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Fatigue Risk Management: Ensuring Safety in High-Risk Work with Susan Sawatzky

The Safety Guru_EP 109_Susan Sawatzky_Fatigue Risk Management Ensuring Safety in High-Risk Work



In this episode, we deep dive into the critical topic of effectively managing fatigue in high-risk work environments with our special guest, Susan Sawatzky. Join us as we explore various factors that contribute to fatigue and discuss strategies to effectively mitigate risks and manage its effects. Tune in to learn how these approaches can enhance worker safety and productivity, emphasizing safety as a priority in industries where every second counts. Listen now!


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Susan Sawatzky. She does a lot of work in the safety space, particularly around fatigue management and the application of fatigue management systems within organizations, particularly in a high-risk industry. Susan, very excited to have you with me on such an important topic. Why don’t we start out with a bit of an introduction to how you got into this space?

Thanks, Eric. Yeah, it’s interesting because I’ve had a bit of a long career path. I actually started my first career as a junior high math and science teacher, and I guess you could say that’s where I learned my stress management skills, which is an area that we specialize in. But through a series of events, I ended up leaving teaching and moving into health and safety. And I worked for one of the key safety associations. And in that work, I ended up managing the fatigue portfolio for the Canadian oil and gas industry. And that was a really enlightening moment for me because I discovered my passion for managing this was quite strong. I found it was very much an under-recognized hazard, and I really enjoyed making safety information relevant and meaningful for people. Right. And so, I shifted my career and really tied that into a key focus of what I was doing, especially as I became a consultants. In terms of certifications, I have a master’s in industrial psychology, and a lot of people aren’t really aware of what an industrial psychologist does, but it’s basically a professional who helps organizations develop the systems and processes that they need to enhance their human capital, their people. And what we’ve really learned is that making businesses better for people just makes better businesses. I do work as an adjunct professor. I guess carry my teaching on a little bit in that way as well. I instruct for three different universes. To say it is also very much an honor to be on your show and share some of this information with your listeners.

Cool. So, let’s talk a little bit about fatigue and why we How do you care about fatigue within an organization.

Yeah, I think the best place to start is with probably one of the most famous studies ever done, Looking at Fatigue. And that just notes the impairment that fatigue causes when we reach the higher levels. And this study was done way back in the 1990s, but it’s been repeated so many times since. And in essence, what the researchers did is they got a lot of people drunk. And then once they sobered up, they let them become really tired. They kept them awake for 28 hours straight. And they just compared their ability to perform mental and physical tasks in both of those states. And what they found was that Now, at only about 17 or 18 hours awake, we perform at the same level of impairment as somebody with a blood alcohol level of 0.05. Around 21, 22 hours awake, we’re as impaired in our abilities as someone at the legal limit with a blood alcohol level of 0.08. And at about 24 hours awake, we’re as impaired as somebody with a blood alcohol level of 0.10, which is well over the legal limit. And if you take that information and you put it into a work application and you think about someone who shows up at the workplace legally drunk, you’re not going to give them the keys to the company vehicle and say, Yeah, just be careful out there, right?

But if somebody shows up and they’re like, I’m exhausted. I haven’t been able to sleep. I’ve not slept for several days. We just don’t have that same awareness of impairment and how it can endanger someone. It’s interesting because the National Safety Council has noted that fatigue is contributing to about 13% of all workplace injuries. I mean, that’s a significant number. More than one in 10 likely have fatigue contributing to it. I find that when I work with organizations, a lot of the incidents that are related to fatigue get overlooked. So, companies are really good at figuring out those low-frequency, high-severity incidents. The guy drove off the road at 2:00 AM. Okay, yeah, we get that’s fatigue, right? But those higher frequency, lower severity incidents are often the ones that companies miss entirely if they don’t have fatigue integrated into their incident investigation process. So, these are the incidents that often get reported as work or error. And the key to identifying or ruling out if fatigue was contributing to those incidents, it really comes down to asking the right questions and noting the precursors within an incident to recognize that and fatigue was a big part of that.

And are there organizations that are more at risk? Are there some factors that are more likely to increase the risk profile?

Absolutely. There really are organizations that would be what I would call high risk in terms of fatigue and fatigue-related issues. And I think one of the more difficult safety aspects to thinking about that is that we all know that fatigue involves not just workplace factors, but also personal factors. So, we know that when it comes to the personal factors, it’s dependent on how much quality or quantity of sleep people are getting. Do they have a lot of personal commitments? Do they have sleep-related issues or health concerns or commute a long way to work? But within the workplace, there are definitely factors that influence how high risk a company is. Some of the factors that an organization wants to be aware of, number one, high-risk schedules. Do you have shift work, night shifts, long rotations, long work hours? Those immediately put an organization into a higher risk because you’re setting up a situation where people are likely to become fatigued. Other risk factors, any driving requirements, and whether that’s driving on site, like a warehouse or mining, transportation or long commutes, all of those increase the risk. Physically and mentally demanding work will increase the risk of fatigue, but surprisingly, also monotonous and boring work can increase those risks.

Because if you think about it, when you’re doing something really boring, you start to… Makes sense. Yeah, tired and tuning out. And situations like control room operators, for example, that can be a really big issue. Anything that’s safety sensitive, and I define that really loosely, if someone No one doesn’t follow the protocols and they can get hurt doing it. I call that safety sensitive. High stress environments, especially if you got high demands from clients that you’re trying to meet. And then just general things like lack of breaks or resting areas, chaotic environments, noise, vibration, all of those add to it. And one other thing that often gets missed is the demographic of your workers. So, if you have workers of older workers, and by that, I mean, really, honestly, over 45 doing shift work, that can start to have an impact on how likely people are to be fatigued.

Is there something as well in terms of the types of shifts? Because sometimes, as an example, there’s a six on, three offs where you’re having to do early mornings and switching to late evenings or those types of pieces having a different impact versus four long days. Is that a variable as well to consider?

Absolutely. And in fact, it can be relatively complex to figure the best shift to have in relation to your organization. When it comes to shift scheduling, I often refer to a client who runs the biomathematical research on the existing schedules. But there are some general principles. In general, you shouldn’t shift people backwards. They should shift forwards, so they should go afternoons to evenings rather than evenings backwards. Yeah, other general principles are just keeping the reasonable. We know that after four-night shifts, Workers tend to become more fatigued because we recognize that by the fourth night, that sleep debt is starting to catch up and your circadian haven’t shifted you to the new shift. And a lot of the shifts that do exist, for example, the four and two, four and three, for example, those have been run through the biomathematical modeling to be determined as good shifts for those organizations. So, I would strongly suggest that when a company is looking to optimize the shifts that they have, they run that through the software and really understand where the risks are greatest.

We’ve touched a little bit on some of the patterns that can impact or increase your likelihood of having some issues around fatigue within your organization. What are some effective strategies that you’ve seen in terms of managing that fatigue risk within an organization?

When it comes to managing fatigue in large and even mid-size organizations and high-risk industries, I really have three principles that I apply. The first principle, the first main thing is that the complexity of your fatigue risk management strategy should align with the complexity of your risks and your operations. So, I’m not going to put this big, complex strategy on a medium or low-risk company that has pretty straightforward operations. But if you have really high risk and lots happening in your operations, you are going to need things like what’s called a five-level fatigue risk management strategy, which just has redundancy built into it to help ensure you’re better managing the risk. And to figure that out, I normally just do a bit of a fatigue audit and then provide them a gap analysis. Like, what do you have for risk? What do you already have in place? What are the things you need to add to really make sure that you’re managing that to the best of your organization’s abilities? I think my second key principle is that when you’re doing that overarching fatigue risk management strategy, I can design that for the company, but implementation has to be collaborative.

You have to have input from workers to operations, supervisors, across the board, if you really wanted to integrate and make a difference. There is no one size fits all. Here’s a strategy, everyone uses it. You’ve got to really have the feedback and tailor it to fit what you’re already using for safety strategies. And then I think my final one, and I know our company is a little bit unique in this approach, but I really think you should try to make your strategies quantifiable. And when you do that, you just create a clear course of action for supervisors, workers, and there’s just no guesswork. And I’ll maybe give you an example of that because that one’s not quite as clear. So, Let’s say you have a worker, and they show up, and either they self-identify fatigue or the supervisor who’s been trained, they can see it, they recognize it. First step is quantified how tired you think the worker is, and you do that on a scale. So, you can use descriptive words like a little bit tired or very tired, but you put those on a numbered scale. Next step is you’re going to have a structured conversation between the supervisor and the worker.

And again, every question that the supervisor asks gets rated on a numeric scale. So, it’s not just the qualitative answer, there’s a number. And then it’s really easy to take those numbers and say, okay, well, if self-identification and discussion led to this number, here’s the list of countermeasures that you should be looking at doing. And it could be everything from have someone grab a cup of coffee to take a nap before they start shift to, we’re not putting any safety-sensitive work in front of this person because they’re just not going to be safe doing it. So, when you quantify it, I think it just makes all the decision making so much easier. And those are the three big principles we apply when I work with companies. Sure.

And what are some of the set challenges that you face or that fatigue management approaches will face in organizations?

That’s a really good question. And I think it’s important to think about that when organizations are working to bring in fatigue risk management. Knowing those barriers ahead of time is just really useful in anticipating them and then working to overcome them before they block your progress. Right. Some of the big barriers I see is lack of training. If your organization, and by that, I mean your workers, your supervisors, even your contractors, if they don’t really understand that fatigue is actually a health and safety concern, if they just see it as, Well, that’s part of the job, or that’s what we have to do to get the work done, you’re going to face barriers right off the top. It makes sense that people don’t always see it because as a society, we pay people and reward fatigue. You get paid more to work the night shift or the longer hours. So, we’ve incentivized it. So, it is a little bit of backtracking to say, okay, well, now we see that this creates risk. I think another issue that lack of training is, workers will just have their one or two go-to strategies, and they won’t have a big toolbox of strategies.

I have those one, two that I always use, but I don’t know about all these other ones that could help me better manage fatigue. And then There is definitely the Superman mentality. So, it’s just what I term. I mean, everyone can relate to that concept, right? The workers who are like, I’ve done this for years. I only need five hours sleep. Fatigue doesn’t impair me at all. I’m good. I’m good. I’m good. And research, hands down, shows that over time, the more and more fatigued we are, our impairment does increase, but we become less and less aware of how it’s impairing our abilities. So, it makes sense that people don’t think it’s impairing them, but it definitely is. I think another big barrier that I often see is employers that don’t fully recognize the risks to their organization when they’re not managing fatigue. So, they might not see how it’s impacting things like worker health, which, of course, can impact your worker’s compensation or your benefits and even absenteeism. Of course, worker safety, not always recognizing those incidents, but other areas like productivity or employee retention or even just your overall work culture. Tired and cranky workers tend to create more conflict in the workplace.

It’s not such at the right place to be. So, all of those can have an impact. Right. And I think one of the biggest barriers overall that I see is that, especially in certain industries, it’s simply perception. So, in some industries, it’s acceptable. In things like aviation, for example, or even long-haul transportation, you can pull over and have a nap on the job. That’s all right. But many industries, sleeping on the job is just seen as lazy and incompetent and not acceptable. And this really does bother me a little bit because I think a nap as short as 10 or 15 minutes can help with at least low levels of fatigue. So, letting someone take a normal break that they would already have and go for a 15-minute nap, that might be completely unacceptable. But that same worker could go for a 15-minute smoke break, and nobody has an issue, right? So, I think challenging those perceptions that people have about sleep and napping on the job, that’s a really big barrier to be aware of.

And we’ve talked about this before on the podcast. Are there ways that you’ve seen that work? For example, in tech, they often will have an official nap room, or they’ll have special chairs that encourage people to nap that essentially are helping create a new paradigm around What is acceptable here?

Absolutely. Yeah, there’s physical changes you can make within your work group, within your work environment, for example, napping rooms, as you mentioned, or even treadmill and ways for people to stay active if they’re in a control room environment, for example. But I’ve also seen companies that go ahead and put in these napping rooms, and no one uses them because it’s still the culture that it’s not really that acceptable or who are you to have to go for a nap? The rest of us are just fine. And so I think influencing the culture is really your biggest one, making sure people are aware of why we care and why we want to manage it. But there are a lot of things environmentally, so napping rooms, but also lighting, ergonomics. There are many things you can do that will reduce overall fatigue people are feeling.

This episode of the Safety Guru podcast is brought to you by Propulo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at

Are there differences by industries that you’re seeing in terms of strategies that do work around fatigue? In some environments, it’s a legal requirement. You talked about long-haul trucking as an example. There are requirements around rest and up that are legislated. What are some of the practices you’ve seen around by industry that work well?

I think one of the reasons that fatigue is often under managed in a workplace is that with the exception of only a few industries like transportation or nuclear, fatigue is just not well regulated at all. Sure. And even some industries that do regulate it, like ground transportation, The legislation isn’t always aligned with what we know about human fatigue and circadian rhythms, and it can sometimes even inhibit the ability of people to manage fatigue in the work, right? So, although if the legislation is really good, it isn’t a catch-all. They can still have issues in those industries. But employers in other industries where there’s no legislative framework around it, they have to really go above and beyond to fully manage that risk. And I mean, a big piece of that comes down to recognizing how it’s impacting your company and some of the negative impacts you’re already having in terms of safety and health and whatnot. Employers that do bring in comprehensive fatigue risk management, they’re really choosing to do so based on their understanding of reducing risks. So, reducing safety risks and recognizing the financial advantages when they increase worker productivity and retention and overall worker health.

OSHA really overall for most industries, rather than setting legislation, they just have recommendations when it comes to fatigue management. And of course, And one of their key recommendations is providing worker training and education so that people are at least aware of the hazard. And to me, that one makes a lot of sense. We train on so many hazards in the workplace, and yet I’ll go into high-risk industries and high-risk schedules and say, When’s the last time you did fatigue training? And they’re like, oh, I don’t know. Maybe 10 years ago, we talked about it. It’s funny how that one just doesn’t get trained on the level that people should be aware if they’re dealing with a hazard.

I think you touched on a point there in terms of the legal requirements. The legal requirement is the minimum requirement. But as you said, they’re not always designed with the best medical guidance and advice. Sometimes you can rest on saying, I’m meeting the legal requirement, but it doesn’t mean you’ve eliminated fatigue. It’s how do I go above and beyond? As you mentioned before, there’s a lot of very negative incentives Overtime being one of them, and how overtime gets allocated, specifically in some industries, where I remember we talked in a prior episode of this podcast, even in healthcare as an example, that in the UK, they legislated how many hours people could work, but it didn’t stop the extreme overtime that was occurring because the incentives are still there. In some cases, some industries, when you’re getting to double overtime, triple overtime, it can be very lucrative to work those long days and risky.

Yeah, I couldn’t agree with you more. And sometimes it’s not even the employer that’s putting up the barriers in terms of fatigue management. Sometimes it’s the union or the workers themselves. I’ll share a quick story about that. I was doing some work up north in the Yukon, actually, and I was working at a mining organization and doing some training. And I walked in the door and the head of the union for the miners walked up and said to me, Lady, because it’s a mind, and he goes, Lady, if you’re here to tell us that we have to change our shifts, we’re walking every last one of them. And I’m like, Okay, it’s all right. No worries. I’m just here to share some information, do some training. And so we did the training. And as bad luck, I guess, would have it, they did have a fairly major incident and one that could have caused a lot of fatalities. It was pure luck that it didn’t cause fatalities, and they could recognize it completely as caused by fatigue. And so, I went up to the mine about a month after this, and the exact same guy, Frank, I’ll never forget him.

He walks up to me, and he goes, Yeah, okay. We’re open to some conversations. So, I think The training can just play a really big part in that. It’s not going to overcome the lack of legislation and certain industries. It’s going to take a lot of work to really move that culture forward to recognizing and managing fatigue. But I do think getting the information out there is a great way to start.

It’s also a topic that we’ve never learned. You don’t go to school and learn about how to sleep. You don’t hear or learn about this as you your career, except in some industries. I started in aviation, and in aviation, there was a lot of focus around fatigue, mostly around managing jet lag. And doctor would come and present and teach, and there’d be very practical applications around it. But in most other industries, nobody comes to talk about sleep, fatigue, and managing it.

Yeah, you are 100 % correct. And it’s interesting, we talk about the three pillars of health, those three decisions that we make every day that it has such a huge impact on our health and wellness. And the first, of course, is nutrition, and the second is exercise, and the third is sleep. And we tend to know quite a lot of information about nutrition, and we know the latest hit workout and running and all of that. Tons of information on exercise. But yeah, sleep is just not as well known in terms of the science behind it and the things that can help us sleep better and nap better. And yeah, I agree. It’s really one of those areas that we haven’t tapped into in terms of awareness and education that we really need to.

And in some industries, I think there’s also some reluctance to address it because you’re starting to touch the out of work environment, starting to start reaching into your home and how you rest and the home circumstance. And I know for some executives, that can be a scary piece because it’s one thing to control the work environment at work. But here, sleep is not something you normally do at work unless you have nap time.

Yeah, absolutely. And it’s a little bit like a lot of human risk factors. It’s that Squishy part of safety. It’s hard to put together a perfect SOP that’s going to manage all those risks. You can do that when you’re looking at confined space and working at heights, but fatigue is just not that easy. It’s so much more complex. And I think you touched on what is really one of the foundational pieces in managing fatigue, and that is you can’t just bring in a bunch of policies and procedures and expect to manage fatigue in your organization because you’re only addressing the workplace factors. Unless you really engage your workforce and bring people on board to recognize that fatigue is a health and a safety issue that impacts all of us, that’s the only way you’re going to start to have an impact on some of those personal outside guide factors that influence fatigue in the workplace.

Absolutely. Thank you so much, Susan, for coming and sharing some of your experience around fatigue management and how it can be a key contributor to safety outcomes and some ideas around how to make a positive impact in this space.

Yeah, it’s been a real honor. Thank you so much, Eric, for having me on. I appreciate it.

And if somebody wants to get in touch with you, how can they do that?

Absolutely. People can reach out through my email. It’s Susan, S-U-S-A-N, and then, so I-N and then a hyphen, and then Also, our website, which is also You can go there and check us out and feel free to reach out.

Perfect. Thank you so much, Susan.


Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.   

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Susan Sawatzky is the President of In-Scope Solutions, a company dedicated to managing human risk factors or “The People Part of Safety” with a focus on fatigue risk management, stress management, mental health and wellness, enhancing healthy workplace cultures, and psychological health and safety in the workplace. Susan leads her team in providing awardwinning training based on a belief that emphasizes the importance of engaging people with the content and fostering a deep understanding of its relevance to their work and lives.

Susan is an instructor with the University of Alberta, the University of New Brunswick, and the University of Calgary, instructing Fatigue Management, Safety Management Systems, Business & Leadership, Human Performance Leadership, and Psychological Health and Safety, among other courses in their various OHS Programs.

Susan’s specialization in fatigue risk management began over a decade ago when she managed the fatigue portfolio for the Canadian Oil & Gas Safety Association. Since then, she has assisted numerous organizations in conducting fatigue risk audits, developing customized strategies, integrating fatigue mitigation measures into their workflow, and implementing fatigue-based technology. Her clients span through numerous industries all across North America.

