Taking All Forest Service Employees on a Safety Journey

SLP 7 Safety Team: Taking All Forest Service Employees on a Safety Journey

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SLP 7 Safety Team: Taking All Forest Service Employees on a Safety Journey

Executive Summary

Safety Team: Taking All Forest Service Employees on a Safety Journey.

Angela Baca, Chris Fettig, Rick Lint, David Mertz, Heather Provincio, Jaelith Hall-Rivera, Deidre St. Louis.

On average, six Forest Service employees die in the line of duty every year. This is not acceptable. While the Forest Service has many of the components needed for a good safety program, it is based primarily on compliance. The team maps out the steps and develops products to facilitate taking all employees on a safety journey. We produced examples for consideration and further development. The report outlines the safety journey of the Team and uses the steps from The Heart of Change book to guide the Agency as we change our current culture. By becoming a learning and reporting organization with a just culture, we will become a zero fatality organization.

Our journey began as a dialogue among our team members. We interviewed agency leaders and agency safety experts. We also talked with unit-level safety officers, safety and risk management specialists, human performance experts, and others outside our Agency. We read the Dialogos reports and read books on safety, human performance, and change. Additionally, we went on site visits to take training offered by other organizations, to view first hand their operations, and interview their leadership.

The steps for successful large-scale change include increasing urgency, building guiding teams, getting the vision right, communicating for buy-in, empowering action, creating short-term wins, not letting up, and making change stick.

We created a video to emotionally urge people to accept that change is needed. We provided a case study about increasing trust and open communication. We suggested changes to our mission, vision, and guiding principles to include safety. We drafted an employee bill of rights and provided questions to ask when there is an event. We included a copy of the Coast Guard’s green-amber-red risk assessment. We drafted talking points for leaders to use in dialogues with their employees. We also included examples of including safety in ECQs and a job announcement. Finally, we provide a skit that demonstrates the wrong way and a better way to react to an event.

One of the most important lessons we learned on our journey, was that we need to learn to “fail softly” in an error tolerant workplace if we are going to be a learning organization. For example, we need view events as opportunities to learn and dialogue so we can change conditions that might have otherwise led to more serious injuries or fatalities. We gained insight into why blame-free reporting is essential to becoming a learning organization. Additionally, we learned how important it is to understand that mistakes cannot be punished away. We also learned that the role of safety is not to reduce the number of adverse actions but it is to enhance our ability to succeed under varying conditions.

SLP 7 Safety Team: Taking All Forest Service Employees on a Safety Journey

Introduction

We first heard Chief Tidwell talk about zero fatalities at our first Senior Leadership Program (SLP) session in January. The Forest Service has an average of six deaths per year – and that is unacceptable. While the Forest Service has many of the components needed for a good safety program, it is based primarily on compliance and should be based on learning. This project lays out ways to make this change successful. We believe that by becoming a learning and reporting organization with a just culture, we will, in fact, change – and ultimately become a zero fatality organization.

Fatalities persist despite continued efforts in safety.
Data from OSHA (http://www.osha.gov/dep/fap/fap-inj-ill-stats.html)

Explanation of the Project

Team Dynamics – We approached the project by first exploring our Team dynamics. We discussed the results of our various personal assessments, our strengths, and how we wanted to “stretch” ourselves in the SLP. Then we discussed what this meant in terms of working together. For example, we discovered that, combined, our Team contained 24 of the 36 strength themes from the Strength Finder assessment (Attachment 1). We also discussed the importance and seriousness of this topic. We relayed to one another personal experiences with safety – from incidents we had been involved in, to fatalities on our Units, to reactions from our supervisors after an event. One of the first concrete products we developed together was our Team Agreement (Attachment 2). This was an important way to lay a foundation for how we would work together as a Team for the remainder of the year – including how we would deal with disagreements if they arose. Throughout the year, we made it a point to not only work on our project, but also have fun together. For instance, we went to a Nationals baseball game, took the boat ride and visited Mt. Vernon, went on hikes, and enjoyed multiple meals together as a team.

Interviews – We started by interviewing Agency leaders and safety experts. We interviewed the Chief, Associate Chief, two Regional Foresters, Ralph Dorn – Director of the Office of Safety and Occupational Health, a Forest Supervisor, and John Phipps – our project sponsor. We selected these people to interview based on their involvement and interest in safety in the Agency. We also talked with unit-level safety officers, safety and risk management specialists in Fire and Aviation, and Forest Service human performance experts Ivan Pupulidy and Jim Saveland. Through these interviews, we learned about the National Leadership Council’s (NLC) safety learning journeys and realized that we too were on our own safety journey. The NLC journeys provided a constant touchstone for us throughout the project, where our own learning was enhanced because our leaders were exploring this subject as well.

We also took the opportunity to talk with another organization that had recently undergone a significant change in their safety culture. On the recommendation of Sidney Dekker, author of Just Culture, we interviewed Jim Krieger with the Federal Aviation Administration (FAA) at the O’Hare Tower in Chicago. We were struck by similarities between the O’Hare tower “then” (i.e., prior to their transformation) and the Forest Service “today”. Many of the issues that the O’Hare Tower had grappled with, like lack of trust and under-reporting of incidents, are struggles that the Forest Service faces. Their success demonstrated that we could change as well.

