Are you working safely or are you just being paper safe?

September 22, 2023



For decades, western societies have become increasingly committed to demonstrating in the most tangible way possible (i.e. through procedures) that risks are mitigated to all possible extent. Quantification and documentation have gradually come to dominate every aspect of risk, and disconnection with the reality of work has lead many to question the purpose of what we have created around work and safety. Greg Smith in his book “Paper Safe” has brilliantly unpacked this issue and the assumptions that sit in the back of it. Nippin met Greg while in Australia for a conversation that sheds light on how paperwork has so often become a blanket that rather than keeping us safe and warm, is blocking our view over the things that help us understand and tackle risk.

Further information




Hello and welcome to another episode of embracing differences with me Nippin. I am the founder of novellus, a company based in the UK specialising in organisational culture and risk maturity. Our work is to make organisations rather people culturally sensitive and risk intelligent. And we promote the idea of transdisciplinary thinking and managing risk, which basically means bringing together different disciplines to make sense of how human beings make decisions, how we learn, and how we learn to work together. Our area of work includes organisational culture, accident investigations, leadership training, and a culture of learning through proven experiential learning methods based on social psychology of risk. Everything we do is semiotic meaning our methods are visual and verbal. And it is only through visual and verbal methods that we begin to appreciate that no two people see the world in the same way. Meaning, if I see things differently than you, then slow down, ask open ended question, start respecting and listening to my point of view, so that we can both learn from each other. This is a very special episode for me for many reasons, and one of them being that I was in New Zealand for a couple of weeks ago. And on the way back, I had this opportunity to meet with problem, the founder of social psychology of risk in his hometown, Canberra. And on the way back, I thought that this would be a great opportunity. Now that I’m already in Australia to also meet with Greg Smith, who’s based in Perth. So I actually flew four and a half hours from from Canberra, to Perth, to meet Greg. And Greg’s work has always intrigued me.



For many, many years, his book Paper safe is quite an influential thesis. If you have not read it, I would strongly recommend that you read. And my curiosity was that despite the fact that his book has had an immense impact in the world,



for for for a very simple and yet very powerful argument that it doesn’t matter how many documented processes you may produce, what is really important is that, that your processes actually aligned with their intent. And that is important from Greg’s perspective, not just for operational and business reasons.



But also from a legal perspective, which is quite rare. Because often what we hear in many organisations is that when things go wrong, it is quite, quite easy to hide behind processes, and lay the blame on on people who actually do the work. So this is the question I wanted to ask from Greg that, despite writing such a powerful thesis, which makes sense in many, many different ways, why is it that so few organisations or have have have, have really taken his his work



to discipline itself implementing the safety management systems and management systems in general? So we had a great discussion on this topic. And so I, I hope you enjoy listening to this discussion. And any questions, you can always come back to me or you could write straight to Greg Smith, he is on LinkedIn, and I’m sure he would respond to you. If you asked a question.



Greg, nice to meet you. Good to have you here and even is saving me the time to come and visit. Oh, it’s I can’t believe it’s been a lot of zoom calls and online discussion, which I think is okay, but this is nothing like this. Yes. So thank you for inviting me to your place. lovely to have you here. Greg,



I have a question actually. And the question is this that your book Paper safe?



It makes so much sense to me



at a commercial level, at an operational level at the regulatory level level.



And I think the message is very, very clear. Maybe the starting point is for you just to just to still tell us what this book is all about. And then see where this goes from here. Yes. So the primary rationale behind the book was



what I perceived as a disconnect between process and purpose. So organisations would invest a lot of effort and energy in creating lots of safety paperwork.



And then the, the organisation then struggled to demonstrate either what the purpose of the paperwork was, but more importantly



or not.



Initially, just the paperwork, the process was was the process of achieving the purpose that was designed to achieve.



And I think there’s been some more simplistic interpretations of the book, which says, get rid of paperwork.



And I think I’d like to think that the message is a bit more nuanced than that. It’s not just to get rid of paperwork, although



I do think there are lots of processes we can get rid of in safety, a lot of its duplicitous. It. It’s, it’s just overlaying bureaucracy, on bureaucracy without any real need. But the real message of the boot was, what? Yeah, how do you know that your process processes are achieving the outcome they’re designed to achieve?