Susan is also an international speaker and keynote conference presenter. She has presented for a variety of conferences and organizations with notable clients including the American Society of Safety Professionals, the Global Conference on Fatigue Management, and the National Aeronautics and Space Administration (NASA).

For more information:

Susan Sawatzky, MA Ind. Psych, B. Ed, CRSP, HSA

President, In-Scope Solutions

[email protected]

P: 403-874-8271




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The Power of a Safety Agreement to Boost Safety Culture with Ken Roberts

Dr Nippin Anand_The Power of Organizational Learning



Don’t miss this engaging and enlightening conversation with Ken Roberts, who brings over forty years of rich experience in mining, heavy industry, and construction. Ken shares invaluable insights on how frontline workers can buy into safety by building trust within teams and understanding the profound consequences of their actions. He emphasizes the importance of creating a safety commitment agreement for frontline workers to truly embrace safety in their daily lives. Ken also introduces the concept of ‘Convenience Kills.’ He discusses its stages and explains how organizations can effectively engage frontline workers in a powerful safety agreement to enhance their safety culture.


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Ken Roberts. We’re going to have a fun and exciting conversation. I can predict it based on prior conversations that we’ve had. Ken has a program that talks about convenience skills, a book on it as well. We’re going to dive into it. He’s also talked about something really cool that he calls the agreements culture. Ken, welcome to the show. Really excited to have you with me. Let’s get started with your story in mining and how you got started moons ago.

Wow. Such a great story, too, Eric. So please, hang on to your seat. So, my story started many, many years ago. 1981, I was 16 years old, and I went to visit my friend who lived in a place called Southern Cross, which is a mining town. Western Australia is a mining state. We have the biggest mining company in the world, BHP, pretty well owns us. I ventured to Southern Cross. I visited my friend, and we’re a bit sneaky, you see. I’m 16 years old. He’s 17. We drove to the pub, you see. We’re going to go into this hotel. We looked all of 12, and we walked into the front bar, and we’re sitting there having our first ever beer and looking at each other. The next a minute, this big old miner comes over. Cole, his name was. He had a big bushy beard and mud all over his boots. He comes in, he wraps his arms around us. He goes, hey, boys, you’re looking for some work. I was on school I’m in school holidays, and I thought, Yeah, I’m looking for work. Yeah, that’s us. My little high pitch voice. He’s all right, I’ll pick you up in the morning.

Me and Jeremy were standing at the front of his house, and along comes this old Yuit, this old mining Yuit with the numbers on the side and coal in the driving up. He says, Get in, boys. We jumped in and he threw us a can of Coke. He goes, this is Coke. This is the best cure for a hangover. He took a big swig. That was our first ever safety.

Oh, my goodness. So, we drove onto the mine site, and there I am.

 I’m a 16-year-old in sand shoes and a tank top. And when I’m shoveling, you see, just all day, there’s a hole in a conveyor belt. Rather them to stop and fix this thing, they thought they’d hire me for the day. And I just shoveled all day in this sand, this big pile. I look at the end of the day and the miners come up and they said, Wow, good job. You want to come back tomorrow? And I did that for a week, and they said, would you like a full-time job. So, I rang up Mama, says, Mama, I’m not coming back to school. That’s it. And that was my first ever venture. I was earning more money than she was, and she’s a schoolteacher. Went to university, and here I am earning more money than her at 16. And that was There was no such thing as safety back then. It was more about survival. How do you nimbly get around all of the gear without hurting yourself? So that was my introduction.

I think one of the things that struck me is you said, then safety started coming along, but nobody enjoyed safety. Tell me more.

 Well, we used to have a lot of fun, you see. You could get to the gold room by jumping in the front of the loader bucket, or you could jump into the back of the Yuit. I was driving the Yuit at that stage. I was 6 now. I didn’t even have a license for the road. I remember once I was reversing the vehicle and just being a little bit young, I suppose, and I nearly reversed this thing over the side of the pit. I jumped out and I looked down and there it is, hundreds of feet down there. We didn’t have any wind rose. There was no real signage or anything, and they had to get a loader to pull me out. But it was fun. We really enjoyed it. I used to love going to work, 16, 17. Went underground when I was 17. I remember the first day on the site, I was working around the brace up the top and the shift boss, old Doc Snell, you see, he comes up with his glasses and he says, Kenny, we need you to go down the hole tonight. And I’m thinking, you bet.

 Yeah, absolutely. Go into the changer and grab yourself a pair of overalls. So here I am with these big overalls. I don’t know who they were, and floppy rubber boots. I jumped into the skip, and then he looks at me, he goes, Rob, you’re not 18, are you? And I thought, Oh, that’s it. He’s going to pull me out of the hole. But as I stepped out, he pushed me back in and he goes, no, you can go down tonight, but listen, if you hurt yourself, I’ll bloody kill you. That was my second safety message.

Oh, my goodness.

But I loved it. When we went to work, it was fun. It wasn’t very safe, Eric, but it was a lot of fun. And so, over the years, I’ve noticed that as I progressed and I started getting roles as leaders, supervisors moving up in management roles and safety came in, it was so much more control. The idea of fun, I felt, was being replaced by control.

You then had an aha moment later on in life that really took you from living in a min environment, living around safety, to really having a spark and new ideas when it came to safety. Tell me a little bit about that time.

Well, that was too. So, I’m in and out of mining and construction as well. I got an apprenticeship as a carpenter and then went back on mine sites building. And when I was about 38, I was going through my midlife crisis, as we may Maybe most men do. And I joined a group called the Mankind Project. I did this special weekend, which is called the New Warrior Training Adventure. And it was about having a look at myself and how I was showing up and what were the things that I was doing, and the consequences of my actions were creating a dynamic where my relationship was failing. I had children to two different women at that stage in my life, and I wasn’t going anywhere. I didn’t have much purpose. And I started to see, and they showed me some principles: accountability, personal responsibility, what are the consequences of your actions? These are things I’ve never heard, especially not in the mining game. But I took it like a fish to water, and I really started to look at how I wasn’t taking ownership for my actions. And so, as I became more proficient in facilitation, and I started to get some qualifications in the field.

I really love the idea that I could actually literally change myself through changing the way I felt, the way I thought, the way I behaved, what were the consequences of my actions in my personal life. And as I started getting roles as a construction manager, and I moved into safety eventually, there was the same philosophies could be applied in the workplace. I had work teams that were not achieving any real passion in their work, basically. They were not finding any meaning in what they were doing. I started to apply these personal development techniques, and I found that I was encouraging them to find a little bit more satisfaction in what they do, that they could go home at the end of the day, that their job meant for something, and that they were able to get a sense that their attitude was able to create a workplace which was a lot of fun because we had all these controls, you see. Go out, do your JSA, take time, take charge, take five, all of the different names that we have for things now. But Where’s the fun? Where’s the enjoyment? And that was the epiphany that it was leaving.

There wasn’t any sense of joy in what we were doing anymore. So, I made it an effort to try and bring that back, and I felt it was starting to be recognized as a person who was able to connect more with the work crew. 

And I think one of the pieces that you shared with me before that I really liked is the element of the power and agreements. And We had some really cool stories around how you got people to follow rules that was not the traditional way. Tell me more about that because there’s some really cool elements in that part, and it’s connected to that aha moment you just walked through.

It was definitely in personal development. In the Mankind Project, we do this thing called accountability. Most men end up in situations in their life, and I was one of them, where I didn’t follow through with my word. I would say that I was going to take the kids out for the weekend, but if a good footie match came on, that went by the wayside. Or I promised the wife that I would be taking her somewhere or doing something with her, or even just simple commitments around home. I was never taught. My father didn’t show me these things, and especially not in the early days in the mining. The idea that you can make an agreement, follow through on that agreement, or own up to something when you didn’t keep it. So, we would sit in meetings, and if I arrived at a meeting five past seven, I would be asked by the facilitator, So Ken, what was the agreement? To Are you here at seven? Did you keep that agreement? No, I didn’t. So, what did you make more important? What did you do instead? Where did you think that not keeping that agreement was going to work out for you?

And then the big question, what’s the impact? What was the impact of you not keeping that agreement? Well, of course, I kept the meeting back. Now I’m standing here looking like a fool. I’m bringing shame upon myself because it’s ultimately, what is the impact on me? And so, these questions, they were really foreign to me. So, I used to start doing pre-start meetings. So, team, what time did we agree to be here? Seven, Ken. Cool. So, did everyone keep that agreement? And then a slowly a hand goes up. And I arrived here. And so, I would run that process. And then I started to apply it to things like, say, working at heights. You got a working at heights team. And you’d be, as a supervisor, about to send them out in the field. And so, it’s like, have you got your PPE? Check. Have you got your risk assessments in place? Great. Do you have your training? Have you got your permits in place? And then I would say to them, good. So, before you go into the out into the field, I want to ask you this question. What will be the consequences if I walk out into the field and you’re not wearing your PPE?

And when I first started this, of course, it’s a smile. Oh, we’ll put them back on. I go, Well, no. What if we applied something that really made you think about what the impact might be if we don’t keep this agreement? And eventually, we’d get to a negotiation. We would negotiate terms where they would say back me, all right, if you come out in the field, Ken, we’re not wearing our PPE, we will have to do retraining. We’ll go back and get our working at heights, because obviously… So, the whole goal is to get them to create what the consequence will be up front if they can’t meet the agreement. Now, I can tell you, Eric, over the years, it’s just amazing how we develop this conscience. You say, oh, this is a real agreement. And There’s consequences in place. Now, I really need to keep this. Now, it’s happening like we just did it the other day in the refinery here at Olympic Dab. For years, people have been taking their phones into the tank house. One time, the supervisor said, well, let’s make an agreement here. What if? Because there’s safety issues. If you drop a phone into one of the tanks, there’s an acid reaction.

And also, so texting your girlfriend while the overhead crane’s rushing around is not really conducive to your own self.

That’s a good idea. 

Good idea. So, we just made a… Just called it out. So, what are we going to do about the phones? And one of the guys standing there said, well, you know what? We’ve been banging on about this for 20 years. If you take your phone into the tank house and somebody sees you, it’s a written warning. Now, I was a little bit thought, wow, that’s pretty harsh. You’re going for the joke here. But everybody agreed. They said, yeah, you’re right. Why do we keep going on about this? So, we got a little note, a texter, got it out onto the whiteboard and we said, so it’s with the team, the negotiator’s no phones in the tank house, consequences, written warning. Now, that was months and months ago. We have not had this issue yet. We’ve seen it yet. But people start to develop the idea that this is an actual, really clear engagement with each other, and it builds trust, Eric. We have now built a level of trustworthiness. I myself am trustworthy. I can keep agreements, and I also trust you because you can keep agreements. Its just personal development introduced into the workplace.

I think the magic of this is you’re co-creating Most organizations, they go straight to the consequence, but it’s not co-created with the employees, and so they don’t feel a commitment to it, and then they fight it, union grievance, et cetera. But here you’re getting them to say, okay, what are we going to do? What’s the consequence? Getting them to create that buy-in, that commitment. And 20 years couldn’t get it right, and now you can get it right. Simple change. 

It is a simple change. Well, we used to make up the consequences, you see. Some leaders, and I included, we didn’t have really clear expectations. They’re ambiguous. They’re gray. Do you have rolled up sleeves? No. Our letter of offer said you’d wear your PPE in a certain way. Rolled up sleeves is not really to do that for reasons where it can get caught in machinery and things like that. But people still did it. When we started making agreements, Okay, PPE. Let’s make an agreement here. And who agrees that we’ll keep our sleeves rolled down and wear our PPE as designed? And when everybody says, Yeah, okay, but this negotiation, some people will say, well, look, I’ve got to go into this part of the area where it’s really hot and I need to somehow get some personal comfort. So as a leader, I might be able to negotiate. All right, well, let’s put a risk assessment in place. What will you do with the sleeves? Well, I can wrap some tape around them. So, we’re actually talking about things now that we never used to talk about. They would be expected or implied around things because we’ve opened up the idea of negotiation.

 The work crew now have a say in the decision making. I think that empowerment has given them some ownership in their work tasks that they never had before.

 It’s backed by research. If you look at the psychology of influence, it highlights the very same concepts you’re talking about in terms of get people to put skin in the game, and they’re more likely to follow through.

 Well, and I think we should be extending this more than safety. What are some other aspects of a culture that are really important? Trust, not being talked down to. We I encourage people to speak up all the time. But sometimes when they do, we’ll say, well, let’s not talk about that now. Some leaders find that they lose control when people speak up. We’re trying to teach the leaders now that if you’re in a pre-start meeting and you’ve particularly asked, all right, team, any agreements to discuss? And someone will pipe up and say, Yeah, I’ve got one to discuss, and they might get a little hot under the collar. Well, they’re invested. They’re engaged. Why would we try to block that down? I encourage him to come out, vent his feelings, a bit of silence, and say, okay, so what’s been the impact for you, man? Tell us. Underneath the emotions in any workplace, there’s always an impact on somebody, and we really go there. But that impact is psychological, could be physical. More often than not, it’s about a person’s belief about themselves. And quite often, safety doesn’t allow that belief to come out.

 Everyone has to act the same way. I remember inductions in the early days. No common sense in the workplace. This idea that you don’t think for yourself, just follow our procedures and you’ll be safe. I’m bringing it back, you see. I want to bring common sense back. There’s going to be a renaissance in common sense.

 The worst I ever heard was, I’m only paying you from the neck down.

 Yes. I used to hate that one. And you think about an induction room, right? You’re sitting there in a classroom. There’s a row of desks. You’re sitting there, you got a pen and paper. And what do you do? You do a test. I can think of better ways to do inductions.

 So, if people commit and they come up with their rules, have there been cases where people break those commitments? And then what happens?

 Well, we’re human beings, aren’t we? Yeah, of course. The process is two-pronged. So, you have to be able to set an agreement. That’s fine. How do you reset one? How do you allow human fallibility? I said it, Eric. You see, human fallibility in the workplaces is a foreign word. You can’t make a mistake. And especially in mining- We all make mistakes.

 When have we not make a mistake?

 How do we create a workplace where mistakes are part of the deal, and we are able to create a space where… Because I’ve been in the I’ve been in pre-start meetings where I’ve been in the work crew and someone’s had an incident and in comes a lead and say, Right, you broke the bloody lost time injury frequency rate. Now we’re bugged. I don’t want to see any incidents today. I got to… And this idea that we don’t. Yeah, it doesn’t. And so, the agreements model allows somebody to stand up and own something, but we take the energy off the person. And the way I’ve been able to do that is with the work teams and the leaders, we create what I call culture goals. What are the things that you’d really like to see in the workplace? Now, I’m a little sneaky. What I do is I meet with the work crews, and I say, What’s so stuffed about this place? What don’t you like? What is it about coming to work that’s restricting you from, I believe, finding some meaning in your work, finding that you are appreciated for and valued for what you do, and that there’s some sense of fulfill at the end of the day.

 When we flip those, then it’s usually about we create a workplace where you can speak up, where there’s 50/50 respect, where our voice is heard, we have a say in the decision making. And these are really common themes across most workplaces where we do this process. Now, if I put that culture goal and I write it up and it’s sitting there in the pre-start room, now what mistakes or even misdemeanors are based against is not about me and my character, but about how are we not fulfilling our culture goals, which we created as a team. Now what we can say is, so did you keep that agreement? Yes, or no? Well, what was the impact on our culture goals? When you take the energy off of the individual and it stop blaming them for their behavior, there’s another one, you see, this idea of behavior in the workplace. Don’t get me started on that one. See, behavior is something that’s instinct. It’s something that’s evolved through generations. But conduct, we have control over. So, I prefer to call it conduct-based safety, to be honest. But when you’ve got the culture goals up there, now we can say, all right, so do you believe in the culture goals?

 Anything we have to tweak? Is there something about it that you haven’t bought into? And most times I say, no, I’m just being human. But here’s the deal. What was the agreement? I didn’t keep it. No. What I made more important was this, and I see the impact it has had on you. I want to get back into, say, integrity or back into agreement with the team. And I’d like to reset that. Would everyone like to support me? Now that’s clunky. They don’t actually talk like that. So, I’m paraphrasing. But the energy is, if we want to be able to, you can see my picture of the hill at the back here. The idea is that we’re all trying to get into a sense of teamwork. And teamwork is allowing people to make mistakes, allowing people to find their trust again by remaking agreements. So, it’s not about punishing anybody. It’s not about picking faults with somebody’s personality or their behavior. What is the agreement to the culture goals? And would you like to maintain that? Yes, we welcome you back into the fray.

 This episode of the Safety Guru podcast is brought to you by Propulo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at

 I want to pivot to convenience skills. But before we go there, you met somebody who’s been on this podcast before, and not because of this podcast, but you had an amazing encounter and a great aha there as well. Tell me a little bit about that.

 You’ve met him, Theo Venter.

 Yeah, Theo.

 That was an amazing experience for me. I was working with a company that was having some problems with their safety on a BHP site, and I’ve got a lot of experience with BHP, 25 years, in fact, as a consultant through basically every mine site that they operate in Australia, from BMA to Iron Or right across Nickel West and now Olympic Dam. I remember they said, oh, we’re going to bring this speaker in to help you, Ken, with the culture. I’m going, Yeah, that sounds great. I sat at the back of the room, got my laptop on my knee. You see, I’m arrogant. Theo started talking, and then slowly my laptop comes down. He really grabbed me with his story. He was up in a work basket, and he took his gloves off to access a 10-millimeter nut. But at that time, you see, I had investigated hundreds and hundreds of incidents, and I kept seeing this pattern in every single case, bar none. There was this idea that right at the moment of impact, a work crew were trying to get the job done. It’s like our biology. See, it closes everything out. We just focus on, here’s a task.

I’m really challenged. I need to get this job done. What do I got to do? Get this job done. And so, the idea, am I going to go back to the workshop and get a ladder, or am I going to stand on that drum? Am I going to crimp this hose and just quickly change the tap off at this nozzle over, or am I going to go back to the tap and turn the tap off? And here he was, living proof that this idea I was thinking of, convenience. The idea that convenience is the root cause of all workplace incidents and accidents had been shown here right before my eyes with this guy called Theo. So, I went up to Theo afterwards. I said, Theo, we really need to talk. And he’s thinking like, yeah, I get this all the time. I go, no, no, we really need to talk. And he says, well, he’s looking at his watch. Sorry, but I’ve got to be out of here. I’m going to see to this remote mind site in the middle of nowhere. I need to get going. And I said, oh, yeah, me too.

Where are you going? He says, Rocks be Downs. And I said, I live there. And he looked at me and I said, well, this is serendipity, isn’t it? So, he went on one flight. I was on another. We arrived there two days later at the Rocks by Tavern. I said, Theo, I know why you took your hands out of your gloves. And he goes, Yeah, looking sideways like, where is he taking this? I said it was convenience, wasn’t it? You could have gone back to the yard and got a tool, or you could have turned the power off, you could have I’ll go with the basket and check the risk assessment. But right in that moment, what was the most convenient choice for you? And he said, Yeah, it was. And his eyes lit up. And we were silent for a while. And I said, We’re onto something here. Why don’t we join up and write a book? And so we wrote Convenience Kills together, and the rest is history. It’s starting to really make an impact. It was mainly because of a chapter in a previous effort I had called Convenience Kills. People were talking to me just about that a lot.

