In part two of their article on ROPE theory, Paul Verrico cmiosh and Sarah Valentine explore Planning and Empowerment.
In our last article, we discussed Sir Edmund Hillary’s ascent of Everest, which forms a powerful metaphor for many workplace activities. Jon Krakauer (2011) also writes about a mistake made by Adventure Consultants’ expedition leader, Rob Hall, during an ascent of Everest in 1996, that led to his death and the deaths of a fellow guide and two clients.
Hall’s party was not the only one attempting to summit during favourable spring weather. Four days before Hall’s ascent, after watching another party return without summitting, Hall told Krakauer: ‘To turn around that close to the summit… that showed incredibly good judgement on young Göran’s [Kropp] part. I’m impressed – considerably more impressed, actually, than if he’d continued climbing and made the top.’
To a health and safety professional, Kropp had risk-assessed the hazards, considered the likelihood and the foreseeability, and had ‘stopped work’ before his actions became reckless.
Before the climb, Hall had reiterated to climbers the importance of obeying his orders on summit day: ‘I will tolerate no discussion up there… my word will be absolute law.’
On the morning of the fatal ascent, Hall had told the climbing party this ‘turnaround time’ for the group was 2pm – the turnaround time being the point at which every member of the team, regardless of where they are on the mountain, must begin the descent. There were delays en route; some ropes were not in position and the lead climbers were delayed. Hall failed to stick to the agreed plan, which was calculated (or risk-assessed) to consider the weather, daylight, temperature and fatigue.
He changed the risk mitigations. It was, in fact, after 4pm when the last of Hall’s group successfully reached the summit and, by then, external events, including a storm and plummeting temperatures meant the initial mitigations were hopelessly overwhelmed. The climbing party had difficulty communicating and staying on the agreed route and were overcome with exhaustion. The results were catastrophic.
Case Study: A failure to plan leads to a fatality
Our client was a very large transport firm, which frequently undertook road resurfacing during which there were lane closures. Heras wire mesh fencing was used to separate people from moving vehicles, marshals would walk the length of excavations, and residents were guided into driveways by a lead vehicle.
Where inner-city works took place, the characteristics of the neighbourhoods required careful thought to identify hazards and control risks, such as petrol stations, hospitals or nurseries. Each section of road presented unique issues.
At one project’s inception, a dedicated traffic planner was tasked to identify the needs of the neighbourhood and create a detailed plan. As the months went on, the traffic planner became overloaded – he was expected to produce drawings and risk assessments at short notice. Standards started to slip and risk assessment was delegated to site managers. The managers began confidently, faithfully following the process. But as time went by, those risk processes began to be applied superficially. Assessments for sites a mile away were cut and pasted into a new document with a different street heading.
The devastating consequences of those decisions came to fruition when works ran alongside a care home. An elderly dementia patient was unable to decipher the traffic route and stepped into traffic. His death exposed the deficiencies in the system and the company received a significant fine.
Planning – the P in ROPE
Planning is one of the fundamentals of modern life, which we all practise to some extent. Yet the Planning extolled in ROPE theory goes beyond setting policies. As was seen with Hall’s fatal mistake, thought must be given to considering ‘what if’ scenarios when conditions or factors change in a dynamic setting. Kahneman et al (2021) describe how groups amplify noise. If groups learn the views of component members, social influences diminish diversity without diminishing the collective error. For many decisions, there are clouds of possibilities, only one of which is realised.
Attending to the judgements of others can cause a bias towards the first mover. The order in which cues about a developing situation come about and their relative persuasiveness may have far more impact on workers at the sharp end than on those planning at the blunt end.
When we investigate incidents, it is important to realise people act rationally at the point of decision-making because there are strong initial cues that suggest the situation is under control and can be continued without changing the likelihood of misfortune. If things change slowly, people fail to respond in a timely way, becoming situationally blind.
Conklin (2017) notes ‘prevention efforts can’t prevent causes that were not expected, just as planning can’t plan for unexpected events. We are so invested in preventing all accidents we don’t build the ability for our systems to recover if the accident happened. We investigate to determine how we failed to prevent the bad thing from happening.’
It is essential that proper monitoring is conducted to provide assurances the work envisaged is an accurate representation of how it is performed. It is important that this monitoring exercise is not viewed as satisfying numerical metrics but as a way to properly feed back on the way the work is being completed against the work planned.
Planning in ROPE theory is about considering the skills workers will need in a dynamic environment. It is about considering the metrics and data that need to be gathered to become a learning organisation, and understanding where measures succeed in stopping fatal outcomes and what recoveries are possible in a mature system.
Ensuring the right people are engaged in the planning process is crucial. People who are not competent in the full lifecycle of the activity can create oversights that are not corrected when completing the planning process. Additionally, engagement with the workforce is essential to understand the requirements of the work being performed to identify demands on planning, such as time estimates, local conditions, equipment availability and so on. Reactive planning will expose employees to risk. Proactive management of work activities will remove these risks and enable the work to be completed as imagined.
Case Study: Empowerment: psychological safety
Our client was a multi-national manufacturer with a six-sigma philosophy (using data analysis to assure high quality). The culture was one of relentless focus on performance and output.