In fact, a recent Washington Post article highlighted the increase in reported incidents at the FAA over the past few years – and quoted the head of the Agency as touting that increase. Reporting is necessary for learning and the FAA now has a blame-free system in place that protects controllers when they report a near miss or incident. While this set an excellent example for our Team to learn from, Mr. Krieger also cautioned that things could backslide easily. He told us that he constantly worries that one “set back” will take them back to where they were a decade ago.

Readings – Another important element was exploring where we have been with safety in the Forest Service. Of particular importance were the two Dialogos reports that the Agency commissioned in 2007 and 2008 to address the “safety culture” in the Forest Service. They found that safety problems, although a critical issue, were symptomatic of other latent factors, including:

1. Lack of leadership alignment

2. Lack of clear direction and mission

3. Existence of a “family-based” culture

4. Self-suppression of a safety dialogue

The Dialogos reports resonated with our Team and we found some quotes from employees from the first report particularly disturbing.

In addition to the Dialogos reports, we found the following books of considerable value to our learning about human performance systems and safety.

· Just Culture: Balancing Safety and Accountability by Sidney Dekker.

· Whack a Mole: The Price We Pay For Expecting Perfection by David Marx.

· The ETTO Principle: Efficiency-Thoroughness Trade-Off – Why Things That Go Right Sometimes Go Wrong by Erik Hollnagel.

· The Heart of Change: Real-Life Stories of How People Change Their Organizations by John P. Kotter.

One of the reasons we read these books is that many of the people we interviewed mentioned them. They also provided a perspective of what is going on outside the Forest Service in safety. Here we learned that not only can safety be a core value, but it also represents a field of science.

In summary, these readings helped us gain insight into why blame-free reporting is essential to becoming a learning organization. Additionally, we learned how important it is to understand that mistakes cannot be punished away, which generally has been contrary to how many have dealt with accidents. This is because success and failures can have the same origins, and the role of safety is not to reduce the number of adverse actions but it is to enhance our ability to succeed under varying conditions. Furthermore, we learned the steps necessary for changing our culture and the importance of reaching people at an emotional level to bring about that change.

Site Visits – The last component of our journey was going on site visits. We felt that it was important to learn from outside organizations that have been successful in changing their cultures. We took Human Performance Improvement (HPI) training at Los Alamos National Laboratory in New Mexico and interviewed key leaders and instructors at the lab.

We also visited the Coast Guard Station in San Diego, California where we were able to experience operations first-hand and interview key agency leaders. Both of these visits enhanced our Team’s safety journey immensely and we brought back valuable lessons learned that shaped our project’s findings and recommendations.

Findings and Recommendations

We began our journey by interviewing the Chief. When we asked him how our Team might help with zero fatalities, the Chief asked us for ideas on how to involve all employees in a way that they would embrace and make it their own. Because the safety journey we took was so powerful for us, we concluded that “taking all employees on a safety journey” was the best way to engage all employees.

We read the book The Heart of Change and believe it provided an exceptional framework (or a ‘roadmap’) for changing our safety culture. It resonated with us because structure and guidance is needed through the resistance that typically prevents lasting change. Our Team, along with the NLC members we talked to, know that “zero fatalities” cannot become “just be another initiative.” The Heart of Change emphasized that to make change permanent, it is not just one step that needs to be taken, but it is multiple steps for multiple reasons. It also reminded us that meaningful change takes time.

Step 1 – Increase Urgency

The Forest Service can increase the sense of urgency by helping people to see a truth, feel, the need to change, and want to act. A key recommendation in the book was to hit people in the heart and affect them on an emotional level. To grab employee’s attention so they feel the need to change, we recommend the FS build on the video concept we developed and share this with all employees as a way of illustrating the problem and generating discussion. To gain acceptance and eventually have employees embrace the change, it is important to truly feel the need for change. People most often initiate change based on emotional reasons – not because someone presented them with facts.

Step 2 – Build the Guiding Team

It is important to include the right people, including everyone who is directly affected, to get change to stick. Leadership sets the tone and re-enforces actions. Open communication is vital. We cannot underestimate the value of sharing stories and talking openly and honestly. We think the NLC Safety Journeys are a great example of this step and believe there is a need to form additional groups comprised of employees at all levels within the Agency. As part of this, we will need to have honest, candid discussions that build trust. We have provided a case study where a Forest Supervisor personally visited with all her employees to improve communication and provide “psychological safety” where concerns can be expressed openly and candidly (Attachment 3).

Step 3 – Get the Vision Right

The NLC safety vision message that developed from their journey is the start of getting the vision right (Attachment 4). Meaningful, thoughtful products such as these help “align” the safety message and set cultural change in motion. No matter what, it is important to keep the message simple and aligned throughout the Agency. Questions are a good way to paint pictures of the future for employees. Questions we might ask ourselves during this phase are:

· What change is needed?

· What is our vision for the new organization?

· What training would we provide?

· How would we make sure that people have the right skills?

· Does the organizational structure change?

· How do we communicate the Vision?

As we collectively create that vision, it needs to be emotionally powerful. Clarity is also critical. Although we realize how well-established our mission and motto are, we suggest that safety be added to those, in addition to our vision and guiding principles (Attachment 5). This following is what we suggest:

Mission: Sustain the health, diversity, and productivity of the Nation's forests and grasslands safely to meet the needs of present and future generations.