Lesson six, identifying more behaviors and ways to influence them. So if you remember right at the beginning of this course, I asked you to write down some of the things that you would be observing that for you would define a safety culture within your team. And I've given you some suggestions, like members carrying out safety checks, team members stopping what they're doing to attend to safety. Everyone were in the correct PvP, team members approaching each other doing interventions. So these are my suggestions, things I would look for in a team to see whether I think I have a safety culture. You may have come up with some more.

So if you have you need to be thinking about right How can I apply the principles of what we've done here to those specific areas. So if you didn't do that exercise, I'm gonna ask you to do it now. Think about some more specific observations that you will be looking forward to see a culture of safety. The reason it's important is because it's all of those individual bits of behavior added up together that create the culture. So hopefully you've had a think about some more areas that you could be observing. If you're still struggling, I've got one more that I'd like to give to you.

And this is that a possible further observation would be a team that's willing to own up to and recognize mistakes, and look for ways to improve. So you'll notice that we've got the airline industry, we've got the space industry, we've got heavy industry, probably things like nuclear power generation, those sorts of things. Those sorts of organizations tend to adopt a robust way of learning from the stakes. If you're in Interested in this as a subject on its own, it's a really interesting subject. And there's a writer called Matthew side who wrote a book called black box thinking. And in that he argues for the importance of industries and organizations, finding a way to be able to identify their own mistakes, and look for ways they could improve.

So get getting down to the root cause of what happened and actually finding a way to improve industries that are willing to do this willing to be open about their mistakes, generate highly reliable organizations. And there is a category of organizations or businesses or sectors called the high reliable or high reliability organizations. The more you can do that as a business, the more likely it is that you're going to create a culture of safety that you're going to create a safe environment. So for a few minutes, I want to talk about how you might get to that place. So how do you create a team where it's able to recognize and understand its mistakes and put them right. So one of the things that you can do is identify near misses or hazards.

You can also regulate, review those near misses or hazards and small incidents. carry out a root cause analysis have a way of doing this analysis where you're not looking to attribute blame, but to find all the contributory factors that came together to make that incident happen, including this player actions from these reviews, including who's going to take the action and by when so one of The things that we mentioned in these highly reliable organizations is they do this root cause analysis, they try to find out what really happened. Now we can draw a really interesting lesson from lean manufacturing here. And continuous improvements. I'm just going to take these tools and just use them for this purpose. In fact, they use in health and safety all the time.

And the two tools that I'm going to talk about are five why and a fishbone diagram. These are both root cause analysis tools. So let's start with five Why are really all five why's is it's a very simple method to find out the root cause of something that's happened. So in health and safety, you may have had a near miss or unique may have had a hazard that you spotted, or of course it could be an incident or accident. Clearly the more near misses you discuss and identify the more you And get to the root causes and avoid the actual thing happening. So that's why you encourage people to look for near misses things that nearly happened.

Accidents that could have happened, or hazards which could be contributing or may one day contribute to some sort of accident. And you're just asking why that happened five times. So we'll do a little exercise to explain how that works. So imagine an incident where someone slips on a wet floor and strains their back. So this is actually an incident it's not an MS. But you're doing a five why on this incident.

So I'd like you to do a hypothetical five, why exercise to find a possible root cause. So just pause this video now, and think about how you might identify the root cause. So the first question you'd ask Why did the person slip on the wet floor? The second question you might ask is, why was the floor wet? Then you might find the answer to that. And the question is, well, why did that happen?

And so on. So you're going through and the idea is that you're asked that why five times and you get the answer. So hopefully you've had a go with an exercise. If you've not then by all means pause now and go back and have a go at that exercise. Here's an example of the things I came up with. So first, why why did the person slip while the floor was wet?

Pretty obvious. Second, why, why was the floor wet reason? Well, there was drips from the hand cleaning station so somebody would wash their hands and there was drips of water on the floor, near the cleaning station. Y where that drips from the hand cleaning station. Well, actually, we'd run out of paper towels, so the person would wash their hands have no so dry them, try to flick them dry and bits of water go on the floor. So why how do we run out of paper towels?

Well, we don't really have a system for replenishment. Why don't we have a system? There's actually no good reason. This is the thing we need to fix. So that's a good example of we've had five why's, and we've actually got down to the root cause of the issue is that we don't have a proper replenishment system for paper towels when they run out. It can take hours, or even days before somebody gets around to putting some new ones in.

In the meantime, people wash their hands, wet hands, bits of water on the floor causes a hazard. So we've got down to the root cause so now what we need to do is look at what can we do about it? So a what can we do about process? And what do we need to do to make sure this doesn't happen again? Well, it seems quite obvious that we need a simple replan or replenishment process, possibly a combat. So what's a combat?

Well, combat is very simple. It's a little signal to say that we need some more of whatever it is we've run out off. So it could be in this washing area, that actually we have a spare set on the shelf. So we have some paper towels on a shelf next to the actual dispenser. And as soon as that is used, then that triggers some sort of replenishment activity, so that becomes a signal. So that could be a little card that you then take to somebody to say that it's needed or just a big red sign to say, needs to be replenished and somebody has the job of checking every day to make sure that's done.

Well. That way you never run out of paper towels. So we've done a root cause analysis, and then we found a way to do an improvement. And the second root cause analysis tool that I mentioned was the fishbone diagram. So again, Fishbone diagrams are taken straight out of lean manufacturing, but they are used by health and safety professionals, and by managers trying to find the root cause for some near miss hazard or incident. So I'm going to do a little bit of an example of how that might look.

So we might have a situation where our last time incidents have increased for the first three months of the year. So maybe we've started to get an increase in accidents or incidents, and we want to find the root cause of that. So this technique is called the use of a fishbone diagram for this reason because it kind of looks a bit like a fishbone You really try hard, you can see it there. So these are the standard labels, the one and you have the effects you've had. So that would be the incident accident or near mess that you want to investigate. And then you've got equipment, people, methods and materials.

So let's take these elements one by one. So we'll start with equipment. What is it about our equipment that could be contributing to the effects, or the accident or the incident that's in the effect box. So it could be a number of things. It could be that we've had some breakdowns. It could be that it's actually not designed for this product.

It's difficult to carry out safety checks, and so on. Let's also have a look at methods. So what is it about our methods that could be contributing to the effects that we don't want? Well, it could be something to do with the order that we're doing the exercise in or doing the product in a cup. It's too difficult to do things the right way. way if it's too easy to take shortcuts, unclear operating instructions and so on.

Materials, what is it about the materials that could be contributing to the effect, or the thing that happened, the accident, the incident, the near mess. So it could be something to do with a new grade of material that we're using, or many of the things that might relate to the materials. And finally, let's have a look at the people element. What could it be about the people elements that could be contributing to the effect? Is it a lack of training? Is it that we're not reporting properly?

Is it a confusion over rolls? It could be any of those things. What we then do after we've done the fishbone diagram, we have a look at the things that we want to focus on. So we've got a couple there that we want to focus on, and we'll start to find possible solutions about that. So what can we do about it the same as we did with our five Why exercise