They’re saying, Ken, this thing about convenience, you’d so right. I remember my phone going off in my car, and I was just about to reach over to answer it while I’m driving. I thought, Oh, yeah, convenience. Convenience kills. So, we had to take note. And the impact it’s having now, we remind work teams before they go out in the field, hey, be careful. Convenience will lure you today. It’s in your biology. That’s why we have the wheel. That’s why we have refrigerators.

Theo’s story, for those that haven’t listened to that episode, is basically he was doing electric work, and you always do it with big rubber gloves when it’s energized. And literally, there was a bolt that he couldn’t just get quite right and took one of the gloves off just for a second. But that particular part should have been safe. And if I recall, it just slipped a little bit, and then he made energized contact, 22,000 volts going through his body. In the other part that was interesting is, I think it was a week or a couple of weeks prior, he had seen somebody else for the first time break the cardinal rule of doing work without rubber gloves. So, he had also gotten a signal that maybe that cardinal rule is not as cardinal as I think it is.

Well, I’ve done a lot of asking. I would catch people immediately after an incident, and I build trust and rapport with them. And I usually say, look, I’m not here to ask you about this, not about investigation. What I’m really interested in is what was going through your mind immediately prior to the impact. And time after time after time, again, they would say, I just needed to get the job done. So, I’ve discovered that in the heat of the moment, all of a sudden, our brains, our biology, are absolutely determined to get this job done. We call it Swiss cheese model, and we’ve got all sorts of behavioural-based ideas about why a person takes a shortcut. But I found it is because there is no other thought in our mind in that moment. In Theo’s story also, you expand that. He covers so many different layers. Agreements. He had an agreement with his wife that he would look after himself, had an agreement with his father before he came to South Africa, that he would make a fist of it and not stuff this up, as he said. So, the agreements model was reflected a lot in Theo’s story as well.

 And trust. He was there, he was going to… He’s sitting there and he’s got a black mark around his arm. And he asked, what’s that for? And we’re going to have to amputate. And they’ve come at him with five signatures. You see, they’re all signed except the fifth one. It was his signature thereafter. And he’s going, no way. But before he goes under anesthesia, he pleads with the plastic surgeon, please, Dr. Ann Newey, who he now has a great relationship with. He had to trust it as he fell under anesthesia that he would do his best to save his arm. He wakes up in the morning, here, shake on it, Theo. Trust, I think, is the glue that holds any workplace together. I’m worried that safety has become more important than trust. My feeling is if we can build a workplace where we keep our agreements, where we’re able to show trustworthiness, and we have camaraderie at a deeper level, deeper connection, the safety would naturally take care of itself.

You talk about convenience skills. You’ve got a culture hill that comes with it. What’s the impact of introducing this concept that convenience can kill? How does it help a team member?

What I’ve been able to do is I went back to the science. I felt that if you have a look at the basis of agreements, it’s on the consequences. What are the consequences of any action, especially of not being able to keep a commitment? And so, the model that I’ve been following for a long time was called OARBED, O-A-R over a line, B-E-D. And I think Robert Kiyosaki and the well-known proponents of personal development used this, the O stands for ownership, A for accountability, and R for responsibility. And with the line, to stay above the line, you would have heard that concept, means that you don’t go to blame, excuses, and denial, bed. And so, I’ve been using that for a while, but it just wasn’t… There was no traction. I’m trying to introduce it to work crews. And basically, people say, what, you think that I’m not accountable? So, they switch off. I heard somewhere, I think it was on YouTube, a guy was on a video, and he said, Why all bed doesn’t work is because if you’re above the line, you’re good, and if you’re below the line, you’re bad. I thought, that is so true.

Here I am promoting the idea that we don’t accuse a person’s behavior, take the shame off that so that they can take ownership. No one’s going to own anything if they have punishment for doing so. So what I did was it came to me, a guy here on site, Kenny Manumea, was a manager who first employed convenience skills. He was the first one to see it with work with his work groups. And he introduced me to tribal leadership and the idea that there are five cultural stages. And I got that idea and I thought, so it goes from stage one, which is life sucks. Stage Two is this suck, or I suck. And then it goes through stage three, four, five until you get to a life’s great culture. But I turned it around to using Australian cool localism. And that’s stage one at the bottom of the hill is it sucks. It’s a person who says, you know what, just pay me the money. I’m only here because I have a mortgage and I’m not really bought into this. They probably have low self-esteem. The idea of agreements and keeping commitments wouldn’t be high.

And basically, from the Orbed model, blaming other people, having excuses, and denying. The thing about this model, though, is at stage one, if your HR department has done their job, we don’t really bring those people into the organization. But occasionally, even I go there, this place sucks, but we can jump out of it pretty quickly. The next stage on the hill, I call nothing changes. Now, this is a clique of people who quite often will engage in conversations talking about how this place never changes. What are they bringing in that for? Not another one. Gee, we tried that last time, and it didn’t work and not going to work this time. Now, they take up quite a chunk of energy in a workplace. The problem for a leader is the moment you engage at that level; you’ve lost the mantle as a leader. At the top of the hill is a person standing there, hands in the air. I’m great. I made it. I took the ownership. I was accountable. I call it agreements. And I changed responsibility to respect because I felt that respect was probably ownership, accountability, responsibility mean the same thing. 

So, I changed A to agreements and R to respect. The problem with the person standing at the top of the hill is, there’s still a lone wolf. It’s like, I’m here. I made it. I’m good, but you’re not. Because I’ve got things. I want to go places. I’ve got progression. But it’s a necessary stage, you see. But at the top of the hill, at least you can become a leader and you can say, hey, my attitude, my mental approach to being in this workplace was able to create a level of stability and leadership for you to follow. But if you’re a leader and you go back down the hill and engage with people that nothing changes, you might be there, look, I’m going to introduce something, but it’s not going to work this time, and you join into those conversations. You have basically diminished your role as a leader. So, we say this, if you’re a leader, you can’t ask anyone follow you if you’re not at least at the top of the hill. So, I remember when I said this into a supervisor’s workshop I was running, and I remember one guy, Ryan, he’s sitting there, his hands between his knees.

I go, Ryan, what’s the matter? And he says, I just led a priest start meeting from the bottom of the hill. And I went, yes, you’ve got it. And so, they all made an agreement with themselves. Why don’t we just, if we’re not at the top of the hill and we can’t get ourselves up there, let’s ask someone else to run the meeting for us. So, this concept that our own personal attitude and our own demeanor can affect the rest of the work team is so important. It’s about taking ownership of my own attitude, but especially as a leader. And then, of course, the moment I reach down the hill and drag a few nothing changes up, I’ve jettisoned myself into were great. The idea that as a collaborative organization, the teamwork, it always feels more empowering than doing something on our own. We’ve got the model up on all the pre-start meetings now, and it’s really simple. Hey, team, where do you think we are on the hill? And now you have a visual, immediate, real-time, finger on the pulse. Oh, this is where the culture is right now. And a lot of people will say, Gee, we’re right down the bottom there. 

Now they’ve got an opportunity. How do you correct it? It’s simple. The signpost says ownership, agreements, and respect. Obviously, if we were blaming others and we’re not taking ownership for the consequences of our actions, obviously, it’s going to throw us down the bottom of the hill. But now you have a visual representation. I don’t think that’s ever been done before.

What I love is it’s in colloquially speak, it resonates with the frontline team members. It’s not an academic model. It’s really to drive that conversation you’re talking about with the team members in terms of where we are and how do we need to show up differently, reframe the current state to address this.

Yeah, and I’m trying to take the stigma off it. It’s no longer above or below the line. I don’t know if I can say this, but I can say it like this. If you’re on the left-hand side and you’re at the bottom, you’re pushing it uphill. If I’m in a pre-start and I’m saying, who needs support? I don’t know what it’s like where you Eric, but in Australia, that’s a little bit… It’s not real. That’s not how we talk. But if you say, who’s pushing it uphill? Yeah, that would be me. Great. Who needs a hand? Yeah, it’s very Australian. But if we talk in the language that’s not condescending. I think safety can be condescending. I think not because we want it to be, but we have so many rules and we have so many expectations, and they’re necessary, totally necessary. I’ve been in safety for over 20 years. I absolutely buy into it. But how do we do it in a way that is natural and as part of our culture? Brings me to the next point, which is- Go ahead. Who believes in it? Safety. You see, 40 years in the game, one of the things that I just can’t get my head around is, I’ve asked people this all the time, do you enjoy safety?

Do you believe in your safety system? I have never met one person yet in my 40 years of mining and construction and heavy industrial, put up their hand and say, yes, I believe in it, or yes, I enjoy it, probably because of my culture. But why I feel it now, my voice has changed because it really affects me. How is it that we’re not buying into the one thing that’s absolutely there to save our lives, that’s there to keep us out of harm’s way? And so, I’ve dedicated my life. My passion and my purpose are to bring back that joy I had when I was a young man but do it safely. How can I create the empowerment that I had that I was making my own decisions, but now with the insights that I have as an older person, an experienced person, how can I still have that joy with the idea that safety is absolutely necessary to keep me out of harm’s way? I think if we find that answer, we will all be billionaires, but it’s so important that this changes. I can’t wait until I have a team of people who say, we love safety.

We love our safety, man. It’s cool. You should see what we’re doing with our safety. And they might be terming it like psychological safety, which I believe is more important than anything. If I can be psychologically safe, I will be empowered to keep myself physically safe. I think that’s a really important It’s an important point. 

I love the topics you introduced. I think the power of the agreement is something that we often miss. And I think this element of going straight to consequence blame or punishment, as opposed to saying, how do I lay the foundation so that we don’t end up there? I think that’s a very powerful, simple thing that anybody can implement. It doesn’t take a lot, just how you frame things as you start. Then the other one is really in terms of this element of convenience and how do you relate it to Kraft employees in terms of simple constructs, simple ideas in a way that they speak, but also highlighting when you’re stuck Back in that moment, Theo, I remember, I just needed to get the bolt on. But he could have gone down, he could have done in many different ways, but it’s just that moment, tunnel vision of I need to get this done that can get you in arms’ way.

Well, I call it the backstop. If you are in what I call the heat of the moment. Now, things are great when you’re in the pre-start or in the crib room and you’re writing your risk assessment. Yes, if this happens, we will do that. Yes, we have this control in place. But in the heat of the moment, when everything changes, what’s going to kick in? And I believe that that is a deeply invested engagement with your work environment before you go out and do the task. When my mind is totally focused on taking that nut off, when is it that my biology will then ask me the question, is this in line with my principles. So, we rarely have our principles worked out in advance. That’s why I go with the culture goals. We create a workplace that empowers communication, camaraderie, respect, and the idea that we can all speak up in the workplace without recrimination. Now, if that was my mantra, I think I’ve got a better chance of being able to process what I’m about to do that could be dangerous through that prism. See, here’s the thing about Theo, and I think this is really important, and this is why the Culture Hill works.

Theo is up in the basket. Nico has a go. He can’t do it. But see, Theo is the go-to guy. So, you always go, Theo, you have a go, mate. They swap over. Now, Theo is there. Nico is in the basket right behind him talking to the safety observer down the bottom, right? Now, if I’m a lone wolf, and I’m even… This is the dangerous part about being at the top of the hill. I’m good. I’m going to say, I’ve got to get this nut off at all costs. It’s up to me. I’m the go-to guy. I can do this. What if this had happened. What if the prism was, I’m in a team, we’re great together, we collaborate, we can solve these problems as a team. All Theo had to do is elbow Nico in the ribs. Nico, you think I should take my gloves off. You think about that moment right there. So, you’re either going to be the lone wolf or you’re going to be in the wolf pack. Now, that can only be determined by the culture of your workplace. If you create a wolf pack mentality where collaboration is key and where you can work together and solve problems together, and that you are empowered to have a say in the decision-making process.

So, People won’t feel that. They won’t be empowered to speak up, and they won’t be empowered to use collaboration and teamwork unless they feel like they have a sense that they were part of the decision-making process. And That’s where the agreements come in. Team, any agreements to discuss? That sentence there is my purpose. If I can get every single pre-start in the planet, just kick off their pre-start meeting with team, any agreements to discuss? You think about that. Now everyone’s invited to talk about their culture. Yes, I’d like to raise something about respect. Or yes, I’d like to raise something about the housekeeping. Or yes, I’d like to raise something about that I don’t really understand the task I’m about to do. To be empowered to have a say is about what is the basic agreement that you have a voice, you can speak without the fear of recrimination, that your part of a team, and what you say matters to us. If you can build that and get that culture happening, and we’re starting to see the green shoots of that now, where everyone has an equal say just in that moment, that first 20 minutes at the start of the day, now we can start to create a place where safety is elevated because of the collaboration.

No more lone wolves. Sure. Most incidents are caused because of the lone wolf syndrome. I’m on my own. I can do this. I’ve got to get this done, as opposed to, what would the team think if I did this? I don’t know of any other method that can appeal to the subconscious and conscious minds in that way, because it appeals to us that we have a say.

Ken, thank you so much. This has been a really fun conversation. Somebody wants to get in touch with you. You’ve got your website, Any closing thoughts? I love your storytelling today.

The closing thought is If we can create more enjoyment in the workplace, we will get more engagement. If we can create more engagement, we’re going to be able to have people who buy into our systems and buy in. See, the reason why they’re not bought in is because they haven’t been able to raise the parts that they’re not bought into so that they can be resolved.

Excellent. Thank you so much for joining me today, Ken.

You’re welcome, Eric. Thank you, listeners. Looking forward to the next time.


Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.  

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With over forty years of rich experience in mining, heavy industry, and construction, Ken Roberts is a pioneer in transforming workplace cultures. He is the creator of the ground-breaking ‘Convenience Kills’ program, designed to move cultures from being convenience-driven to being consequence-driven, through his innovative “Agreements Culture” formula, which promotes voluntary accountability and ownership. His extensive global experience in enhancing safety cultures directly tackles key workplace challenges like low morale and conflict, fostering a sense of camaraderie and empowerment within teams. Ken’s dedicated efforts significantly boost safety, productivity, and leadership effectiveness, leading to profound improvements in organisational dynamics and outcomes.

For more information:


Transfoorm™ Culture Hill

The Culture Hill illustrates the progressive stages of cultural development within an organisation, with each stage representing a significant shift in attitudes, behaviours, and shared values. It is inspired by the ‘Tribal Leadership’ model from Logan, King and Fischer-Wright. Here’s an explanation of each stage depicted in the image:

Culture Hill by Ken Roberts

LH Signpost – Blame, Excuses, Denial: This phase is located at the base of the hill and characterised by a culture that deflects responsibility. Instead of taking ownership, there’s a tendency to blame others, make excuses for failures, or outright deny responsibility. It’s a reactive stage that hinders growth and learning, where individuals avoid accountability.

  • “It sucks”: These individuals embody the LH signpost showing little to no enthusiasm for investing the effort needed to overcome the cultural obstacles before them. They resonate with the inefficiency of their current circumstances. A notable absence of dedication to transformation is present, with the dominant mood being one of discontent and a resigned belief that the existing conditions are permanent. Either HR didn’t do their job or that signpost needs to turn into an exit door.
  • “Nothing changes”: Further up the hill there’s dissatisfaction that company inaction is responsible for their inaction. “Nothing changes” is marked by frustration, as there’s awareness of the need for change, but either the pathway to change is too hard, been tried before but failed, not expressed in terms of the work crew’s values, or there’s an absence of momentum or support to make it happen. Arms folded they form cliques to reinforce their paradigm and make them right.
  • “I’m good”: Reaching the peak of the hill signifies a moment of self-realisation and positive affirmation. When asked how they are, the response is always “I’m good.” It’s here that individuals start to recognise their own ability to effect change, marking a turning point in personal accountability and a shift towards a more proactive and positive attitude. If there’s any downfall it’s the difficulty to shed personal achievement and accolades aside for the benefit of a collaborative effort. 
  • We’re great”: Coasting downhill now, the other side of the hill represents collective achievements. “We’re great” signals a culture of collaboration, mutual support, and collective accomplishment because it feels better to share the experience with others. It represents a proactive, positive culture, where the focus is on shared success and ongoing improvement. The moment someone turns to help others up the hill from the “I’m good” stage, their effort is met with a sense of purpose and meaning.

RH Signpost – Ownership, Agreements, Respect: At the other side of the hill, these elements reflect a mature culture where individuals and teams have taken the journey through the various stages and emerged with a strong sense of ownership over their roles and actions. There’s a commitment to living up to the agreements made, and a deep respect for one another that permeates the culture, contributing to an environment where individuals are valued and accountability is a shared responsibility.

The terms “Convenience” and “Consequence” at the top and bottom of the image respectively, illustrate the choice between the easy path of short-term convenience, which leads back to the base of the hill, and the path of understanding and embracing the consequences of one’s actions, which leads to the summit and beyond into a culture of collective excellence.

In essence, The Culture Hill is a metaphorical journey from a negative, reactive state to a positive, proactive culture that thrives on ownership, accountability, and respect.




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Safety Is All About Learning with David East

Dr Nippin Anand_The Power of Organizational Learning



Join us to explore the profound lessons and our understanding of safety in high-risk fields with our special guest, David East. In this episode, he brings his deep expertise in Human & Organizational Performance to discuss critical risks, learning from incidents, and the interconnected factors behind them. Drawing on examples from aviation and his experience in the Royal Australian Air Force, David shares his insights on transitioning to a learning zone, emphasizing that safety is all about learning. Tune in to gain valuable insights!


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now. 

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me David East. He’s an Air Force veteran from the Royal Australian Air Force, as you’re going to hear from his accent very soon, has made a career out of it, but also a huge thought leader in the human factors, human performance space, and hop. So, David, welcome to the show. Very excited to have you with me. 

 Good morning, Eric. Thanks for having me, mate. 

 Great. Let’s start out by your passion in safety. How did it start? Where did your journey begin? 

 Yeah, my background. I joined the Air Force in the mid ’90s as an aircraft technician. I’ve been working around planes my entire career. I worked for 10 years fixing planes. Then I changed over to crew as a flight engineer and a load master on C-130s. Now, my safety journey. It has been an interesting one because when I was young in my early 20s, safety was the furthest from my mind. I don’t know how I didn’t hurt myself more than I ever did. I got through it pretty well, injury-free. But as a young fellow, I didn’t really care too much about safety and just did what I needed to do to comply. It wasn’t until I became an expert That I really started thinking, All right, now I’m in the back of this plane a lot. I have a lot to do with the outcome of this flight, of what we’re doing. I better start paying some attention. But the critical thing that happened to me was I became a human factors instructor, well, facilitator. I was put through the human factors course. Back then it was called CRM, the crew Resource Management. Now we call it NTS, Non-Technical Skills. 