And also, and this is probably more of a legal risk management perspective. But if you’re not prepared to put the time and effort into understanding if your processes work, you’re probably better off not having them. So rather than building mountains of checklists for your workers, that you never really check and see if they’ve been done properly, or if they work, don’t have the checklists, because they’re not adding any value and you just don’t know what’s in them. Yes, not only they’re not adding any value that actually undermining both reputation as well as the legal aspects of it. I think that’s, I think that’s the risk.



And this is the difficulty that it’s hard because you can’t you can’t apply a one size fits all and say, if you’re not doing this, you’re creating legal risk, because you might not be it might be that your people are paying close attention to the process and diligently understanding it and apply it. Okay.



My experience tells me is that we don’t know the answer to that question until something goes wrong. And it’s not until something goes wrong. And when I say and that’s not even quite right. It’s not until something goes wrong, that a regulator comes and looks at it, that we know the answer to that question. Because typically, in our own organisations, when something goes wrong, we will look at



the immediate circumstances around the incident. But we won’t go back and look at the history of our process to see what that shows us. So it’s not until something goes wrong. And a regulator comes in and starts pulling it apart, that we actually understand whether there’s any alignment between our process and what we’re trying to achieve. And so it’s just sort of sitting in the background ticking away, like an unexploded bomb waiting to go off, and we don’t actually know what’s in it.



And so, from my perspective, when you think about



what is the gold standard look like? It’s, you have a process.



The purpose or the objective of that process is well understood people understand the process. And all of the supporting material, as part of that process is all consistent. And, and evidence is compliance. And that’s what we don’t have.



Now there are,



the other part of it is



whether the processes, even if they are done well, are inherently helpful. And I know you’ve spent time recently with with Rob long, Rob has strong views about what is good and bad.



My views about what is good and bad, are less tightly held, I do have some views, they’re less tightly held.



But my conversation with people is will show me that it works for you.



And you can take something as simple as a zero harm mantra in an organisation I, it doesn’t appeal to me personally.



And we know there is plenty of literature that says it can be problematic, and we understand all of that. And I guess the challenge to organisations is to recognise all of the assumptions that underpin your processes and explore them. does this process work for your organisation, rather than a blanket? And I think



I think we’re seeing this a bit in safety to the safety differently movement. So people will say learning teams are great.



As though that’s a universal given.



And it’s not, you can you can have learning teams that are really good for an organisation or even even parts of an organisation might do them better than other parts. But to say everything in safety is universally and automatically a good idea is just I don’t think that’s a defendable position, you have to understand does it work for you as an organisation?



And that that’s kind of the key message I think, in paper safe.



And I think one of the mechanics to try and do that is probably to remove stuff from the organisation that doesn’t add value. Right? And yes, you’re what it is.



talked about it.



So Greg, the message is is is clear, is very clear that, that the process must meet its purpose. Right? Otherwise there is very little in terms of value addition. Yes. And ethics, it is unique in that sense, you can you could apply the same to quality and environment and HR and any of those sorts of management disciplines. Yes, it does. Yes, that makes us so, and it’s, you know, you probably a lot of people in the Risk and Safety world have read this book. They are here, I think they are a lot of people are convinced with the message,



I still struggle to understand, why is it that that it makes so much sense at each every level? Commercial, operational, you know, why doing some things that don’t add value is a very commercial question. Also, in some ways, it has an operational value. It has a, it makes a lot of legal sense to me, although I’m not a lawyer. But the question is, despite all these wonderful and robust arguments that you’ve put through, why is it so difficult for organisations to actually have people to embrace this idea?






it’s a funny one, I struggle with it, even myself advising clients, you always get a bit nervous, saying, oh, you should take that, take that away.



Because ultimately, if something goes wrong, everyone’s quite happy. So Greg told us, we should take that away. So there’s,



there’s a nervousness about it.



It’s, it’s interesting, I think, I think the regulator has a role to play in this so often in this is very much in an Australian context. But the regulators are very much show us the documentation. So I think a lot of what we do is, is just there to satisfy regulators. And I think that’s uncomfortable. And part of the problem.



And again, this might be a bit Australian centric, but I suspect it’s broader.



Companies are very, very compliant to health and safety regulators. If the regulator comes in and says, we’re going to issue you this improvement notice, or we require you to develop, you should have this checklist, we kind of just do it. We don’t push back, we don’t challenge. We don’t argue the toss. And we end up building this mountain of stuff dictated to us by regular. So I think that’s part of it.



I think there’s a cultural issue, and you’re probably as well qualified to speak to this as anybody.



