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Reflexes or reflections. Why do we tend to repeat the same mistakes?

eric@opensky, haakon@opensky

Incidents, accidents and near misses occur frequently in the workplace. They are often in the domain of health and safety. When, or if, we analyze the causes we often see elements that should already have been in place. Hence, the causes could have been avoided if we had taken the opportunity to reflect and learn earlier when it happened last. How can we improve on our ability to explore and learn from these processes?

The American philosopher John Dewey might be well known for the quote, “We do not learn from experience...we learn from reflecting on experience.” We could easily add “….together with others”. One paradox is that such reflections often must be forced upon us, for instance following a serious incident or accident.

In modern work-life many organisations struggle with incident or accident reporting even though such reports provide the basis for reflections and learning. One question we often ask or discuss with clients is how we can remove barriers and promote an active reporting of cases that reveal a valuable insight into the causes of potential incidents with a large loss potential. The obvious barriers are bureaucracy, inefficiency, fear of negative consequences - and lack of focus. Even with this knowledge we see that companies struggle, and the result is a loss of explored opportunities and the potential loss of financial and human resources. The sole focus on the immediate actions for the sake of regaining control, being the organisational reflexes, often stand in the way of more structured reflections. When we have regained control, it might seem as we are in full control. We need to do both, reflexes and reflections do not exclude each other, rather complement each other.

Some of our associates are regularly contracted to investigate serious accidents, either with a great loss or loss potential. When analyzing the causes, we often observe that in the cause/effect chain there are numerous actions that could have been in place to reduce the probability of the accident or incident. When discussing these potential actions with employees in the workplace it is stated that actions have been discussed among workers and with management without action being taken. In our world this point at an inefficient process for hazard identification and risk assessment.

Back to John Dewey. He is well known for his theories on learning by doing. In modern (agile) service and product development we are encouraged to fail fast. Not because we want our colleagues to fail, but because an early failure is less costly and finally; because every failure contains valuable information to improve.

It is likely that we will continue repeating old and known mistakes. It is further likely that new accidents will occur; some of these with serious consequences. However, the probability can be reduced by improving the safety culture in the company. Some industries are positioned in the premier league so what does it take for others to follow?

  1. Safety must be on the senior management agenda to such an extent that it is made part of the company DNA. Honest commitment matters, starting with visibility and walking the talk, also when other issues than safety are on the agenda.

  2. Incident and accident reporting must be part of all business processes. Any focus on the number reported by each employee is counterproductive. It is much better with focus on involvement, engagement, trust, and removal of root causes. Often actions will involve senior management. Make yourself a role model.

  3. Hazard identification and risk analysis are not only useful tools. They are also the best way to reduce risk and avoid losses. It gets even better when learning from the stories of others and other incidents. Involve and engage all organizational levels in this work.

Even though the thoughts presented here are linked to our experience with health and safety, this can equally be applied in other functional areas. If you are interested in knowing more about how we can contribute to improving your organization’s ability to reflect, please reach out.

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