That really got me on the road to safety. It’s all about education. Now, how have I gotten to the point where I’m super passionate about safety? Just realizing some gaps within the workforce. They’re not big gaps. It wasn’t because people didn’t care. I was able to influence people in the safety space and the human factor space, and I enjoyed it. I started my side hustle, and I still do a lot of work within the Air Force around safety. I just find a passion, and it works. 

 One of the things we’ve had several guests come on the show with background in Aviation Air Force. One of the things that I know when we first spoke is you really advocate for a more proactive approach to safety, which I think is so critical. Tell me a little bit more about how we learn from events, but even before an incident happens. 

 Learning from events, that’s really important, isn’t it? It’s the fourth principle of learning and improving is vital. Within defense, everywhere that you go, pretty well has a pretty good safety suite on their software system. Defenses are really good. We have a very good We report everything from the very serious incidents right down to the miners. That safety suite is fantastic. It’s got a lot of data in there. But how do we learn from that? But actually, I From time to time, I have an issue with how we learn from that. Because often what happens is the safety representative within your workplace will normally just send an email. But here’s the critical safety events that have This occurred this month, this quarter, this year. We are supposed to then just read that email and glean the lessons learned from it. I don’t find that as a very good way to learn at all. I think to learn in the safety space, it really is about face-to-face. You’ve got to get face-to-face with people, whether it’s a facilitated session or just having conversations in the crew room with other workers, other people, and just start talking about incidents and see where the conversation goes. 

 That’s where the real learning happens. That, I often find also doesn’t happen as well as it used to, especially around the junior. In defense, we call it we’re all aviators. We run around the junior aviators, that crew room discussion on safety topics just doesn’t happen. We’re generally just learning by osmosis through one or two courses where we learn one or two case studies. And that’s about it. I like to keep the risk conversation alive. Matt Confer from corner industries in the US. He’s coined the term sticky, which is stuff that can kill you. And that’s fantastic. If you go to junior aviators and say, all right, let’s talk about the stuff that can kill you while you’re doing this job, while you’re out there on a Hercules doing an engine change or whatever job it is that you’re doing, what are the risks? What can kill you? A lot of young people, they don’t know. They’re like, oh, I don’t know. You’ve really got to drive that conversation, haven’t you? But once you get them used to those conversations, let’s have a sticky conversation. They understand the risks and they get to own the risks. 

 That helps them learn a whole lot more than an email of the aviation safety accidents that have occurred in the last period. 

 I think one of the things learning, you’ve got a good point that it’s got to be very immersive. It can’t just be an email. One of the things I’ve seen is at least when it is communication, this was in aviation, it’s very targeted to who receives it. If you’re flying a certain type of aircraft and the issue has to do with that certain type of aircraft, those are the people that receive it. Whereas in business, often it’s these mass broadcast, so you get flutter with a lot of things that don’t relate to your job as an example. But the other element is learning from things like the near misses you talked about, some of the little things. In business, I was talking to one audience not too long ago, and we’re just translating it for an aviation, a crash is equivalent. It’s a serious event, just like you would consider a siff event on the ground. At ground level, you’re thinking about serious injuries or fatalities. Is the big thing that could go horribly wrong. But too often people are learning from the cuts, the scrapes, the bruise, fingernails. They’re looking at trends that have no correlation with serious events, and they’re not opening the door to all the other things that may be going. 

 So, they’re not fixing the real issues. 

 It all comes down to, I think if you want to learn from those minor events, you need to understand the controls that are in place and to find out if those controls are effective, I guess, don’t you? Yeah, right. Also, with your point, you talked about how aviation, you might get specific to a specific aircraft type, whereas business, you just get a broad shotgun approach. That’s really interesting because the question is asked, how does this relate to me and how can I relate it to me? That’s a very difficult thing to do. I think we have a very strong reliance on rules and procedures, admin controls. We think that they are the critical controls that are going to save us from a serious incident. I think we also… A lot of organizations, the Air Force, we have a very strong, just culture. 

 Yeah, that’s a key component, right? 

 It’s predominantly no blame, and we try to learn from it, of course, and that’s important. But we still don’t… I was talking about those sticky conversations. We still don’t understand the critical risks and the critical risk controls. We don’t understand why they’re there. If they’re engineering controls, especially, sometimes they’re obvious, but sometimes they’re not. If you’re a brand-new aviator on the flight line and you see a brand-new piece of equipment, you don’t understand why it is built or designed in a particular way. Sometimes because the lessons learned have been built into that vehicle, hopefully, so the critical controls on it work and it makes it simplified. But we need to, from the executive level, top-down management. It’s important. Of course, it’s important. But top-down, they want us to make sure that we’re following rules, which, of course, is important. Those controls are important. But The guys on the floor, they’re going to follow a procedure. Therefore, they’re going to follow the rules, of course. But it’s not until they understand the critical controls and the critical risks. So, when something goes wrong, they’re the ones that have the ideas that can fix that, and they can understand it better. 

 Because if something goes wrong, it’s going to be the worker that’s out there doing the job that’s going to get hurt, isn’t it? We don’t want them to carry that extra risk. We want them to understand it so they can work with it, work around it, and hopefully, fix those that risk, those critical controls. So that next time someone has an accident, hopefully, the outcome is a horrible SIF event or an aircraft crash, hopefully it’s just something minor. When we get the plane on the ground or someone just has a minor injury, and we talk about all these minor events and don’t have a lot of big things to talk about. But that’s a utopian world, isn’t it? 

 Yeah, but it’s something we can strive for. I do believe you can eliminate aviation. You can eliminate serious events. If we look at aviation, I was pulling up some stats in the US several years back, and In the 1960s and 1970s, on commercial aviation, there was roughly one person dying every second to third day. To last 15 years, where only three people in commercial aviation lost their lives. That’s a substantial difference in outcome. If you focus on the right things, you can drive the right bike and it becomes, essentially. 

 I completely agree. You know the aircraft that I predominantly have worked on, the Hercules in Australian Air Force, we have never had We’ve had a fatal accident with him. We’ve been flying him since the late ’50s, early ’60s, I think it’s been with the early. 

 It’s an old plan. We’ve updated the aircraft. 

 Of course. I would hope so. Never had a fatal accident with them, which is a fantastic record. 

 There is a lot of… Obviously, our publication suite, it’s a live document. It’s developed over the years. It brings in live rules. The training is fantastic. We trust it. Another big thing is we trust our aviators to fly them. You might have a junior in their early 20s, a guy, girl in their early 20s flying that plane. We put a lot of trust. That’s the same in all aviation, isn’t it? You train them, you put a lot of trust in them to do the right thing. Aviation is just one of those industries where it’s just done really, really well. 

 Absolutely. You touched briefly on the topic of just culture. Tell me more, because that’s a very key component to get to the near miss reporting so that you can build the learning culture. It’s something that I think a lot of businesses still struggle with because it’s this element of, I need to learn, I understand that, but is there an element of accountability and how do I balance this through just culture? 

 It’s just a word, isn’t it? Just culture. It means a lot. It means that we need to… If something does go wrong, that there is effectively no blame around it, but there also needs to be accountability, and that’s super, super important. 

 That’s the key thing. 

 It is. Blame fixes nothing. Error is normal and blame fixes nothing are the first two principles. And everyone understands that, and everyone can look at them and go, Yeah, that makes sense. But it’s not until you really get into them and try to understand what happens. So, I’m very big on the brain body contract. What happens to a person in their mind and physiologically when something goes wrong and someone points the finger at them, because that hurts. It really does. It wipes down deep. And that’s a core memory that you will keep forever because it brings out an emotion, doesn’t it? A lot of people think that because it’s a no-blame culture, they’re not going to get in trouble. And that’s well as much as far as it’s going to go. But what you get then is you get a lower level of accountability. So, you get people that are just cruising along. They’re just in a happy zone, and they don’t really mind what happens to them. It’s not until you give them… Sure, you’ve got the no blame, but until there’s some motivation, are you motivated to do your job? And guess what? 

 If something does happen, there’s going to be some accountability. Definitely, if you’ve done something wrong, if there’s a violation 100% there’s going to be some accountability. But we need to be accountable for what happens when something does get wrong. And what happens then, if there’s too much accountability and no blame, you have people living in fear of I’m going to work. I don’t want to get in trouble for doing something. But if there’s a healthier level of psychological safety and emotional intelligence around it and a healthier level of motivation and accountability, then what you get, you get yourself up to the top level where you’re really in that learning space. I’m happy to take the hit. I’m happy to put my hand up and say, hey, look, I actually made a mistake there. That was my fault. And this is why I made that mistake. I didn’t follow the procedure. The control was wrong. Whatever led to that mistake happening or whatever the outcome of that mistake was, if it was a bad one, let’s learn from that. But get yourself out of the cruisy zone, get yourself out of the fear zone, and get yourself above all those, and get yourself into that learning zone Where, yeah, I’ll take full responsibility or not necessarily take full responsibility. 

 I’m just a worker. Error is normal. But what was the outcome of that error and what can we learn from it? So that when that error happens again, and it will, probably by me, how do we make sure that no one actually gets hurt by that? And once we’re in that learning zone, you’ve got Then you’ve got a true just culture. It’s important that it’s done correctly. 

 I think one way I lived, somebody was explaining it in a prior episode, is that there’s just culture Sure, it’s about removing blame, but there’s still accountability. Because with the two pilots, there’s very strong accountability on each other that’s built. You touched on CRM. CRM is really about building that accountability, the communication between each other. There’s peer-to-peer accountability that sets in. But the position and length of the choice of words is that there’s still a consequence. But the consequence doesn’t necessarily mean it’s a negative. It may just be We discovered there’s a gap in our training, or maybe you need more training in this particular scenario. We’re going to put you in a simulator with scenarios that are similar around it. You get to walk away and there’s no conversation, essentially. It’s just we want to learn from anything that can happen because when you’re in the air, it’s highly unforgiving if something happens. We learn from it, but there could still be a consequence, just not a negative punishment in the way we normally talk about it. It’s not that we’re avoiding termination or things like that, although it’s much more about the learning that happens there. 

 This episode of the Safety Guru podcast is brought to you by Propulo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at 

 I’ll tell you one thing I got to do which was fantastic. I’ve been an air crew for many years, but for the last three or four years, I’ve been on the ground doing ground-remanded roles. One of those roles was working with the safety management system within the support system of an airfield. We’re talking about the people who load aircraft, aviation, firefighters, aviation refuelers, and the people that run the fuel farm and all the fuel systems throughout the base. We got to introduce some human factors and got to introduce some safety training courses to that workforce, which was fantastic. It was the best job I’ve It was cool. But there was one crew that worked at the fuel farm, which is where we store all the fuel, the jet fuel. The fuel farm at this base, it’s fairly old. It was built in the 1970s when we bought F-111s because we needed a significant amount of fuel to run those things. They’re awesome jets. It started to show its age. Still works, of course, but it was starting to show its age. By me, What I mean started to show its age, a weld would start to leak. 

 It might just be a pinprick leak. They’d have to fix that, for example. The guys that worked there, they lived in fear. Their accountability was really high, and the blame was really high as well. 

 Whenever something wrong- Which is not good. 

 These guys had only worked there for a year or two, we’re getting caned for it. I rolled in with a couple of my colleagues, and we made a learning team, effectively, which was, this is not an investigation. There is no blame. There are no punitive measures to be taken here. We just want to understand what is happening in your workplace. We put it on a whiteboard, and I said, Let’s learning 10 is, what are your issues? We’re not going to talk about solutions. I only want to hear the problems. And of course, I let them have a pretty good whinge. But the outcome was we got a really good list on the whiteboard of some of the real issues that this problem, that This place was facing. Some of them were admin-based, some of them were engineering, etc. And from that, I was able to go to the commanding officer with this list and say, hey, sir, look, this is what is happening at your fuel farm. He goes, okay, I didn’t fully understand it. I knew we had a problem, but I never fully understood it. From there, they were able… Six or eight weeks later, we had the DG Log, the Director General of Logistics. 

 The guy in charge of logistics for the Air Force. The equivalent for America would be like a two-star general for logistics. He came out and they let… Actually, let one of the younger fellows there explain to him some of the issues because he was the one that understood it. He was really nervous, but he did a great job and explained what was going wrong here. He went, Cool. Now I understand it. He helped with funding to help fix it, and they prepared that. A lot of it, actually, they haven’t just They’ve prepared it. They’ve put in a system to rebuild the whole thing anyway because they need more capacity. That’s a classic example of how going into a workforce and saying, we’re not here to punish you. We’re here to learn and understand. The outcome of that was absolutely fantastic. I saw one of those guys a couple of months ago in Emblem when I was up there, and he said, oh, look, what we started back then was fantastic. I’ve been working around this industry for 10 years, and that day that When you came in and started talking to us in a learning fashion was the turning point. 

 That’s what I put out to everyone. It’s just having a conversation and just try to understand the controls, what’s fouling and how you can fix them. 

 So simple yet so powerful. 

 It’s just human interaction face-to-face. It is powerful, isn’t it? 

 How do you shift leaders’ mindsets around this? You talked about this environment that was previously very high accountability, very high blame. How do you shift mindsets around this? 

 That is a good question, Eric. I don’t know. To be honest, I will be completely honest. I haven’t yet had 100% success in shifting a leader’s mindset as an enduring to an enduring level. I will be honest with that. Maybe it’s my personality. But I think the hot principles, I’ve been through the hop principles with a bunch of leaders, and they resonate with them. But it is so easy. It’s human nature to go back to… It’s very easy. We are hardwired to blame people. We are. You just watch any movie throughout all of our history, we are very hardwired to blame people and to hurt people, unfortunately. I don’t know why that is. 

 But it’s also easier, right? Because the last point of failure is a person. Yes, normally. Even if you go precondition right before that failure, then you’ll get to something that’s maybe they were fatigued, they were stressed, which again, you could easily say, Well, you were the one who’s supposed to sleep, as opposed to for me to really understand the chain of causality, how the system factors came in, all the various things that caused this person maybe to be fatigued and make this error, or the gaps in the training, That’s a lot harder. 

 It is. There will always be a human at the end of it, won’t there? Yes, as you said, given the fact that we come up with these systems in our mind, we invent them, we design them, we manage them, We operate them. We are heavily involved in everything. That’s the human nature. I guess when we are hardwired to blame, when we are hardwired to want to find someone to pin this on so it doesn’t come back to them or the C-suite or the executive suite, it’s all about I guess that’s why I like the hot principles, because so many times I’ve been able to go to my management and say, Hang on, now your response to failure really matters. We had a failure this morning, and the way you responded was probably You need some coaching on how to deal with that response better because you didn’t handle it really well, because those people that were involved in that incident or accident, who really had nothing to do with why it happened, but they were the ones that were the last ones to touch it. You actually made them feel pretty bad about that. But having said that, if you’ve got someone… 

 My current boss is actually quite good, a very intelligent person. He’s super intelligent. A lot of the times you’ll find that people who are super smart haven’t got very good social skills. Well, this guy has actually found the way to have pretty good social skills, so it leads his team pretty well. He sets us up with a level of trust, and that’s what it comes down to. He trusts the worker. I work in an office environment, but we plan missions for all of the AMG aircraft, air mobility aircraft, all the transport aircraft. We plan all the missions. There are so many things that can go wrong with the mission, even in our planning phase. He trusts. There might be a brand-new operations officer who’s straight out of training. They do a couple of weeks of training, and they’ve got someone beside them. They’ve got a little wingman to help them out. But he gives them a level of trust that a lot of young people would never have in executing that mission to make sure it goes off. He can make some decisions at 10:00 PM at night when a C17 breaks down in America that other 21-year-olds might freak out about completely. 

 But if something were to go wrong with that, the next morning when he finds out about it, he’s like, Yeah, okay, that happens. That’s completely okay. What can we learn from it? 

 Which is a red response. 

 It’s perfect. But that has been… I introduced the whole principles to him a number of years ago, and I drive them on him. I hold him accountable for those principles. Hey, you said you like these things, and your response to failure matters. And now his response to failure is quite good. It’s excellent because no one feels punitive like measures from that, which is fantastic. So, it’s a lot about you’re The question was, how do you get leaders to really look after their teams, to not want to be the blame and punishment people? It’s just about having a champion that gets in their face all the time and holds them accountable because that is super important. So once again, it comes back to face-to-face communication and relationships, doesn’t it? Often hard to do because often you don’t have access to all of the executive team, do you? So, you’ve got to be the right person, right person, right place, using the right equipment. It really, really helps. And who understands the big picture. And who can be held accountable when something goes wrong. Yeah, that’s important as well. 

 But I think it starts with a level of ownership that’s very strong. To be able to do this, you have to take very strong ownership of the role and responsibilities and also the flaws. I think as well, the element that I’ve seen, unfortunately, in some organizations, they will take something like hop and say, blame fixes nothing, and use it as a transference of blame. Instead of blaming the employee, now I’m blaming the senior leaders, because the senior leaders created the system that allowed it. But it’s not about shifting blame, it’s about learning. That blame fixes nothing is about just let’s understand the full system and all the interdependencies that are connected. 

 I know. It is so funny how you said, they don’t blame that person, but they blame the next level up. We love to find someone to blame them. 

 We love to, yes. Unfortunately, it’s convenient. It solves a lot of issues when you simply blame. But I think the other element is it’s not about absence of accountability because I think that’s one area where I’ve seen a lot of leader’s struggles. I don’t fire people. I remember I had one person I talked to, and he says, Yeah, we have a great safety program. We call it an at-will safety program. You make a mistake, I fire you. That’s the extreme level of blame. Yes, you’re not going to hear about a single thing that went wrong. You’re just going to have calamities after calamities if you take that approach. But you still have accountability. I would argue that the level of safety ownership I’ve seen in aviation is much higher than anywhere else. That comes from a high level of personal accountability and team accountability between the pilots as well. 

 I’ve got a friend who works for a construction company, and she says that… I’ve done a little bit of work with a few companies outside of my own, with my own business as well. Yeah, you see this all the time. But blame and punishment is just everywhere. It’s a thing. It is very challenging to change that mindset from the top down. Whereas from the bottom up, they’re like, Yeah, we love this mindset. This is great. We don’t want to get punished. But it needs to come from the top down, I guess, doesn’t it? It probably needs to be both. But anyway, my friend has been able to convince the executives for her construction company of the hot principles and learning teams and the 4Ds and having sticky conversations. They said, Yeah, cool. We really love what you’re talking about. It resonates with us. Here’s the red carpet. They basically rolled out this massive, long red carpet for her program and said, Yeah, make that happen. We will support you 100%, which is fantastic. Imagine that. If every Hot professional had that treatment, they’d be very, very happy. I track her I talk to her quite often and say, hey, how is it going? 

 Is it actually working? Because, yeah, are the hop principles, are they just a philosophy? Or are they something- They have to be more than that to work. To be meaningful. 

 They absolutely do, Eric. Are they just a philosophy or are they just a set of values? Or is there some real meat in it that is actually beneficial? She says, no, it actually does work. The workers love the approach where they know when the safety person comes in, they’re not going to get in trouble. They’re not going to be talked about all the things that went wrong. She talks about all the things that go right What is working well, and talk about the critical controls which the workers… She has helped the workers understand what isn’t happening right. And they love that approach because there’s no, hey, look, this happens, so don’t do Make sure you wear your proper PPE. They don’t have those conversations because they don’t have to, because they really trust the workers. And that trust works both ways. And the company seems to be doing really well as a result, which is fantastic. 