And it’s something I’ve heard Professor Dru Ray talk about this idea that if you’re critical of anything in safety, and you say we should get rid of that, then you’re seen as anti safety, and you don’t care. That’s, I think that I think that really plays a part of it. And it’s interesting. So, again, Dave Provan, and drew rea talk about creating this term safety clutter, to try and create a safe space, we can have that conversation about things that don’t add value.



And I remember very early on in the piece, even before I wrote the book, talking about things like J Ha’s and those sort of frontline documents, and very often coming up against the argument that



it’s better to have something that doesn’t work than to have nothing at all,



very often hearing that and thinking, Oh, that’s just I just don’t know where that come from.



But looking back with, you know, probably another 10 or 15 years under my belt, I think it is, again, this idea of what Provan and Ray would talk about as demonstrated safety, we need to be able to show something.



And it doesn’t matter how many cases you put up and say here’s a decision. They didn’t have any documented systems, they were able to defend the charge. Here’s a decision that had all the documented systems in the world, but they didn’t align to the way work was performed. Therefore, they had no defence.



And it’s just, it’s not, it’s not



it’s an it’s a I think it’s an emotive attachment to processes, not necessarily rational reason. No, you’re absolutely right. There is an emotive aspect to it. But it’s going back to this idea of demonstrating safety through process and you call it proving safety in the new book.






I think I don’t know what you think about it, but



does demonstrating safety mean holding more documentation?



Ultimately, no, I ultimately No, I don’t think so.



That the documents



go down a real rabbit warren, here’s our quiet try and be brief but the documents at the start point of your conversation. So if you if you have a signed checklist it’s been in



incident involves a piece of equipment, there’s a signed checklist, the check or the checklist is evidence of that somebody’s completed a checklist. It’s not evidence of their understanding of the of the equipment, it’s not evidence of their understanding of the risks associated with the equipment. It’s not even evidence that the equipment



was fit and property use. So it’s not an all of that stuff. All of those questions, which are the actual questions that matter,



are dealt with, through witness interviews and cross examination and further investigation? So



you have a



checklist says everything’s in good condition.



And the objective evidence when the piece of equipment is looked at is that well, it wasn’t in good condition, it was missing things that that’s what gets done. And



then the question becomes, okay, is this improperly completed checklist? And this is terminology I use? Does that represent a one off departure from our system? So do we have a good system where people are trained and understood and they normally complete these things properly? Or is it evidence of systemic failure? And very often, what you get is evidence of systemic failure to a checklist was completed six weeks ago, and it says this guard was missing off the equipment. And that goes in and nothing gets done about it, and all the checklists after that, so the guard was in place. And that’s surprisingly common in these sorts of incidents.



And and what we don’t have is anybody



organizationally, going back and checking, here’s a completed checklist, does this checklist



represent the state of the equipment, what what we what we measure and count is the number of checklists that have been completed, yes, one has been done every day.



And so



that’s that’s the, that’s a conversation about if you’re not prepared to put the time and effort into understanding it’s been done properly, don’t do it at all.



You could just as easily have a by exception reporting. So if something is wrong, then it gets reported rather than this. Here’s a checklist to show it’s been done.



As a, as an exercise, in theory,



you get exactly the same outcome.



As you’re not potentially creating a database of



non compliance sitting over here.



And, and,



again, this is the agony if you’ve got a system like that, and you’re going to invest the time and effort to make sure it’s done properly, you’re not doing something else.



So if we’re not going to going to invest the time here, let’s get rid of it. So it doesn’t create that kind of risk. And we can invest our time deciding what we’re going to do properly. And this.



I don’t I still don’t think, particularly from from a personal safety perspective, let’s say from a process safety, but from a personal safety perspective, we’re not, we’re still not very good at criticality, in trying to understand this is what’s really important, we’re going to pay attention to that, and other stuff isn’t so important.






yeah, we tend to



our priorities in safety, tend to swing pretty dramatically, and typically following an incident, to have had an incident that involves somebody losing the top of their finger, or all of a sudden, everything is invested in that.



But even then, and you would appreciate this snippet, even then somebody loses the tip of their finger. The investment in energy is typically around the mechanics of the loss of the finger. So the equipment, the PPE, the individuals involved,



very seldom, in my experience, at least you draw back and say,



Well, what are the broader training competencies, supervision,



production pressures, access to resources? Does this loss of a finger is that representative of, again to use what I said before? Is that representative of a one off departure from our system? Or is there something more systemic under this? We’re very, we’re very good at small snapshots



and not holistic views. Absolutely. I’m just listening to you for the last few minutes. I’m just starting to think that maybe we don’t understand we don’t have, we don’t even have a definition of what a process means. Because everything that you’re suggesting so far, is that a process is not so much a documented thing. No, no. Maybe we need to unpack this whole idea of what is a process or a system? Yes. So the classic one I would give is



You know, when you’re a child, you’re taught to cross the road, look to the left, look to the right, look to the left, again, you cross the road.