A fatality occurred when unplanned maintenance required workers to move a heavy machine. The team devised a method involving a wheeled sled, while a member of the team was grinding bolts at floor level. The machine toppled, crushing him. The site at which the incident took place had not reported a lost time incident in more than five years and won head office awards for safety project work on defined risks. Management expressed amazement such an event could have occurred at one of their safest locations.
Investigations revealed a very low level of safety competence at the site. The safety manager described himself as ‘really a quality man’ and suggested he spent as little as 10% of his time on safety. Managers and supervisors had attended IOSH Managing Safely courses where risk assessments and method statement completion were discussed; they concluded these were unnecessary at their site because it was foreign-owned and, because they had no risk assessments, none were needed.
The man who lost his life had previous safety infringement investigations, one of which had seen him sent to hospital. The local management had decided not to record this as a lost time incident. The corporate focus on zero harm effectively incentivised under-reporting. No one at site level felt empowered to escalate safety issues to divisional management as previous poor audits had not been dealt with authentically. Managers felt unheard and, ultimately, became tacitly complicit.
Empowerment – the E in ROPE
Allied to stress management is the final ROPE element: Empowerment. Krakauer explains that, as he began his descent, he noticed wispy clouds forming around other Himalayan peaks but thought nothing of it. A fellow climber who was a pilot by trade later told Krakauer that, in his experience, wispy clouds are sometimes the ‘crowns of robust thunderheads’.
Yet that life-saving information was never passed to guide leaders. It had been explained in the pre-ascent briefing to the guided party that Hall did not wish to hear dissenting views while the expedition made the final push to the summit. Krakauer felt detached from the other climbers – they were linked only by circumstance, not by commitment, trust or loyalty.
If Planning involves ensuring that workers have the ability ‘to be able to do work in a varying and unpredictable world’ (Conklin, 2017) or ‘having the capacity to make things go well’ (Hollnagel, 2014) then Empowerment is about giving local teams the ability to speak up and act in accordance with their training, rather than sticking by rote to policies that were made off-site for work as an imagined task rather than for work as done.
The role of a leader is to create an empowered workforce that feels able to voice issues to feel psychologically safe and to focus leaders on problems brewing below the surface. If the leaders rule with an iron fist, managers will not feel comfortable questioning processes. They will not feel empowered. This can lead to accidents and near misses, impacting an organisation’s overall health and safety record and performance.
Edmondson (2018) posits that we live in a VUCA (volatile, uncertain, complex, ambiguous) environment. Workarounds can occur when workers do not feel safe enough to speak up and make suggestions to improve the system. Teams with high psychological safety focus on diagnosing problems and improving processes so accidents do not happen again. Those with low psychological safety rely on workarounds. Leaders need to convince workers they are ‘not pro-failure, but they are pro-learning’.
To start developing a good culture, leaders should encourage open discussion, work collaboratively with employees and encourage them to develop and question the way things are done.
Cowley and Borys’ (2014) view is that it is important for organisations to empower employees to adapt to dynamic situations. Organisations need to build employees’ adaptiveness and resilience to ensure human variability is seen as an asset and an important element of effective safety management. Introducing elasticity within the safety management system and stepping away from rule compliance empowers employees to anticipate risks before failure and harm occur.
Focusing on positive feedback to motivate employees to identify and improve health and safety issues should be encouraged, rather than penalising those who do not speak up about issues that they have spotted. Conklin (2017) correctly identified that ‘workers aren’t the problem; workers are the problem-solvers’. Good health and safety empowerment within the workforce can assist in driving down incidents and increase overall productivity. Creating ambassadors to drive performance and facilitate a common framework enables a link between the overall strategy and the employees’ everyday work situations.
Additionally, organisations should promote local ownership and create authentic experiences from which workers can learn, engage and share with colleagues. This will all improve employee engagement and, therefore, empowerment. Sir Edmund Hillary conquered the ferocious conditions on Everest by modelling safety behaviours from which we can all learn.
A rope is part of the fundamental equipment for successful climbers. ROPE is essential for senior managers and safety practitioners to navigate the high altitude of the workplace safely.
Paul Verrico is head of the global EHS team at law firm Eversheds Sutherland.
Sarah Valentine is a senior lawyer in that team and an assistant coroner.
References
Conklin T. (2017) Workplace Fatalities: Failure to Predict. PreAccident Media: Santa Fe, New Mexico.
Cowley S, Borys D. (2014) Stretching but not too far: Understanding adaptive behaviour using a model of organisational elasticity. Journal of Health and Safety Research and Practice 6(2): 18-22.
Edmondson AC. (2018) The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Wiley: New York.
HSE. (2021) A brief summary of Plan, Do, Check, Act. (accessed 1 November 2022).
Hollnagel E. (2014) Safety I and Safety II : The past and future of safety management. Routledge: Oxfordshire.
Kahneman D, Sibony O, Sunstein CR. (2021) Noise: a flaw in human judgment. First edition. Little, Brown and Company: New York.
Krakauer J. (2011) Into Thin Air. Pan Books: London.
Van Dongen HPA, Maislin G, Mullington JM et al. (2003) The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 26(2):117-26.