 That’s cool. David, thank you very much for your thoughts and insights on HOP and some of your experience from aviation in the military. Any closing thoughts for us? 

 I’ll just reiterate the point. If you want to be a good safety leader, just get out face to face, talk to people, understand them, understand the critical controls, understand the critical risks, and help your workers do the same. You’ve got a whole system of safety behind you. You can use that whenever you need to. But if you have that approach, I think you can do better in the safety world. So good luck in doing it. Eric, thanks for your opportunity for doing this today. It’s been good fun. 

 Good. And if somebody wants to get in touch with you, how can they do that? 

 LinkedIn is best by David East. And I’ve got, because there’s a thousand David Easts in the world, mine’s got a little hand emoji beside it, so I stick out. So, feel free to get in touch. I love having these conversations with like-minded folk and also non-like-minded folk who are happy to challenge me and challenge some of these principles because those conversations are always interesting as well. I have drunk some of the cool aid, but it’s not the only way. There are many ways to do safety. This is just the way that works for me. Happy to have those conversations. It’s good fun. 

 Thank you. Safety is about learning. I think that’s the big takeaway. 

 That’s what makes it sexy, Eric. Actually, safety can’t be sexy. Anyway, thanks, buddy. 

Awesome. Thank you so much, David. Really appreciate it. 

 Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.   

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David East is an accomplished Human Performance, Safety Management System & Leadership Consultant with a passion for enhancing workplace cultures, safety systems and optimising human potential. With extensive experience in multiple industries, he operates CrewFusion, a consultancy offering comprehensive training, facilitation, and advice to organisations seeking to improve cultural, safety & leadership practices across any workplace setting.

David’s expertise lies in developing and maintaining robust Safety Management Systems, and he is particularly specialised in the aviation sector. However, his diverse background also includes successful engagements in construction, emergency services, logistics, and healthcare safety systems. His broad industry knowledge allows him to adapt his skills and insights to meet the unique challenges and requirements of any sector.

While running a successful consultancy business, David continues a career in the Royal Australian Air Force (RAAF). Beginning as an Aircraft Technician, he worked hard to rise through the ranks to become Airmen Aircrew serving as a Caribou Flight Engineer and later as a C130J-30 Hercules Loadmaster. This extensive operational experience provided him with firsthand understanding of the critical importance of safety and human factors in high-pressure environments.

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The Power of Organizational Learning with Dr. Nippin Anand

Dr Nippin Anand_The Power of Organizational Learning



Are we truly learning from accidents? In this compelling episode, Dr. Nippin shares a different perspective on the Costa Concordia disaster, enriched with his deep insights and research, alongside an exclusive interview with Captain Schettino. He delves into a profound understanding of risk and safety, emphasizing the impacts of culture and shared responsibility. Tune in to uncover valuable lessons about the power of organizational learning and how it can help us make meaningful changes.


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

 Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me, Dr. Nippin Anand. He’s caught my attention because he’s got a deep background in organizational learning. He’s a host of a podcast, Embracing Differences. He has a new book that just came out around, Are We Learning from Accidents? Phenomenal background, phenomenal stories. Looking forward to our conversation. Nippin, why don’t we start maybe with how you got into this space? Because you have a phenomenal story there. 

You mean the title of the book? Yes, it’s very tied up with my life stories. Not just one story, it’s tied up with many stories. I write that in my book as the opening, Eric. Starting off with the idea that failure was never an option for me. I come from a middle-class family in India, a very religious family. I was going to board my first ship as a cadet. This is going back to 1995. The night before I was leaving home, my mom came to me and said that I’m aware that life at sea is very hard and you’re going away for 18 months. Do us one favor, at least. Don’t come back home before you finish your contract and 18 months. That actually put an immense burden on my shoulders. It was a feeling that failure was not an option. I worked for almost about 11 years. I worked a job which I never found appealing from the very first day. And this is very common in many cultures that you end up doing something because of the societal expectations, because of the family expectations. Until I had a near accident, and this was a near collision.

It wasn’t a collision; it was a near collision at sea. We were just approaching a boat first thing in the morning in Japan, and my ship just about touched another ship, also approaching port. It was a very tense situation. And I thought on that night after I finished my watch that because the accident didn’t really happen, there’s no real fuss about it. But the next morning when I woke up, Eric, the whole ship was seeing me very differently. So, from an expert doing a job for almost about 10, 11 years, dedicatedly fulfilling all my responsibilities as a professional, I came to be seen as the idiot of the town. From the next morning, every Everyone, including the seaman who was on look out with me on the night, started to doubt my competence. And at that point, I decided that it was time to… Well, I didn’t at that time, but it took me almost about a year after losing all my confidence to come to the conclusion that this was probably not the job for me. And interestingly, I stayed in that negative spiral for almost about maybe good 8 to 10 years until I came to the UK.

I did a PhD. And after doing the PhD in Anthropology, I discovered the power of narrative and how the same accident could be narrated in so many different ways. And if we truly want to learn, then I think we should be open to all the narratives. Now, Eric, there are very different narratives that we tell in different cultures. I study mythology, I study religion, I study Anthropology. One of the things that you cannot escape is the power of myth, which is belief. Not myth in the way that the Western world understands it. Myth as in what is it that we believe in? What stories do we believe in? If you look at the Christian world, which is where I live right now, I live in Aberdeen. In the Christian world, there are God created the world in seven days or six days. On the seventh day, he put the human beings there. It was a very stable world. The moment you put human beings there and you put your children there and you told them not to do something and they still did it, that’s when human beings became corrupted and could not be trusted.

So, the whole purpose of life is to follow the word of God, which is to follow the process. We call it in safety management system. That’s one way of looking at the world. So, the narrative of an accident investigation is something went wrong because you did not follow the process. That’s the Christian myth. Then there is the Greek myth. The Greek myth is not about compliance. The Greek myth is the opposite. The Greek myth is about defiance. So, there is the oppressor who is all out there to oppress the world, to become a hero, maybe, to attain heights, to attain success in life. You oppressed people. In the Greek myth, your job is to go against the odds. There is chaos out there and you need to create order out of it. So that’s how you become recognized as a hero. So that’s the myth of the heroes and the anti-heroes. People who go to the outside the fringes or the boundaries of the society and do something exceptional, whether it’s good or bad. That’s where you have people like Captain Sully and Captain Francisco Estacio. One becomes the hero because he saves the world.

Another one becomes the anti-hero or the villain, and he actually causes havoc to the world. And that’s the Greek myth at play. That’s how you tell the narrative of an accident or a near miss or whatever you want to call it. And that’s the Greek myth had played. Then you have the Indian myth had played, which is not about compliance or defiance. It’s about self-realization that the world is not stable, and the world is not chaotic. The world is what it is. The important thing is that what do you realize or what do you learn about the world as you go through this journey, what we call life? Sure. In this journey, it’s not It’s not important to understand whether people who were present in an accident, whether they complied with the rules or they went against the rules to save the world. The important thing to understand is when you investigate an accident as an investigator, what do you learn from it? That’s the world of self-realization. I think one of the things I realized is that there is no objective reality out there. It’s how the investigators present the story. It’s how they collect the data, what questions they ask, how they go about processing and analyzing the data, and how they go about presenting the information.

Until the investigator becomes cognizant or aware of their own biases, nothing changes. This applies not just to investigators, it applies to everyone, a leader who goes to the site to engage with people, somebody as an inspector who goes to audit the site or the workplace. The important thing is that we don’t realize we have our own biases. Biases are not a bad thing. Biases is what makes us humans. The important thing is, do we realize that we have certain assumptions, certain narratives, certain experiences, certain qualifications, certain family background, certain aspirations, certain motivations that push us to look at things in a certain way. And a lot of learning opportunities are lost because we are so busy creating objective narratives and making that separation between the narrator and the narrative which does not exist. So, until we become aware that we are biased, and we need to appreciate other narratives, other stories from other people, other point of views, it’s very, very hard to learn anything from accidents and non-events, both. So that was my biggest realization.

Phenomenal. A really interesting story. I’d love to pivot to when you’re talking about incidents, investigations, you had a very unique chance to speak to the captain of the Costa Concordia. I’d love to hear some of the themes, the story, the conversations you had with him along the path we just explored.

Yes. The interesting thing is that because I had a background in safe airing, and I had, at that time, already started blogging, writing blogs. When this accident happened, well, I met him five years after the accident. When that accident happened, my rapport, my blogs, the way I used to write, was very helpful to establish that initial connection with him. I just had to approach him through another person, say that I would like to interview you, and this is my background. And very quickly, he responded with a yes, that yes, it would be nice to meet up. I document that in my book, how we went about it. It was quite easy. I think he also was very appreciative that in those five years, between the time the accident happened, that was in 2012, and the time when I met him, that was in 2017, nobody from the industry had come to speak with him. Nobody. Really? I was the first person who approached him from the industry, apart from lawyers and solicitors, to who genuinely wanted to understand his point of view. So, he was very appreciative of that. From my point of view, the story resonated because what I saw in the press was an extreme form of how I was treated Eric after my own accident at sea.

And there you have an initial resonance already between him and me. Building that rapport and approaching him and making a contact with him was easy. The next thing was, I flew to Sorento, his hometown in Italy, where he was under house arrest, and I spent four days with him. We had a great conversation. We were trying to understand his perspective, not just his perspective, but who he is, his relationship with his community, with his people, with his family, trying to understand him, why he chose a career such as seafaring, and then trying to get to understand how he moved through his career. And then the accident itself. So, a genuine interest in understanding the person even before you dip into the accident case. There’s a reason why I’m saying all this, Eric, because today, a lot of times, we go into accident investigations and audits and inspections, and there is little interest in understanding people. Because there is little interest in understanding people, there is little reciprocation from the other side. If you consider that the origin of all decision making is the unconscious mind, which is the unaware mind, which is the non-rational mind, People will tell you nothing from the non-rational unconscious mind until they see a genuine connection with you, you are making a genuine connection with them.

So, without relationship, there is no learning at all. Absolutely none. And so, getting to know somebody not just as a victim of an accident, but also as a father, as a brother, as a community member, as a husband, as a sibling, is so important before we get to understand why they did what they did on the day of the accident. Because then they can tell you things that you were probably not even expecting. And that’s the beauty of learning, that learning is a discovery. Learning is a discovery, and discoveries can only happen when we find something that we were totally unaware of. And that can only come when we make a genuine connection with people and listen to the unconscious mind of these persons. Yeah, it’s very important. Something we consistently miss in our accident models, whether old ones or contemporary ones, doesn’t matter.

Because you jump straight to the decisions, the occurrences, and you’re trying to track back to a very linear cause an effect. But what did you gain from that? Because four days is a lot of time. You’re really trying to understand the person, you’re trying to understand what was going through his mind, indirectly his mental model, which touches the biases. How does that lead to something different in terms of what transpired?

The biggest learning from this accident was that people involved in accidents, both as part of the experience of the accident, but also as part of being investigated, are traumatized. This is a very traumatic experience, both Not just experience an accident, but also going to an investigation. The first thing I would say is that if you do not know, if you’ve not been trained in trauma, if you have not been trained in how to handle a distressed person, never go into an investigation. Because that’s precisely what happened to me, and it took me nine years to come out of that cycle. It’s the first question, usually, that you ask from the person, sets the tone for the rest of the investigation. If you don’t take the time to connect with the person, you don’t take the time to understand the person, if you don’t see learning and healing should come together, then all you do is come back with data, come back with some extracted information, which is nothing but a story, a very carefully crafted story of a rational mind, a very logical story that people want to tell you because they know that’s what you want to hear.

And so, there is no learning. And a lot of times, we are missing that very crucial point that go with an open mind, connect with the person, listen to them, try to understand their stories. Try to understand what is it that shocks you the most when they’re telling the story. And there you have a very rich story from the person. And do not interrupt at all as the person is speaking, because this is something… When they are giving you something from the unconscious mind, just sit there and absorb as much as you can. There is no need to interrupt. There is no need to feel apprehensive about the silences. There’s no need to feel uncomfortable about things that go against your values, against your culture. Just sit there, be in the moment, and listen as much as you can with open questions. Things like, what would you like to share? Where would you like to begin? What? Walk me through the steps. What have you learned? These are very, very open questions, avoiding any probing, any prompting, even the person goes silent. That’s a very important thing. But Eric, Underneath all this is a methodology which is very important to understand that human beings are fallible.

People will make mistakes.

Of course.

You must embrace the fallible When you’ve seen another person, an imperfect person, just like you, you make the connection there and then. But if you’re so busy trying to fix this person, trying to find a solution, and I think quite often those reactions stop you from listening anything. You say something that you didn’t like, and you make a face, you make a gesture, and it just disconnects you from that person completely. It’s very important to go with a philosophy, with a methodology that accepts another person’s imperfection and fallibility. From there onwards, the flow begins, and you start to listen to the full story. So, your question was that what did I learn from this story? Many things, but I deliberately chose to focus on four important things. The first one was this question that, why did he choose to navigate so close to the land?


That was the first thing that… As I spoke to him, Eric, what intrigued me was that here we are sitting so far away, so distanced from the reality, and this person does not see that as a risk at all. For him, this is a normal practice. This is what a cruise line captain does each day, every day. He balances the competing goals between customer satisfaction, which is go close to the land, and safety of navigation, which is to keep a distance. It is important that we pay attention to these things when somebody says that it’s quite a normal practice to do such a thing. Now, the important thing is that words like normal practices have become very fashionable these days. Everyone wants to study normal practices, normal work whatsoever. What we often forget is that your normal is not my normal. You are sitting in the ivory tower. For you, what is normal is completely different from what I see as normal. It’s very important that when we are speaking to people, when we are engaging with them, we try to understand what’s their normal. So on occasions, people might say things like, Oh, it’s okay.

It’s how we do it here. Oh, it’s quite normal. It’s usual. What they are telling you is that’s their culture. In that moment, we become very excited that how can this person go so close to the land when he should be 20 miles away from the land or whatever is documented in the safety management system. What the industry struggles with is the idea of subjectivity and risk tolerance, which is very individual, very subjective to each person, each culture, for that matter. If I show you a video of how people drive cars in India, in the West, and people get shocked. But equally, people get shocked in the West, in India, when they see how cars are driven in the Western world. The point being that every culture has its own normal. Absolutely. If you don’t understand the power of a worldview, a culture, then you are so far away from what is normal and what is normal work. It’s fundamental to understand. Today, when we talk about the idea of work, we don’t understand that aspect of what is normal. Normality often comes from the idea that this is my belief, this is my myth, this is my paradigm.

When I say it’s okay means that it’s consistent with my worldview. It’s consistent with my culture. It does not surprise me because this is something that has become embodied, it’s become part of my body. So, this is important. And that’s something that I highlight in the book. It’s a major part of the book, which is to understand culture through the lenses of what we consider as normal. And every culture has its own normal. We then go into the idea of why people don’t speak up. That’s another topic, and I spent a lot of time. I devoted a lot of time, actually, to it. Eric, we talked about the idea of myth, the Greek myth and the Christian myth, and the Indian myth. What happens is that people don’t realize that this whole idea of why people don’t speak up is very much the Greek myth at play. What do I mean by that? You have this #MeToo campaign in your country every now and then. We have the people in position of power, and they do things, they do injustice to people, and somebody must rise up to the occasion and stop the oppressor from doing wrong things and speak up.

What most organizations today try to do is create what we call psychological safety so that we can empower the oppressed to speak against power, which becomes abusive over a period. This is the Greek method playing, the oppressor and the oppressed. So, you have to defy the oppressor. This goes back to the narrative of defiance. This is not compliance, this is defiance. And what’s interesting in this narrative is that we pay too much focus to the individual. So, if we can empower people, if we can give them psychological safety, then they should somehow speak up. What became very apparent, what became very clear in the Costa Concordia study, and I’ve studied many, many accidents after that in aviation, in health care, in other areas, what is happening is that there is a very… Take the example of aviation. If you take the Ethiopian Airlines air crash, which happened a few years ago, and then followed by the… Sorry, I can’t remember the second one.

Lion air was first, yes.

Lion air was first, yeah.

In both instances, in the Ethiopian Airlines, for example, you have a pilot with more than 10,000 hours of experience sitting next to a co-pilot who had 200 hours of flying experience. Now, you cannot challenge this because from a certification point of view, both are certified. They are both-Correct. The co-pilot is certified for what it does, and the pilot is also certified, of course. The trouble is that we are not talking about hierarchy here, which has always existed in aviation and the maritime and many other industries. What we are talking about is hierarchy blown out of proportion completely. You have an expert who is far too powerful in this game against the novice who has just entered the profession. This is a systemic problem in the industry, and it cannot be solved through the lenses of psychological safety. You cannot send somebody on three days, five days course, attend a course in psychological safety or crew resource management, whichever way you like, and empowered them to speak up because they just… And we go back to the idea of normal, because these two people belong to two different subcultures or cultures, and they see things very differently.

For a captain who’s navigating the ship so close to the land each day, every day, it’s his everyday work, right? That’s what he does every day. He doesn’t see it as a risk. For the novice, because he sees the captain doing it every day, he does not dare to challenge it because he knows if things go wrong, he cannot handle it. What will he say and what will he do? So, what we are dealing with here is not a problem of speaking up or speaking out or listening in. What we are talking about There’s two different subcultures that see the world differently. And until we create that awareness, the problem is not with people not speaking up. The problem is that people don’t know when to speak and what to speak and how to speak. There’s nothing we can do about this. So that was a There was another theme that came up in the book, which is why don’t people speak up? And I explained that through the book. Sure. We then look at the idea of the emergency plans and processes and why they don’t work in practice when an accident happens. So, in this instance, one of the big things that came out was that sense-making in an accident, which is trying to move forward with limited information, sometimes conflicting information, time pressure, language difficulties, the reality of life, are so distanced from documented plans and processes.

And to be able to live through that trauma of an accident. And the interesting bit is not just the comparison between the documented plan and procedures and how emergency is handled in practice. The painful bit is that information and that behavior being taken to the court of law and compared against what is documented in the process, and then establishing a case for culpability and crime based on those processes is absolutely fascinating. To understand that, one has to come to terms with the idea that there’s a huge difference between how people make sense of the crisis, what it means to be a human being in a crisis, let’s put it this way, what it means to be a human being in a crisis and how you are judged or misjudged based on your behavior as part of the court proceedings that part of the investigation is something to think about, Eric. Yes.

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That was the third aspect of it. The final aspect of which really worries me, Eric, is this idea that We have this slogan that you can either blame or you can learn. One of the things that comes out from this accident, and again, many other investigations that I’ve done, is that there is escape from blame. This is more than, well, this is more than 3,000 years old ritual that started in Israel, which we call scapegoating. And unless you acknowledge that in an accident, in order to give meaning to human sufferings, somebody will be blamed. You have to accept that. And once you accept that, you know that there are better ways to put your resources, better areas to allocate your resources, and not spend too much time on accidents of this nature because they will never create the desired results that you want. So, you’d be better off putting your resources into other meaningful areas because you cannot avoid blame, you cannot avoid scapegoating. It’s inevitable in an accident. So, I use the example of the Costa Concordia, but you could easily use any example. And I think this idea that blame fixes nothing needs to be challenged because if we did not blame the captain on the night, the whole cruise industry would have come to a complete halt.

