived as being critical, all of which cannot be discussed in a short article; however, I'd like to create thought and discussion on the challenges around applying a systematic approach to analysing the risks associated with identified hazards.
"I'm not sure how they can expect us to identify the hazards even before we have started the work. This meeting is a complete waste of our time."
was the response I got when inviting a contracting company to attend a half-day hazard identification meeting that was to be arranged by their client before a job started. It is almost as if the age-old rejection of the "generic risk assessment" had been twisted back onto the client, with the contractor using its perceived limitations to their advantage. Now, whether a lack of understanding causes this attitude, a sign of frustration or a mischievous approach to side-line the task, not attending this meeting was a missed opportunity to collaborate with others, to draw on the available knowledge in a room, to think of the work, its tools, plant & equipment, the substances used, the people involved, and to analyse processes methodically to help identify critical risks linked to each step of the job.
Many businesses have systems in place to identify hazards at various levels of the organisation and at predetermined intervals, but do such frameworks extend to promote the thorough understanding of the identified hazards and the potential consequences they have the energy to cause or are risks predominantly based on speculation? Is there room for the inclusion and analysis of a range of hazard types such as physical, chemical, ergonomic, biological, and psychological and is sufficient time given for analysis to prevent bias towards one type, for example, safety risks only? Do existing processes promote discussion around obvious hazards and include understanding other hazards that are perhaps hidden, combined, or emerging in nature? Are resources available to research hazards both proactively and reactively? In other words, is sufficient expertise and guidance available, used to gather meaningful information to understand the dangers of work predominantly before but also after incidents?
The legislation highlights particular risks which require a formal process to manage them, and these are often included in the critical risks that businesses identify. Clause 5 of the Health & Safety at Work (General Risk and Workplace Management) Regulations require the person conducting a business or undertaking (PCBU) to identify hazards "that could give rise to reasonably foreseeable risks to health & safety". Perhaps this instigates the required depth and breadth of analysis that encourages the identification of critical risks? Legislation aside, though, workers wilful buy-in is a predominant challenge that the health & safety industry faces and perhaps it is this type of preparation and planning that is needed, not only to identify "the stuff that matters", but to create a meaningful and sensible health & safety system that is more likely to attract the workers support?
Perhaps there is still a way to go towards a space where diggers and angle grinders are not seen as hazards but are rather understood as machines & tools that pose various health & safety hazards and risks that should be identified, understood, and individually; managed? (For example, noise, vibration, heat, fuel, fumes and their associated effects.) There is no doubt in my mind that the well-known approach of pre-start discussions and task analysis, conducted by workers and their supervisors prior to the work starting, offers substantial benefit in risk management and engagement opportunities, particularly if the workplace is dynamic, but is it effective on its own, or as the predominant approach? In a workplace that has the luxury of highly skilled and experienced workers with a range of backgrounds, perhaps it is, but perhaps it is up to the PCBU to determine whether such approach is suitable and sufficient for their teams, or whether it should be focussing on increased support structures that help ensure that there is adequate knowledge, the needed depth of understanding, and an approach that is not only in line with legislative expectation but most importantly, is enough to make sure that it protects people from critical risks.
1. Rodger speculates that Major general John Sedgewick chose to take risks to promote morale. It is an interesting observation and makes for another great topic we will explore later in the series. However, my thoughts immediately jump to Covid risk management. Is it possible to take risks purely to promote public morale, and is it worth it?
2. Rodger also observes that each business should develop Risk Management protocols that work for them; a highly recommended book on this topic is Mind Your Own Business – What your MBA should have taught you about workplace health and safety.
3. The age-old question arises: Do workers best manage Risk through buy-in, or is this a big ask?
4. Risks should be identified, understood, and individually; managed, Rodger, refers to the take 5 and also the importance of supervision. In his book, General McCrystal describes a 3 step process namely: Detect, Assess and Respond.
We concluded that Risk-taking is a choice we make; it isn't our fate! We will need to learn how to foresee risks and act early to prevent disaster or lessen the impact if that is not possible. We need to plan and prepare for the next, workplace accident, pandemic or disaster; natural or man-made (terror attacks, global warming etc.). There is no place for She'll be right in Risk Management. The lessons are more focused in the workplace and include tools and machinery.
Don't sweat the small stuff, identify your critical risks, and control them.
As always, I'd be very keen to hear how you and your team make Risk Management work. There is no silver bullet, but sharing some of your insight, approach, experiences, and advice may help others think of an idea that works for them and makes the approach to working in a healthy & safe way just that little more valuable. Please comment below.
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Don't know how to undertake a Risk Assessment? An excellent place to start in New Zealand should you look for an advisor is to consult the Health and Safety Association of New Zealand (HASANZ) register. The HASANZ Register is a national, online register of verified workplace health and safety professionals. It is a one-stop-shop for businesses to find reliable, quality health and safety advice and services. They can search for free to find providers who offer services across the whole sector.
Risk - A Users Guide: General Stanley McChrystal US Army Retired & Anna Butrico
Mind Your Own Business – What your MBA should have taught you about workplace health and safety: Andrew Sharman & Dame Judith Hackitt DBE