Guest Post by Umberto Tunesi (first posted on CERM ® RISK INSIGHTS – reposted here with permission)
Or, why we are not listened to?
Why don’t we listen to those who – justifiably – cry wolf?
Be others or ourselves, it does not matter.
The output of this regrettable way of thinking often results in a “chronicle of a death foretold”. What do I mean?
Though operators – that is, “those who do the job” – very often send warning messages to their supervisors and managers. The latter for a number of reasons, mainly connected to spending, often ignore such messages, with disastrous results.
Operators are usually very close to the key process steps, and they – though not statistically – feel what is not going right, where and when a severe failure is due to occur.
But they often are “a voice in the desert”.
What drives me crazy is that – once the failure has occurred – they are blamed for not having timely informed their “ higher up’s”.
Now, making yourself listened to by a “deaf” person is no easy task. You can use different means of communication other than words – spoken or written – but if the addressee does not want to bring your message home, there is no way out.
True it is that, in human nature, when you have not been listened to once, you will not speak up anymore.
Of course not all and every warning is equally reliable. Yet I believe that is better to be more suspicious than being too self-confident.
There is an overwhelming number of cases where – had the “operators’ voice” be listened to a number of accidents injuring or even killing people (that is, “survival”), or putting their welfare (that is, “life”) at risk, could have been avoided; or, at least, their negative side-effects severity could have been reduced.
“People in the know”, all too often tend to ignore or diminish the lay-man/-woman messages or warnings, whoever they come from and whatever they concern.
Thinking of risk prevention, nothing has to be put aside, everything – even if not sound or demonstrated – has to taken into consideration for a preliminary analysis, at least.
If any “somebody” feels to express – with words or otherwise – an opinion on what we are working at, he or she has to have reasons to do it: we should better listen to or observe, therefore.
I do not mean to be a Cassandra but, if after having read these lines of mine, an accident – whatever – occurs that was warned to you by any of your operators, may be these few lines will become a meaningful reminder.
The classical FMEA approach strongly emphasizes that it has to be a “before” but not an “after” event analysis and activity, Though reviewing occurred events would certainly be important input to before-the-event further FMEA’s.
In the all-too-used example of an extra-terrestrial looking at our car industry recall campaigns, he or she would certainly wonder:
“Why is so much time and money spent in planning failure-preventing activities and – look here ! – it seems the terrestrials still use the least effective, primitive trial-and-error practices.”
The same could be said of cyber systems, of food and health safety systems, of environment protecting systems, of social welfare-enhancing systems.
And these comments would be no compliment to our proudly and arrogantly alleged prevention capabilities.
I recently wrote some lines on the check-listing process: planning, development and use of more effective check-lists, mainly based on previous and existing check-lists’ failures.
Considering the above, when planning, developing, using any check-list, the “operator’s voice” has to taken into consideration be it officially expressed or not; be it any observation of operators’ behavior. Operators not always do what they are told and how to do it. Sometimes, they perform correctly, sometimes better, sometimes worse.
It is therefore our duty to consider these variabilities beyond the invaluable input operators’ knowledge and our knowledge will give to our prevention-enhancing processes.