Somebody had to be blamed. When the ship capsizes, somebody has to be blamed. That person may or may not have anything to do with the accident, but that’s how the idea or the ritual of scapegoating works. So, these were the four main areas that I concentrated upon. I’m very happy to take your questions, but just to end, in the end, I actually provide a method on how we should learn from accidents and how can we learn from accidents. And the basic idea is that stop looking for improvements in processes. Of course, those things are important, then they are a by-product of many other things. But do not, as a default, start to look for processes, systems, fail-safe systems, technologies to make the world a safer place. Of course, do not turn to people who have been involved in an accident. Rather, turn it around to your own self to say, okay, what sense do I make of this accident, of this misfortune, or whatever has happened? Until we take that question to our own selves, there’s nothing that will change. The trouble today in most organizations is that we talk about organizational learning as if somebody else has to learn.

That question has to flipped around to our own selves to say, okay, I’ve been on this site, I’ve investigated this accident, I’ve been on this audit, I’ve done this inspection. What has changed in my world after this? And until we address this question, which is back to the myth that I talk about self-realization in the start. So, it’s not about compliance, it’s not about defiance, it’s about my own world. What has changed in my own world after being through this experience? And that’s what the book talks about. So, I talk about my own self, basically, this journey of discovery, learning, and how it has changed me as a person. To me, that’s the most important bit, and we don’t talk about it often. Interesting.

I think one of my main takeaways is the conversations you had with the captain in terms of getting to know the person, not just trying to connect dots to get to a pretty report on the back end. I think that is a very key component, particularly with the comment around most of our decisions are subconscious If it’s subconscious, you need to understand the person to get there. I think that makes sense. What I do disagree is around the blame fix is nothing. What I mean by this is if I think, particularly in the aviation space, a lot of the removing of blame is so that I hear about the near misses, the things that almost happened that I wouldn’t have known without that information. If we think about the near misses, there were very few self-reported near misses prior to removing the blame in aviation. I think that’s an interesting and very important point is to hear about the things that didn’t actually cause an incident, but we could address. If I think in aviation, we fell asleep, we both fell asleep, things of that nature, which I’ve shared before, I wouldn’t self-report that if the blame would turn at me.

There’s generally no consequence if I’m on autopilot that I fell asleep, assuming I’m still on course and it’s not a long-extended period of time. But it then allows me to understand what we are doing in the system that allows fatigue to build up or creep up.

The trouble with taking blame as the focus is that invariably, whether you call it a system or an individual, there is something to fix. So, it may not be the frontline person, as you said, but now it’s not the person who fell asleep. It could be a monitoring technology that failed to give us the desired data. Or maybe this problem could be fixed using a technology or a system or a process or a protocol.

Or training or other pieces. 

Or training, yes. I have no problems with that. Well, I have a couple of things to think about. I’ll leave you with a couple of things to think about. One is that what we are doing is we’re externalizing learning. Instead of taking the person who fell asleep as a victim, there is somewhere else in the system that needs to be fixed. We are still externalizing the learning. It’s a process or a system or a technology or a barrier that failed that needs to be fixed. Now, the trouble is that you can fix that, you can fix that, or you can put another barrier to it, and you never know what new problems you might have created as a result of that.

Yeah, fair.

As a result of When you’re fixing one problem, you might have created another one. And who knows when it might show up. Potentially, yeah. The other thing is that because you have now allocated the problem to somewhere else in the system, you think that that’s the end of it. That’s what we call event learning. So, we learn because we have sorted out the event. And I think that’s dangerous because you still have, I haven’t asked the question, how has it changed my view about the accident, about the person? If your view does not change, if your attitude towards failures does not change or the fallible person doesn’t change, nothing really moves. I’m not against the idea of fixing things, but quite often what happens in blaming or fixing things is that we end up externalizing the problem and we never actually take the I am to reflect upon how this has changed us as a person. And learning, in true sense, relates to change. Change, not in the outside world, change in the inside world. And unless that connection is clear between learning and change, nothing changes. So, I’ll give you an idea. Sure.

Spinoza, if you look at the back cover of my book, there are four monkeys here. There are four monkeys here. And these four monkeys are basically the result of… When I finished the Costa Concordia accident, I conducted several workshops around the world. I went around the world. At one point, I even did some work with Todd Conklin, and we did some workshops together. Some of the themes that started to emerge from those discussions was that people would either respond by making a joke of the captain during the workshops, or they would have They would finger-point at him that he did something which he shouldn’t have done, or they would sympathize with him, apologize for his situation, or they would try to suggest some fixing that maybe he should have done this, maybe the company should have done that, and this shouldn’t have happened. So, this is interesting because as I was doing my research, the Dutch philosopher, Bark Spinoza’s book, one of his quotes stuck me, which is not to laugh, not to lament, not to curse, but to understand. And to me, until you move away from the idea of spending too much time thinking about whether we should blame this person or not, whether we should fix this person or not, laugh at this person or not, and take it back on yourself to say, what have I actually learned from this?

Nothing changes.

But you can combine the two. Yeah, but you could combine the two in the scenario of the pilots that fall asleep. There can be an internal learning because it could be some elements of, I made some choices, didn’t get a good night’s sleep, things of that nature that I chose from a career standpoint, which is an internalized where I’m not blaming, but there’s a self-realization of what was my part, my contribution. Then there’s also the element from a system standpoint to say, how often is this happening? What measures do we need to have to counteract? I’m hearing about new messages that otherwise we would never hear about. I can be addressing it at the individual level, at the cultural level, and the system level, which I think then addresses the learning piece. 

Absolutely, yes. You said something powerful here that if that realization comes from the person himself as part of interviewing or as part of reflection after the interview, that’s immense learning. That’s liberation. That’s healing, actually. If when this person comes to tell me that, we had a wonderful interview together and you asked some good questions, and as you were asking those questions, this is what I came to realize, that’s liberating. You have moved one person. Of course, you have learned something, and that person has learned something. But again, going back to the idea that if you’re not asking open-ended questions, if all you have on mind is to fix this person and determine how many processes he breached or how we can fix the problem through the social context or the technological context, whatever, then there is very little learning, very little, if any use.

And I think where I would agree is if you’re transferring the blame from the individual to the system, which means I’m transferring it to somebody else, I’m still blaming. Absolutely. And I think that’s the one challenge I have with the element of… I fully agree, don’t blame the individual. But there’s an element of learning. But shifting the blame to say, okay, now it’s all the senior executives that made the wrong decision, is still blaming. It’s just a different person because it’s just system indirectly means other people. I think there needs to be a balance between because it needs to be system learning because nothing happens because of one person. Also, at an individual level in terms of that realization and how do I change.

What I’m suggesting is, and I’m not suggesting these things are not important, What I’m suggesting is, as a default, the first question to ask is, from an investigator’s point of view, what have I learned after conducting this investigation? I think if we don’t begin there, nothing changes. Because at the end of the day, the report is someone’s view. With your bias, yes. It has to be. There is nothing objective in a report. You can have all the micro details, not enormous amount of data supported by timelines and facts and evidence, don’t take anything away. And still, it is somebody’s view, somebody’s worldview. So that is something important. So, unless that person shifts his worldview or her worldview, nothing really changes. If they still see in that accident… And this is interesting, Eric, because when organizations are stuck by failures one after another, I think it’s time to slow and ask, are we stuck with our questions? It’s so important.

That’s a good point. I think that’s a key element because, like you said, our decision Decisions are mostly subconscious-driven decisions. So, unless I understand the context, I’m trying to find clues. And as an investigator, I have a bias in what I’m doing, and the organization has a bias in what they’re doing. And to pull back from it, I think, it is really key.

Yes, very important. And the other important thing in this journey is that you cannot escape your belief system. You just cannot. This morning, I was interviewing… No, a couple of days ago, I was interviewing somebody involved in an accident. And he’s a Muslim guy, and he was a frontline worker. I don’t like the word. And he was involved in an accident, and he kept saying the same thing. I said, what have you learned from this towards the end, from this experience? And he said, Well, it’s God’s will. What can I do? I can’t do anything about it. And here you are, pushing him to follow permit to work system, a job hazard analysis, toolbox talk. He will do all of that. But does he really believe in that? And I think This is something we consistently ignore. To some cultures, an accident is a quest, or the solution to an accident is to find a root cause and put a collective action. In certain cultures, it’s the God’s will. It’s happened because of the God’s will. When you employ a multinational crew, you have people from around the world. It is very, very important for investigators to become comfortable with the idea that different cultures see misfortune or accidents differently.

Differently. Very differently. Yeah.

And it’s important to appreciate that. 

I think that’s an interesting point as well. Nippin, fantastic conversation. If somebody wants to get in touch with you, pick up your book, how can they do that?

Eric, my book is available on Amazon, I believe, in Barns & Nobles. It’s called, Are We Learning from Accidents: A Quandary, a Question, and a Way Forward, because there is a method in the end to show how to investigate accidents. Apart from that, I would say I’m active on LinkedIn. I have my own website, which is I have my company, Any website called

Excellent. Well, really enjoyed having you on the show today, and look forward to maybe continuing the conversation another time 

Sure. It’s a pleasure for me as well. Thank you for reaching out and making the connection.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.  

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Dr. Nippin Anand is a former master mariner with a master’s degree in economics, a PhD in Social Sciences and Anthropology and a desire for life-long learning in the wider disciplines of humanities, social psychology and philosophy. After a near collision at sea, he took up a passion for investigating accidents and helping leaders understand the importance of perspective in human failures. As a former subject matter expert at DNV, Nippin also developed an interest in making compliance meaningful for achieving business goals. He is the host of the podcast Embracing Differences, blogs regularly and is recognised both in the research community and across safety critical industries for his ability to make research accessible to businesses and people at work.

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Bringing Human Factors to Life with Marty Ohme

Bringing Human Factors to Life with Marty Ohme



There’s a safety decision behind every chain of events. We invite you to join us for a captivating episode of The Safety Guru featuring Marty Ohme, a former helicopter pilot in the U.S. Navy and current System Safety Engineer. Don’t miss this opportunity to gain from Marty’s extensive expertise and insights on system factors, organizational learning and safety culture, and effective risk management to mitigate future risks. Learn from the best practices of the U.S. Navy, as Marty brings human factors to life with real-world examples that can make a difference in your organization.


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me, Marty Ohme. He’s a retired naval aviator, also a system safety engineer. He’s got some great stories he’s going to share with us today around human factors, organizational learning. Let’s get into it. Marty, welcome to the show.

Thank you. I appreciate the opportunity to spend some time with you and share some interesting stuff with your audience.

Yeah. Let’s start maybe with your background and your story in the Navy.

Sure. I graduated from the United States Naval Academy with a bachelor’s in aerospace engineering. I’ve been fascinated with flight and things that fly since a very young age, so that lined up nicely for that. I went on to fly the H-46 Delta and the MH60 Sierra to give your audience an idea of what that looks like. The H-46 was flown for many, many years by the Marine Corps and the Navy. It looks like a small Chinook, the tandem motor helicopter. Then the MH-60 Sierra is basically a Black Hawk painted gray. There are some other differences But both aircraft were used for missions primarily for logistics and search and rescue. Then we did a little bit of special operations support. There’s a lot more of that going on now since I retired than I personally did. Then I also had time as a flight instructor at our helicopter flight school down in Florida. After my time as an instructor, I went on to be an Airbus on one of our smaller amphibians’ ships. Most people think of the Airbus on the big aircraft carrier. This is a couple of steps down from that, but it’s a specialty for helicopter pilots as part of our career. Later on, I went to Embry-Rural Aeronautical University, and they like to call it the Harvard of the Skies to get a master’s in aviation safety and aviation management. That was a prelude for me to go to what is now the Naval Safety Command, where I wrapped up my Navy career. I served as an operational risk management program manager and supported a program called the Culture Workshop, where we went to two individual commands and talk to them about risk management and the culture that they had there in their commands. Since retirement from the Navy, I work as a system safety engineer at APT We do system, software, and explosive safety. If you want to figure out and understand what that means, the easiest way to look at it is we’re at the very top of the hierarchy of controls at the design level. We sit with the engineers, and we work with them to design the things out or minimize the risk and the hazards within a design. You can do that with hardware, you can do that with software. And then explosives is a side to that. I don’t personally work in the explosives division, but we have a lot of work that goes on there for those things.

That’s Marty in a nutshell.

Well, glad to have you on the show. Tell me a little bit about organizational culture. We’re going to get into Swiss cheese and some of the learning components, but culture is a key component of learning.

Absolutely. So military services, whatever country, whatever environment, they’re all high-risk environments.

Absolutely. Specific to the Navy, my background, if somebody’s hurt far out at sea, it could be days to reach high-level care. It’s obviously improved over time with the capabilities of helicopters and other aircraft, but you may be stuck on that ship for an awfully long time before you can get to a high level of care. That in and of itself breeds a culture of safety. You don’t want people getting hurt out at sea because of the consequences of that. When I say culture of safety, in this case, a lot of people hear culture, and they think about language like English or Spanish or French or whatever the case may be. What food people eat, what clothes they wear, those kinds of things. Here, what we mean is how things get done around here. There’s processes and procedures, how people approach things, and the general idea. In fact, the US Navy is in the middle of launching a campaign called What Right Looks Like in order to try to focus people in on making sure they’re doing the right kinds of things. Something that’s been around the Navy for a long time and is specific to safety is using the word mishap instead of accident.

Sure. Because in just general conversation, most people will think, well, accidents happen? Really, we want a culture where we think of things as mishaps and that mishaps are preventable. We really want to focus people on thinking how to avoid the mishap to begin with and reduce that risk that’s produced by all the hazards in that high-risk environment.

In an environment like the Navy, it’s incredibly important to get us tight. You talked about what right looks like. But you’ve got a lot of very young people joining a very young age who can make very critical decisions at the other end of the world without necessarily having the ability to ring the President for advice and guidance at every call that happens. But tough decisions can happen at any given point in time. Tell me a little bit about how that gets instilled.

Sure. Organizations have to learn, and they have to learn from mistakes. These high-risk environments, you have to… When something goes wrong, because it will, you need to ask yourself what went wrong and why. In these kinds of environments, and you think about it, then that’s what leads to a mishap investigation. Then in order to do that learning, you have to really learn. You’ve got to apply the lessons that came out of those investigations. Then that means you have to have good records of those mishaps. I mentioned the naval safety command. That’s part of the responsibility of naval safety command is to keep those records and make them useful to the fleet.

Sure. We’ve just touched a little bit on building a culture of learning, how the Navy does it. Let’s talk a little bit about Swiss cheese. We’ve touched on Swiss cheese a few times on the podcast, so most listeners are probably familiar with it, but I think it’s worthwhile to have a good refresh on it.

Absolutely. As I mentioned about having good records, if the records aren’t organized well or structured in a way to make them effective, then it’s going to be very difficult to apply those lessons. As an example, if there’s a vehicular mishap, commonly referred to as a car accident, but we’re going to use the mishap virology here. If you have three police officers write a report on a single vehicle mishap, they’re all going to come out different, probably. One of them might say the road was wet, one of them might say there was a loss of traction, the third one might say that the driver was going too fast. It’s a lot more difficult to analyze the aggregated mishap data if every investigator uses different terms and different approach. This is where Swiss cheese comes into play, and it’s the follow-on. The follow-on works. Dr. James Risen provided a construct that you can use to organize mishap reporting with the Swiss cheese model. In his model, the slices of cheese represent barriers to mishaps. He also identified that there are holes in the cheese that represent the holes in your barriers. Then he labeled them as latent or active failures.

Latent failures are existing, maybe persistent conditions in the environment, and active failures are usually something that’s done by a person, typically at the end. His model has four layers of cheese, three with latent failures, and one with active failures. So, no barriers, perfect. If we look at our vehicle mishap in that way, if you start at the bottom, let’s say it’s a delivery driver. They’ve committed an unsafe act by speeding.


Why did they do that? Well, in our scenario, he needs a delivery performance bonus to pay hospital bills It’s because he has a newborn baby. He’s got this existing precondition to an unsafe act. Sure. Well, prior to him going out for the day, his supervisor looks at his delivery plan, but he didn’t really do a good job reviewing it and see that it was unrealistic. Sure. The thing is that the supervisor sees unrealistic delivery plans every day. It’s ingrained in him that this is normal. All these people are trying to execute unreasonable plans because the company pay is generally low and they give bonuses for meeting the targets for a number of deliveries per day. The company, as an organization, has set a condition to encourage people to have unrealistic plans, which the supervisor sees every day and just passes it off as everybody does it. Then we roll down and we have this precondition of, I need a bonus because I have bills to pay. This is the way that the Swiss cheese model is constructed. A little bit later on, Dr. Chapelle and Wegman developed the human factors analysis and classification system or HFACs.

They did that by taking reasons for slice of cheese, and they named the holes in the cheese, the holes in the barriers, after they studied mishap reports from naval aviation.

Tell me about some of those labels that they identified.

Some specific ones that they came up with are things like there was a lack of discipline, so it was an extreme violation due to lack of discipline. Sure. That would be at the act level. A precondition might be that someone was distracted, for example. Sure. A supervisory hole would be that there was not adequate training provided to the individual who was involved in the mishap. Then overall organizational culture, it might just be that there’s an attitude there that allows for unsafe tasks to be done. That sets everything up and through all the barriers to put our individuals, sets them up for failure and the mishap. We You see that in our delivery driver rec example where there’s all decisions, everything at every level, there’s a human decision made. There’s a policy decision. There’s a decision made to accept all these unreasonable plans. There was a decision that, okay, I must have this bonus. Now, that one, you saw if you could argue that one back and forth, but there was also a decision made to violate the speed limit, and that’s your active one down at the bottom. Yeah.

These helped essentially a taxonomy so that there is more standardization, if I’m hearing you correctly, in terms of incident investigations and classifications of learnings.

That’s correct. The decisions in this stack and the Swiss cheese come together. As you’re alluding to, there’s a taxonomy. So, Chapelle and Wegman, after, I think it was 80 mishaps in naval aviation that they were able to assign standardized labels. Those are the labels that became the names for the holes in the cheese. Once they put it in that taxonomy, they found 80% of the mishaps involved a human factor of some sort. I personally argue that there’s a human factor at every level, even if you go back and look something like United Flight 232 that crashed in Sioux City, Iowa, it all rolled back even to where there was a flaw in the raw metal that was used to machine the turban blade that ultimately failed. Sure. Did they make a decision not to do certain inspection on that block of metal before, and then it just keeps going down the way. There’s a decision in every chain of events.

Also, no redundancy in terms of the hydraulics, from what I remember in that incident.

Right. A design decision.

