It’s clear that when it comes to safety, what leaders say and do matters. What I’ve found is that the difference in behavior between good leaders and great leaders can be very minor, but the difference in terms of outcome can be huge.

How leaders approach “learning from incidents” (LFIs) is one example where small tweaks in behavior can have significantly different consequences. In many companies, information learned as a result of an incident is communicated via an e-mail or a safety bulletin. The intent of these notices is to build awareness of the circumstances surrounding the incident and prevent that incident from happening elsewhere. Unfortunately, pride gets in the way of communicating these messages and having leaders act upon them.

Here’s what typically happens. The LFI notice is written and circulated within the organization. The description focuses on the technical causes of the incident and provides an explanation of the potential root cause. Usually, these LFIs are written in such a way that an advanced level of education is required to read and understand the memorandum.

Leaders who receive the LFIs generally discuss the incident at their morning safety meeting. The description is circulated, and the staff read the description. Then the inevitable question is asked. It goes something like this:

“So, corporate sent out an LFI last night. I’ve made a copy of it for everyone to read. It’s really a tragedy that this happened at our sister facility. I’d like to ask you guys if this can happen here. What do you think?”

The discussion focuses on the technical causes of the incident, and the leadership team quickly identifies what went wrong at the other site. That’s when the defenses go up.

“This can’t happen here. We have a process to prevent exactly that type of occurrence, and our people know better than to do that.”

At this point, the discussion ends, with the leader confident that the job has been taken care of: the LFI has been discussed, and the leader has been convinced that the incident can’t happen at that facility.

Imagine a slightly different turn of events, as demonstrated by the following example. I was coaching a terrific and well-intentioned leader in the Canadian oil fields. He had been sharing LFIs religiously and was an absolute safety advocate. He was confident that the LFIs he shared were being discussed adequately—until he had a repeat incident.

He was clearly upset by the recurrence after he had been assured that the incident couldn’t happen again. I asked a simple question:

“What would happen if you changed one word in your question? Instead of asking, ‘Could this happen here?’ ask ‘How could this happen here?’.”

The simple addition of the word “how” changes the focus of the discussion. Instead of generating the reflexive response “this couldn’t happen here,” the conversation shifts to the rigor of the controls that exist at the facility, the completeness of practices, and the strength of barriers. When this leader heard my suggestion, the light bulb went on. The leader changed his behavior, and his next LFI discussion identified four possible ways a corrosion incident could happen in his areas of accountability, which resulted in changes to processes and procedures.

Imagine the power of a front-line leader’s introducing the single word “how” during tailgate or toolbox meetings. Suddenly, the conversation changes from a monologue to an engaging discussion on weaknesses in training, documentation, and procedures. In addition, if the leader is paying attention, he or she can act on suggestions and improve safety, engagement, and trust.

Not bad for changing one single word!

The next time you get an LFI:

• Circulate a simple LFI description, written at the 8^th grade level or below.
• Use simple pictures (as advocated by authors Larkin & Larkin) to illustrate the incident.
• Ask “How could this happen here?”.
• Solicit ideas on how to make your operations and controls safer.
• Act on those ideas!

About the Author

Laurence Pearlman is a Director with Corven, Inc. in Lisle, Illinois, U.S.A. He advises energy and natural resource clients on safety performance improvement and change management. Laurence specializes in engaging employees and leaders to drive ownership and sustainability of safety processes. Previously, Laurence worked for Amoco, BP, Exxon, and Pfizer. He is an adjunct professor at the University of Illinois. He was part of the team that assessed the culture of BP Refining after the Texas City incident and identified leadership and cultural interventions to reduce risk. He holds degrees from the University of Illinois and the University of Iowa.

Other Articles by Laurence Pearlman in the EHS Journal

• Does Operational Discipline Replace Strong Safety Leadership?

Photograph: Water Lily by Claudia Meyer, Paris, France.

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