That’s the system for managing the risk of crossing the road.



But it’s not documented. You don’t fill out a checklist every time you do it. We use, we use system systemic approaches or systems or processes, however you want to describe them to manage everything we do every day.



Sometimes we do it without even thinking about that’s the whole heuristics side of human behaviour.



And yet, when it comes to safety, we, we seem to have this obsession that we have to proceed realise everything.



I often talk to organisations when I look at investigations, and I say, well, that’s our this, this wasn’t, there wasn’t a procedure for this. So that’s okay. But Did it meet the expectations of the organisation? And it’s like, well, hang on, if it’s not doc, if it’s not written down, we don’t have an expectation about it. No, no, that that’s, that’s not right. We all have expectations in every aspect of our life, about how our families behave, how our friends will behave, what’s socially acceptable, what’s not socially acceptable. And organisations are no different. No, there’s whole lots of things that are never written down. But everybody knows what the rules are.



But safety is that area where we think if it’s not written down, I’ve had this argument with regulators if it’s not written down, it didn’t happen. That’s it? No, that’s just nonsense. It’s just nonsense. And a lot of



it again, it’s injury. So we’ve we’ve just recently had



psychosocial regulations published in Australia. Terrible idea, but we’ve done it.



And there’s



this sort of view that regulation and process, the regulators promote that because it’s good for companies.



I don’t think it is, I think the only entity that benefits from process and regulation is the regulator, because it gives them something to point to so. So historically, so psycho social incidents have never really been dealt with by the health and safety regulator in Australia. There are some examples, there have been prosecutions for bullying, going back a long while. So it’s always been within the the framework, it’s always been within the capacity of the regulator. But now they’ve got a set of regulations, which says, you know, this is what you must do. And these are the factors you must consider. If I’m a regulator, it’s very easy to come in and say, well, regulation 55, D. Four, says, you have to consider this. Can you show me where that was considered? And that’s what we’re going to see. I think that’s now it’s, it’s mechanistic is bureaucratic, it will do nothing for the mental health and well being of people in the workplace.



Yeah, but it’s this creates a process. Yeah.



And you would appreciate that from, from your experience in the maritime industry, and the sort of mental stress



and psychosocial stress on workers in in that industry.



But I suspect that then as soon as you say, Here is a list of things you must consider, then that’s what will be done, the list will be worked through quite independently of the social well being of behind. Yeah, yes, intent behind is loss. And you need to talk before about this idea of not being able to really define,



defined process. This is bring it all together.



To say, maybe summarise it to say, what do you think? Why do you think that the spirits of paper safe, have not been understood? Or embraced in a real sense?



And then maybe just summarise it in a few words? I look, I think it’s, it’s very hard to summarise or to get a view of it. But I think



I touched on I think the role of the regulator has something to do with this.



But I think the



at its heart Nippin for reasons I don’t understand and you’re probably better placed with your background to have a view on this.



I just think



organisations have been conditioned for so long in terms of managerial systems,



that you can only have effective management if it’s documented.



I just think that is so ingrained and conditional in our organisations that it’s hard to release. Yeah. And and you’re absolutely right. When you use the word emotive response, I think there is there’s a deep, there’s a very at a very unconscious level, there is a very strong belief that



All I need is a document.



And everything else can be taken care of. Yeah. That’s I think that’s probably right.



I know of small businesses who have paid a lot of money for safety management systems, you know, three or four lever arch files that they’ve never looked at never read, something’s gone wrong. And they’ve had one to literally say, we just thought we could push these files across the desk. And that would be the end of the matter.



I think that’s a wonderful place to stop and let people reflect on this idea. But thanks. Thanks, Greg. This has been a very helpful conversations. Thank you.



I hope you enjoyed listening to this podcast. As much as I enjoyed sitting down with Craig, and having this conversation.



I hope, the central message of breaks thesis, which is



how well do our processes aligned with their purpose and do should they and is there a need to do that?



Something that makes you think, and if that makes you think and question the status quo, then I think I would have achieved the purpose of this podcast.