A design decision, exactly. That’s a great one. I like to use that as an example for many things, but we won’t pull that thread too hard today. But all these human factors, all these decisions, this is why in the US, the Department of Defense, uses HVACs as a construct for mishap and reporting so that aids in organizing the mishap reporting and the data so we can learn from our mistakes. It makes actionable data. There are other systems that also have taxonomies. Maritime Cyprus collects data. I ran across it when I was preparing for something else. Their number one, near miss, shows situational awareness as a factor in those things.

Situational awareness is a tough one to change and to drive.

It is. It’s a lot of training and a lot of tools and those kinds of things. I bought a new vehicle recently, and it likes to tell me to put the brakes on because thinks I’m going to hit something because it thinks it’s more aware than I am. It did it to me this morning, as a matter of fact. But it can be an interesting challenge.

Yes. Okay. Let’s go through some examples. I know when we talked about You had a couple of really interesting ones, Avianca, Aero Peru. Maybe let’s go through some of those examples of human factors at play and how they translate into an incidence from an aviation standpoint.

Sure. Avianca Flight 52 was in January of 1990. The aircraft was flying up to JFK out of Medellín, Colombia. The air crew received their information from dispatch about weather and other conditions as they were getting ready to go out on their flight. The problem was dispatch gave them weather information that was 9 to 10 hours old. Also, they did not have the information that showed there was a widespread storm that was causing bad conditions through a lot of the up and down, a lot of the East Coast. The other part was dispatch there had a standard alternate they built for JFK, which was Boston, Logan. Boston, Logan had just as bad a condition as JFK. They weren’t going to be able to use that in ultra, but they didn’t check. Then the air crew didn’t check either. They didn’t confirm how old the forecast was. They didn’t do any of those things. They launched on their flight with the fuel that was calculated to be necessary for that flight. For those who are not in the aviation world, when you’re calculating your fuel for a flight, you got to be able to get to your destination, what you think you need for your destination, what you’re going to need to get from there to your alternate in case you can’t get to your destination.

Then there’s a buffer that’s put-on top of that. Depending on what rule you’re using, it could be time, it could be percentage. It just depends on what rules you’re operating under and what aircraft you’re in. They have X amount of fuel. They launch out on their flight where they had 158 people on board. They get up there, and because of the weather, things are backed up JFK all the way up the East Coast as well. They can put in a hole near Virginia for quite some time. Then they get put in a hole when they get closer to JFK. They tried to get in a JFK, and they had a missed approach. They couldn’t see the runway when they did the approach and they had to go around. To go back into holding. The captain, understandably, is starting to become concerned about their fuel state. Sure. He’s asking the co-pilot if he has communicated to air traffic control what their fuel situation is. The co-pilot says, yes, I have. Well, the nuance here is that the international language of aviation is English, and the captain didn’t speak English. Co-captain did, and that met the requirement of one of them to be able to speak English to communicate with the air traffic control, but the captain didn’t know exactly what the co-pilot was telling air traffic control.

Well, that becomes a problem when the co-pilot was not using standard language. He was saying things like, hey, we’re getting low on fuel. That’s not the standard language that needs to be used. Correct. You have two phrases. You have minimum fuel, which indicates to air traffic control that you can accept no unnecessary delays. He never said minimum fuel. When they got even lower on fuel, he never used the word emergency. So, air traffic control did not know how dire the situation was. They It did offer them an opportunity to go to their alternate at some point, but by then they were so low on fuel, they couldn’t even make it to their alternate, even though Boston, the weather was too low there anyway for them to get in. Ultimately, they had another missed approach. They were coming around to try one more time, and they actually ran out of fuel. They ran the fuel tanks nearly dry on approach, and they crashed the aircraft in Cove Neck, New York.


Here we have an aircraft, and you would think that there would be… There’s almost no reason for an aircraft to run out of fuel in flight, especially an eyeliner. But with these conditions that were set, they did. Just as an aside, there were 85 survivors out of the 158, and a lot of that had to do with the fact that there was no fire.

Because there’s no fuel to burn.

Because there’s no fuel to burn. I understand this It had a positive impact on what materials were used in aircraft later on, specifically cushions and stuff like that that don’t produce the toxic fumes when they burn because they could show that people could survive the impact. It was the fire and the fumes that were killed. That’s just an aside. That’s the overview. If we back up a little bit and talk about what human factors rolled into play here. Dispatch had this culture. It was an organizational culture. It wasn’t like it. Sure. They used as a general policy to use Boston, Logan as the alternate for JFK. That was just the standard. They didn’t even check. They may or may not have been trained properly on how to check the weather and make sure that it was adequate for either for an aircraft to get into its primary destination or to its alternate, because the forecast clearly showed that the conditions were too poor for the aircraft to shoot those approaches. That’s an organizational level failure, and you can look at that as being that’s one slice of cheese. If we start going a little bit further down without trying to look at every aspect of it, if we look at what the pilots did, they didn’t check the weather.

They just depended on dispatch and assumed it was correct. Then once they started getting into this situation that they were in, there was communication in the cockpit. That was good, except it was inadequate. More importantly, the pilot couldn’t speak, was the only one in the cockpit that could speak English, so the captain didn’t have full situational awareness, which we mentioned a moment ago. Then he failed to use the proper terminology. That was a specific failure on his part. I don’t know. We can’t say if that was because he didn’t want to admit they were… If he didn’t want to declare an emergency because he was embarrassed, which is possible. He didn’t want to have to answer the captain, perhaps. If you had declared an emergency and ATC comes back and ask them later, why did you declare an emergency? Why didn’t you just tell us this stuff earlier? We don’t have those answers. Unfortunately, those two gentlemen didn’t survive the crash. But these are all things that can roll into a roll into that. When you break it down into HVACs, these preconditions, maybe he was embarrassed, maybe he felt that there was a power dynamic in the cockpit that he couldn’t admit making a mistake to the captain.

Then he had the active failure not using the correct language with ATC, the standard air traffic control language.

It feels as some CRM elements, some psychological safety, probably at play because you would expect the co-pilot to at least ask, do you want me to declare an emergency or something along those lines. For seek clarity if you’re unsure.

Absolutely. That’s a really interesting one to me. I use it as an example with some regularity when I’m talking about these kinds of things.

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How about Aero Peru? Because I think the Avianca one is a phenomenal, really interesting one. Actually, one I haven’t touched on much before. So, it’s a great example of multiple levels of failure. How about Aero Peru?

Aero Peru is another one that’s really interesting. It had a unique problem. So, the short version, just to give an overview of the flight like we did with Avianca, Aero Peru was flying from Miami, and they were ultimately headed to Chile, but they had a stopover. They had stopovers in Ecuador and Peru. During one of those stopovers, they landed during the day, and then the plane was scheduled to take off at night. During that interim time, the ground crew washed the aircraft and polished it. Then the aircraft launched. They got up a couple of hundred feet off the runway Anyway, and the air crew noticed that there was a problem with air speed and altimeter. It wasn’t reading correctly. Well, they were already in the air. You can’t really get back on the ground at that point. You’re already in the air. They flew out and they’re out over the Pacific, and they get up into the cloud. Now they’re flying on instruments, so you don’t have any outside reference out there. Just even if it was clear, flying over the water at night is a very dark place. They got out there, they’re flying on instruments.

Their attitude indication is correct, but they know their altimeter is not reading right, the airspeed is not reading right. There’s another instrument in the cockpit called vertical speed indicator. It also operates off air pressure, just like your altimeter and your airspeed indicator.


They’re very confused. To their credit, they are aviating. In the aviation world, we say, Aviate, navigate, communicate. Because if you stop aviating, stop flying the aircraft, you’re going to crash. To their credit, they aviated, They navigated, they stayed out over the water to make sure that they wouldn’t hit anything because they just didn’t know how high they were. Then they started talking to air traffic control. They’re very confused by all this that’s going on. There is on YouTube at least one video where you can listen to the cockpit recording, and then they’ll show you what else is going on in the cockpit. We don’t have the video, but they represent it electronically so you can see it. It’s interesting to listen to the actual audio because then hear the confusion and the attempts to make decisions and determine what’s going on. Ultimately, they get out over the water. They know these things are not right. They are asking air traffic control, hey, can you tell us our altitude? Because our instruments are not right. The problem with that is that the altimeter tells a box in the aircraft called the transponder. I sometimes call it the Marco Polo box when I explain it to people because the radar from the air traffic control sends out a ping like a Marco, and then the box comes back with a Polo.

But the Polo is a number that’s been assigned, so they know who the aircraft is on radar and the altitude. Well, the altimeter feeds the altitude to the transponder, so air traffic control can only tell the aircraft what the air altimeter already says. But that didn’t occur to anybody, and they’re under high stress, and this is a unique one. So, it’s just as an aside, my only real criticism of the air crew is you have a general idea of what power settings you need and what attitude you need for things, so they didn’t really seem to stick to that. But we all have to remember that when we’re looking at these, we’re Monday morning, quarterbacking them. I don’t ding them too hard. At any rate, long story short, they’re trying to figure out how to get turned around and go back. They’re trying to figure out what’s going on. Ultimately, they start getting overspeed indications warnings from the aircraft that’s telling them they’re going too fast, and they’re getting stall warnings from the aircraft.

At the same time?

At the same time. They don’t know if they’re going too fast or too slow. Overspeed is based on air pressure, which obviously all their air pressure instruments are not working properly. But stall warning is a totally separate instrument. It looks like a weathervane. If you walk onto aircraft at the airport today across the ramp, you may see the little weather looking thing up near the nose. That’s what is there for us for stall warning. They actually were stalling because they were trying to figure out how to get down and slow down since they were getting altitude and speed indications that were higher and faster than they wanted. Their radar altimeter, which again does not work, which also does not work on air pressure. It actually sends a radar signal down, was telling them they were low. They were getting, I’m high, I’m low, I’m slow, I’m fast. All this information coming at them.

That would be horribly confusing at the same time.

Horribly confusing, and there’s alarms going on off in the cockpit that are going to overwhelm your senses. There was a lot going on in the cockpit. Ultimately, they flew the aircraft into the water and there were no survivors. What happened here? When they were washing the aircraft, in order to keep water and polish out of the ports called the static ports that measure the air pressure at the altitude where the aircraft is at that time, had been covered with duct tape. Then the maintenance person failed to take the duct tape off. They forgot. Then when the supervisor came through, they didn’t see the duct tape either because that part of the aircraft, it looks like bare metal, so it’s silver. So, the gray or silver duct tape against the server, they didn’t see it. The pilots did not see it when they primly to the aircraft. So, when the aircraft When it took off, those ports were sealed, and the aircraft was not able to get correct air pressure sensing. Now we have to ask, how in the world did this Sure. Right. If you want to put it in a stag, start looking at slices of cheese, we have to ask these questions.

Why was he using duct tape? Was it because they didn’t have the proper Plug, which would have had a remove before flight banner on it? Was it they didn’t have it, or was it just too much trouble to go get it because they have to check it out and check it back in? Was this normal? Did they do this all the time? Did the supervisor know that and either not care or, hey, this is how we get it done around here. That’s a cultural piece. Sure.

At least use duct tape that’s flashing red or something.

Something. When you start looking at it in those terms, you have the, Is there a culture? Was there a lack of resources? Was there not adequate training? They didn’t know they shouldn’t use duct tape. It just seemed like the thing to Then the supervisor, did he know they were using duct tape? If he did, and it was for one of these other reasons, like resources or whatever the case may be, why didn’t he look carefully to make sure the duct tape wasn’t there because he knew they were using it? Did the air crew know that that’s how they were covering the static ports? Then when you get into the stuff with the air crew, they tried to do the right things. As we talked about, it was a very confusing set of circumstances. Like I said, standard attitudes and power settings would have been helpful. This is how these things stack up and how those holes line in the cheese to give you that straight path for a mishap to occur. It’s just a pretty interesting example of it.  

And multiple points of failure that had to align.


Because assuming the duct tape was not used just that one time, this probably many times where it was used before and didn’t cause an issue because they removed it prior.

Correct. Correct.

Fastening example. So, the last one I think you’re going to touch on is around non-aviation going into maritime, the Costa Concordia.

Correct. This was from 2012. A lot of people probably remember the images of Costa Concordia is rolled over. It’s rolled over on its side. It’s heavily listing. It’s run aground off an island in Italy. This one is truly human from beginning to end. No equipment failed. There was nothing wrong with the ship, anything along those lines. That’s part of the reason that it’s such a good example here. The captain or the ship’s master, depending on how you want to use it in your terminology that you’re going to use, decided he was going to… They got underway with passengers on board. He decided he wanted to do what was called a cruise by where he would sail close by an island, specifically a town on the island, so that he could show off for his friends and wave at them when he went by.

Always a great idea.

Yeah. Most dangerous words in aviation, watch this. He decided he was going to do this, and he had done it before at the same place. But there were some differences. One, the previous time it had been planned. He briefed his deck, his bridge crew, what is going to happen. They checked all the weather conditions, et cetera, et cetera. It was during the day when he did it the first time. This was at night, and he just decided on a whim as they were on their way out that he was going to do this. As they’re sailing in there, they actually hit an outcropping as they were approaching the town It ripped a big old gash down the side of the ship. I think it was about 150 or 170 feet long, if I recall correctly, or about 50 meters. That caused flooding in the ship and a power loss. Then they ended up, as you saw in the photos, and 32 people lost their lives. That’s a real brief overview. But what I want to do here is talk a little bit more about what led into We’ve talked very generally about slices of cheese in holes.

Sure. For this one, I’m going to go into a little bit more detail and use some actual HVACs codes or names for the holes and names for the slices of cheese. When you look at the at the Cruise Company itself, the attitude there seemed to be this captain was getting the job done. When that happens in an organization, somebody gets the job done is obviously has a little bit higher… They’re regarded in a better way than people that don’t necessarily get the job done. The problem comes when that individual is doing in an unsafe manner. Maybe they’re hiding some stuff about how they’re doing it. They’re doing things that are unsafe, but they’re getting away with it. You have to watch out for those things in an organization, excuse me, and for what people may be doing how they may be getting things done. At that level, he was accomplishing things. So organizationally, you have that. Then you can call it organizational or supervision in that next slice of cheese, depending on how you want to look at it. They probably didn’t provide adequate training. In the aviation world, we use simulators a lot. They’re using simulators a lot more in the maritime world now as well, and they can put an entire Bridge crew on a simulator together and practice scenarios and practice their coordination.

Well, they hadn’t had that with this crew. They failed to provide that training. This captain had an incident pulling into another port where he was accused of coming in too fast, which if you do any boating at all, you might see or might be going by a lake or whatever, you might see buys that say no wake zone. Well, the belief is that he pulled into this port too fast, created a wake, and that damaged either or equipment or ships. There weren’t any real serious consequences for him on that. So, they may have failed to identify or correct risky or unsafe practices. Sure. Then that’s, again, if they didn’t identify it, then they didn’t retrain him. Now they failed to provide the adequate training for him, failed to provide adequate training for the Bridge crew as a whole. Now we’ve hit organizational with the culture, we’ve hit supervision with the training on safe practices. Now we go into the preconditions for the next level. Complacency. He decided on a whim, essentially, that he was going to do this sail by. So didn’t check the conditions, those kinds of things. He didn’t consider the fact that it was… 

We’ll get back to that one in just a second. Let’s see. Partly because, or partly maybe because the crew didn’t have the training in one of these Bridge simulators, there was a lack of assertiveness from the crew members to him. That may have been because he was known to be very intimidating. He would yell at people when he didn’t like the information or when they told them things that weren’t correct. Rank position intimidation is one of our holes. Lack of assertion is a hole. Complacency, he didn’t think this was a big deal. And distraction, and this one’s very interesting to me personally. One, he’s on the Bridge Wing, which if you look at a ship, you usually have the enclosed Bridge. Then outside from that, you’ve got a weather area, weather deck, where you can see further out, those kinds of things. He’s standing on the Bridge Wing on the weather deck, talking to one of his friends ashore on his phone. Hey, look at us. Look at we’re coming by. Just get ready. Here we come. Then part of the distraction was there were ships guests on the Bridge Wing with him, which was a violation of policy to have guests on the Bridge Wing when they were in close proximity to shore.

And he had his girlfriend. Excuse me. His mistress. He was married and he was having an affair and had his mistress on the ship with him in violation of policy. So, he had all this distraction going on in addition to he just thought of this as no big deal. So now we’ve covered three slices of cheese, and let’s get to the last one, the ax. So, we have an extreme violation, lack of discipline, where we talked about all these preconditions, and those are examples of lack of discipline as well, where he failed to focus on what he was doing, allowed these distractions on the bridge, et cetera. And inadequate real-time risk assessment, day versus night. I checked the weather, I didn’t check the weather, et cetera. In this case, this is one where we’ve taken the codes, the names of those holes in the cheese and apply them to this specific case. There’s a whole lot of stuff with this one. There’s a reason that mishap reports are hundreds of pages long. But this one comes down to these examples of codes where he violated all these things. That was just before they actually had a problem.

It got worse after that, if you all are familiar with that case. Yeah.

Well, phenomenal story, but very applicable to other industries because there’s a lot of other industries where somebody is known for getting it done and might be doing some risky things in getting it done, just hasn’t been an event or a mishap, and people are not paying attention to those things. How did you actually get the job done? Or in the case of the driver, you’re talking about, the delivery driver, maybe he historically got it done, cutting corners, and they just decide not to look at some of those cutting corners.


Right. Festinating. So really good illustration, I think, in terms of culture, learning, and then Swiss cheese in terms of how different layers come together. Swiss cheese is not cheddar cheese. It has holes in it. It’s just a matter of those holes can line up at any given point in time. They’re existing.

Right. That’s where the latent versus active conditions may be. In the case of DOD and H-Facts, you have the organizational supervision and preconditions. Those are all your latent layers, and then your active layers, that last thing. In this case, where the extreme violations occurred in the inadequate real-time risk assessment.

I think the part I also like about Swiss Trees is it forces people to look at beyond the aviator, beyond the ship’s captain, beyond the team member in an organization that makes a mistake to the latent conditions that are linked to decisions that the organization has made over the time. These people in finance, people in HR, people in a corporate office are making decisions, not necessarily connecting to how it impacts somebody in the field. We don’t know about Aero Peru, but maybe it’s even somebody where in procurement, they forgot to buy the proper tools to do it and use what you have to because you go on to get the job done. A lot of conditions that impact other people in the organization. I think that’s also another reflection in Swiss cheese for me.


Great. Any closing thoughts that you’d like to add?

Sure. Just a couple of things. Aviators are, on the whole, willing to admit their mistakes. It’s because we know that it’s a very unforgiving environment. The ocean and aviation are very unforgiving environments. As an attitude, as a culture, we want to share with others so they either don’t make the same mistake we did, or they understand how we got out of a situation. If you look at Aero Peru, I mean, seriously, has anybody else had that problem ever where there’s duct tape, I run the static ports? I don’t know, but by talking about-Never heard of them. Yeah. By sharing this story, we have the ability to help others avoid that situation in the future. That’s really the way that we do it. The second thing that’s big in aviation is we’ve always had… The way that we really made big improvements in safety in our MSAP record is by planning and talking about these things. Somewhere later, somebody came along and named this the P-bed process, planning, briefing, executing, and debrief. But we’ve been doing it for decades. You actually have a flight You may not execute to that plan specifically, but at least you have a plan to deviate from, I like to say.

Sure. Then you brief it so that everybody understands what’s going on. Then obviously you go and execute it, and you may have to make changes to it along the way. That’s fine. When you come back, let’s debrief it. Hey, we had this mission. Did we accomplish it? Did we have any problems? What did we do well? What did we not do well? So that we can improve later. That really helps in a lot of ways, in a lot of industries or situations, if you just talk about what you’re going to do to plan it out and make sure everybody understands. When you plan it, if you have the right people involved, they can come up with solutions to problems that you see in planning. They may identify a problem that you see that you can avoid in the planning stage instead of running across it in the execution stage. So that planning, briefing, executing, debriefing is a real useful thing to have out Something that can be transposed in any other industry as well in terms of really thinking through the planning.

I think your point around the voluntary reporting is huge because having been in aviation, you hear about things that people would rather not talk about. I fell asleep, things of that nature. But if you don’t know about it, you can’t do anything about it because unless the plane crashed, you would have no knowledge that both pilots fell asleep unless they went off course dramatically. Chances are nothing’s going to happen because they’re going to be on autopilot and it’s pre-programmed and all good. But if you know something’s happening, you can start understanding what are the conditions that could be driving to it.

Right. Absolutely.

Excellent. Well, Marty, thank you so much for joining me today and for sharing your story. Pretty rich, interesting, and thought-provoking story with really good examples. Thank you.

Happy to be here.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.  

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Marty Ohme is an employee-owner at A-P-T Research, where he works as a System Safety Engineer. This follows a U.S. Navy career as a helicopter pilot, Air Boss aboard USS TRENTON, and program manager at what is now Naval Safety Command, among other assignments. He uses his uncommon perspective as both engineer and operator to support the development of aerospace systems and mentor young engineers. Marty holds a Bachelor of Science from the United States Naval Academy and a Master of Aeronautical Science from Emory-Riddle Aeronautical University. He may be reached through LinkedIn.

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Coming Home Safely: Advocating Safety First, Last, and Always with Dr. Lana Cormie

Coming Home Safely: Advocating Safety First, Last, and Always



“Safety is the most important part of your job.” Tune in as Dr. Lana Cormie shares her heartfelt and moving story of navigating life after losing her husband in a workplace incident in 2018. She passionately advocates for improving safety and enhancing an intentional culture of safety in the workplace through ongoing training on the job and prioritizing the reporting of hazards, concerns, and near misses. Lana reminds us of the importance of keeping safety at the forefront and empowering team members to become safety advocates in the workplace, ensuring everyone goes home safely at the end of every workday.


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Dr Lana Cormie, who’s joining us from Australia and who’s a safety speaker. Lana, welcome to the show. Very excited to have you with me today.

Thanks for having me along.

Absolutely. Tell me a little bit about your story.

I guess if we start from before, I feel like my life is split into two halves these days, the before and after. So, prior to 2018, I would say that I had a pretty great life with my family. I was married to Charlie, my husband, and we had two young children who at that time were one and three. And we were living on 40 acres in country Victoria, the south of Australia. And we, I guess, had bought our forever home. And it was very run down. We were working to improve it, both the house and the acreage. And I guess we had moments where we thought to ourselves, we’re pretty lucky, how great is this? We’ve got two healthy children. We’ve got this amazing place which we’d love to spend our life living in. And we were really looking forward to our future. Of course, we didn’t know that things were going to change. We had, at that time, I should say I was working as a veterinarian, working in animal welfare. Absolutely loved my job and my career. And my husband Charlie, he’d had a background working as a stockman on, I think you call them ranches in the northern part of America.

And the He was very talented stockman and horseman, but he’d later gone on to become a qualified carpenter and in fact, a registered builder. But at this time of our lives, he was working in civil construction, mainly because it gave us a regular income. So, it felt like, I guess, a safe option financially while our children were so little, and I was working part time looking after our baby. But of course, we didn’t realize it wasn’t a safe at all. And on the 21st of March 2018, Charlie went to work, and he never came home.

I’m sorry to hear that.

So, on that day, I was at work. The children were at daycare, and we had a lot of work on. So, we were busy doing surgery on animals. And I became aware through the press that there had been an incident and that the highway near to where I worked had been closed. So, we had a short conversation, which went something along the lines of, oh, I hope no one’s been badly hurt, must be a bad car accident. And then we carried on with our work. So, then A few hours later, I went off to lunch because I’d forgotten my lunch that day, and then came back in the driveway at work. And I looked up and there was this helicopter hovering in the sky. And I guess that helicopter signifies the end of life as I knew it. And it was not long after that we discovered through social media that there had been an incident on a work site nearby, that one man was dead and another was injured and fighting for his life, and they were still trying to rescue him. Now Charlie, we found out not long later was the man who had died.

So, my nurse and I drove around to the roadblock to speak to the police officers because I hadn’t been able to get hold of Charlie on the phone. Sure. And I couldn’t get any information through the company that he worked for. So, we went around to where they had blocked the highway, and the police officer informed me that it was my husband who had been killed. The other fellow, his family had also not been notified and had done a similar thing at the at the same time. His name was Jack. He was buried up to his neck with just his head and one arm free. And unfortunately, he never got the opportunity to speak to his family because He was flown to Melbourne, went through multiple surgeries and died in hospital the following day.

It’s horrible.

Yeah, it was horrible. Yeah, look, it has been terrible. I suppose I It’s probably obvious to say perhaps that the worst part was having to tell our children and having to drive to daycare and pick them up and be in what felt, I guess, a little bit like I was in a movie or some nightmarish out-of-body experience where there was some other lady whose husband had died and she was now having to go and pick up her children who now had a dead father. It was really a situation where I was in so much shock that I picked up these children with my mom who had come to help me and took them home and really didn’t know what to do next. So, it wasn’t until later that evening that the police turned up at our house, which was presumably our notification, which you can imagine was far too late. And we, I guess started to, I don’t know if it really sunk in by that point, really, what had happened. And it wasn’t until early the next morning when my children woke up that I had to tell them that their dad had died and that he was never coming home. And that was the worst thing I’ve ever had to do.

No doubt. Tell me a little bit more about what transpired in the work site because you thought it was a safer environment. What was happening in that work site?

I’m a little bit limited with how much detail I can provide here because whilst there has already been a court case and a prosecution, the case is still sitting with the coroner. However, what I can say is it was a deep trenching job, so they were digging trenches to lay sewer to round about the four meters in-depth. And of course, that work requires a lot of safety practices to be followed. There’s a lot of rules and regulations which need to be adhered to. For sure. And on this day, two men died. So, I think that probably tells you about where that was at.

So, the precautions that you normally would need to have because there’s a high risk in an environment like this, that the sides collapse seemingly weren’t present. When you speak about the incident, because you regularly speak about safety and talk about the importance of safety. What are some of the themes that emerge from your experience?

I think a big one is really about near misses. It took a long time for us to understand much detail about really what had happened to Charlie and Jack. In fact, only recently, the coroner found out some information which to her indicated that they were not in the trench at the time of the collapse. So, you can understand how distressing it all these years was not to really understand what had Sure. But certainly, it became clear a lot earlier on that there were some near misses that, I guess, were an opportunity, an opportunity that in this case didn’t result in safety systems being improved. So that’s something that I often talk about when I speak about this to companies, which is really that a near miss is a gift. And if you see that miss and you take the opportunity to improve your safety systems, you have a look at your systems of work, see what’s working, what isn’t, and rectify that. It’s not overstating it to say that that could be the difference between life and death in your workplace.

A hundred %. It’s a huge lever to tap into that so many organizations miss. Issues don’t get reported, they don’t get addressed. And organizations don’t drive the right follow through, which is a huge component. So really a gift when you’ve got those learnings.

Yeah, that’s right. I guess if you’re at the point of having a near miss, you’re a huge component. So, it’s really a gift when you’ve got those learnings. Yeah, that’s right. I guess if you’re at the point of having a near miss, you’re really close to having a catastrophic event. And I think reporting is just so key and not just of near misses, but obviously of hazards and concerns in the workplace every day, all day. It needs to be kept front of mind. And I guess that’s another reason why I’ve taken the opportunity to speak about my experience to workers, to employers, to managers, all of them, because keeping this front of mind is absolutely the key, because we get so tied up with all the pressures on us. We’ve got KPIs to follow. We’ve got production targets to meet. We have financial issues. There might be things happening at home. There’s so much going on in our mind, that often safety falls down the level of priorities, I suppose. And it can’t be that way. It must be number one every day. And it must be the first thing that we do before we think about anything else to do with our work.

So, I always say that safety is the most important part of your job. And that is to make sure you get home at the end of the day. It doesn’t matter how great you are at your job, how much money you’re making, how great your team is, any of Those factors if you’re not alive and if you’re not home at the end of the day. So, it has to be number one. But it’s easy for it to sometimes not be at the forefront of our minds.

It’s a huge It’s a huge challenge for it to keep always being at the forefront every given moment. It’s very easy to get sidetracked by something else or think, this might not happen to me. This whole element of keeping front row center. I remember I worked with somebody who says, if you put a card in front of your head and that’s remembering about safety, it’s so easy for it to slip to the back of your mind as you’re doing the work because you’re in a zone, you’re delivering. How do you bring that card to the front of your mind to always remember that this is the most critical thing right now for every decision I’m making?

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Yeah, it’s absolutely a challenge that us as individuals, but also as organizations need to tackle. Part of that, I guess, is on management to be absolutely vigilant, zero tolerance for unsafe practices, really encouraging people to report and to be thinking about things all the time. It’s also about training. I mean, we don’t know what we don’t know. So not just the initial training, but ongoing training. I didn’t know much about safety, even though I was working in my own workplace. I wasn’t really up to speed with the Occupational Health and Safety I didn’t really understand what that should look like in practice in the workplace. And I think that’s a common experience. I certainly believe that if Charlie and Jack would have had more knowledge or even if I’d had more knowledge, I would have also picked up that something wasn’t right. But certainly, if the workers don’t have the knowledge, they can’t protect themselves. They also aren’t well placed to keep bringing concerns to the employer, which, of course, is so key because managers can’t be everywhere. They do rely on their teams to say, I’ve got a concern, or I’ve seen something. Having our workers really well trained to recognize hazards That’s all part of the picture.

But the other thing I think that’s really this is part of the reason why I speak and go and discuss these issues and do presentations is that I think sometimes rules and processes and numbers, they don’t stick that well in our mind. And so, it can be really hard work to keep maintaining that. And it is hard work. It’s a central but what I’ve discovered is that stories, we’re good at remembering stories.


And not only does hearing a personal story of tragedy in the workplace help to wake us up a bit, that this could happen to me, this could happen in my workplace, this happens to normal people like Lana, like Charlie, like their family. There’s that. It’s the fact that we can identify that it’s not some random person on the news. It’s a real person. But it’s also, and this is what I hope happens, is that if we have a story that links the rules with our emotions and our sense of self, then we’re more likely to carry that story with us in our memory. And not only is that a sense that I have, it’s also something that’s been proven, that stories are something we remember. Absolutely. So, I hope that in the work that I do now, I can be part of that picture, a small part of improving the safety in the workplaces which I speak to.

Sure. I know when we first connected, one of the themes you talked about was how recognizing hazards is not really part of how our brain functions. So, tell me more about that.

I’ve spent six years now and I’ve spent quite a bit of time thinking about these things and certainly speaking to some really interesting people, some of those working in universities and doing studies on such matters. And I always wondered, how could they not see it? How could they not see that they were in danger? But of course, they didn’t. And they didn’t do anything that they felt was dangerous or, in fact, that most of us would think was unsafe. Unfortunately, the systems weren’t in place to prevent something from happening. But what I’m trying to say is that we’ve evolved into this modern world where we now build skyscrapers. We go to work, we dig trenches, we do all sorts of activities. But really, our brains are still cave people. And I’ve had some interesting discussions with some researchers on this that we’re not well-designed to recognize hazards. We’re not well designed to understand danger, particularly if we’re exposed to it on a regular basis. So, if we see something and we think it’s dangerous, Initially, then over time we become desensitized. And as a cave person, we would understand that, okay, initially I was a bit worried about that barrier on that bush.

Now we’ve tried it. It hasn’t made anyone sick. Now it’s a good source of nutrition. We’re not concerned about that anymore. And we had to have that understanding that an exposure that didn’t result in in anything of concern was then something safe to interact with. And of course, as humans living in our life, we can’t run around thinking that we’re in danger all the time or we just wouldn’t function at all. We’d be hyper stressed. We would be. But if we’re in the workplace, of course, this works against us a bit because there are hazards. Sometimes we work in very high-risk environments, and we need to have our mind turned on to recognize those hazards all the time because they could be life threatening. That doesn’t matter whether we see them every day and nothing’s happened yet. It still could progress to an injury or a fatality. And that’s not what we want. So, it’s not really our fault as humans that we’re not great at this. That’s why we need training. That’s why we need to have ongoing processes in place that keep it front of mind, that ensure we’re reporting and that we’re rectifying things as we go along.

I think that’s a really important piece because our brain will naturally start accepting that certain risks are okay. It’s how do we bring a front row center always reflecting the same as people who are working in high-risk professions will often have the retention on the highest risk task. If you’re working next to an electrical conduit and it’s energized, you may be very cautious of the work you’re doing there. But then suddenly driving doesn’t seem dangerous. Or other functions that you may be doing that are not as high risk may also not appear as dangerous, but there’s still danger associated with it. There’s a lot of little tricks where we can get into a lull sense of security around the hazards in front of us. That’s really even the peer reinforcement. But something like trenches, you mentioned, before I got into the safety space, it’s not something I kept thinking about, oh, this is a big risk. Because when you grow up, it’s not something you’re thinking of, front row center. That’s the education when you come on a job site. When you talked about near misses, to me, a big component is also how do you reframe that this is a positive?

Because you talked about the gift, but if you don’t feel psychologically safe to bring it up if people minimize it. I had somebody was sharing a podcast that he had highlighted a risk, and he had been told, are you a man or are you a mouse? That’s going to precondition you to never highlight risks or never highlight near misses.

Yeah, I think you’re absolutely right. It’s not something that comes naturally to us, is it? To feel, to put up our hand and raise an issue all the time, particularly if that’s going to slow the job down or certainly if it’s going to have some negative response. And I think that is Absolutely key. And that’s where the culture of a company and their response to reporting is absolutely integral, particularly to get that culture started. You need to be actually pushing people all the time. Report, report, report. And certainly not even having the remotest level of negativity when that happens and in fact, actively encouraging it.

Encouraging the new misreporting, but also encouraging somebody stopping work if they see something unsafe, because that decision to say, I’m going to stop work is also a very tough one. People will often say, you’re allowed to stop work. But having stopped work early on in my career, knowing the financial consequence of stopping work, which was not a small number, it was a five with lots of zeros after, You start really rethinking, especially when the next day you discover that what you thought was the right reason to stop work actually wasn’t a dangerous case. It becomes very… You really think two times, three times, 10 times before pull the plug. And that needs to be reframed.

Yeah, I completely agree. I honestly, I don’t think that a lot of work, and this comes back to training, a lot of workers actually realize that they can stop work for a safety issue and that that’s protected in the law, that right to do so. But also, as you were saying that something else came to mind, which is that I had a conversation not long ago with actually an OHS manager. And after listening to my talk and hearing my story, he came up to me and he said that he had had times quite recently where he was exactly as you say, really unsure about stopping a job because of a safety concern that he had. And he was the manager. But of course, he’s got pressures above and below. And he was really unsure about that. And one of the outcomes of listening to my story for him was that he felt that made him feel more confident in making that decision. That in his mind it made him feel the pressure to do the right, the safe thing is greater than the pressure, the external pressures of the job, the work, the money.

What might my manager say? What if it doesn’t end up being unsafe in the end? All those things, I guess, reduced in his mind because the story was something that he felt lifted up his safety concern and made him feel justified in doing his job and doing it well.

I think, hopefully, stories like this reinforce it but it’s also the response of leaders. I know when I made that decision, then the next day, it was discovered with new facts that it was the wrong call to make. But based on everything I knew when I made the decision, it felt like the only right thing to Like you said, you’re lucky if it’s a legislator requirement. In some cases, it’s not. It’s a company requirement. But what really made the difference is the COO flew down the next day, even if I’d made the wrong decision to say I had made the right decision and to give me a pat on the back. That reinforces as a signal saying that’s more valuable to me versus making the right call. It was the right choice to make sure people were safe.

Yeah, absolutely. That’s the response that you’d like to see from your upper management.

A culture we’d love to roll out through all workplaces, I think. But it’s also a reflection what do you do as a senior leader when something like this happens? I’ve seen in some organizations, in this case, he literally flew down and not reinforce it. But I’ve seen in other organizations where they celebrate publicly those instances and really reinforce that this is a desired value. Because it’s one thing to say it’s legally allowed, it’s a different thing to actually feel you can actually pull the plug.

Yeah. I I think that comes back to our psychology discussion that as humans, with our brains that we have, we need to be constantly encouraged in a certain direction. And it doesn’t take much to end up sitting not saying anything. It can be scary, even in a good company, to have to stand up and say, I don’t feel safe, or I don’t think this is a safe practice or indeed to stop work. It’s quite a scary prospect for most people. But I think it comes back right to the beginning. Before you get anywhere near an incident or a near miss or a serious concern, that day to day conversation around hazards, about risks, about the right way to do things and educating your workforce. It’s a big task, but like I say, It’s the main one, because if we can’t do that bit right, there’s no point doing the rest.

Correct. So, Lana, thank you very much for sharing your story with audiences across Australia and around the world. If somebody wants to get in touch with you to have you share your story with them, again, like you said, the power of storytelling is huge. In this element of we remember those stories and they’re memorable, and they can be the little catalyst to elevate a decision to where we want it to be, how can somebody get in touch with you?

Yeah, sure. So, as you said, I do face to face talks in the Southern part of Australia, but also do online talks both nationally and internationally. So, if anyone was interested in having this as part of their work to improve safety in their workplace, I can be contacted through CNBSafe and their website,

Excellent. Well, thank you very much, Lana, for joining me today and for sharing a story with our audience.

Thank you so much for having me.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.  

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Dr. Lana Cormie and her two children are navigating life without a husband and father as a result of a workplace incident. Lana was at work when her staff saw the rescue helicopter hovering over a nearby construction site. She didn’t think much about it until she called her husband Charlie on her lunch break and he didn’t answer. The helicopter was there for her husband and a workmate who were fatally injured in a workplace incident.

She had been a happy mum, wife and vet who, like most people, was blissfully unaware of what happens when a loved one doesn’t come home. Her life changed dramatically from that day forward.

Lana has become a passionate advocate for safer workplaces, campaigning for better policies and improved legislation for workplace safety. Lana now shares her life experiences in an effort to help improve safety and educate employees and employers on the importance of a safe workplace.

Lana believes by sharing her lived experience she can influence safety cultures and that the most important part of work is to go home at the end of the day.

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