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Some time ago, I was in a public

toilet in Amsterdam when I saw mychance, whipped my camera out, andgot the picture. “I’ve wanted a shot ofone of these for ages – I’ll have greatfun with this when I get home,” Ithought, as the other occupantswatched me in alarm. . .

The painted ceramic fly on thetoilet bowl at Schiphol airport (whichwe men simply can’t help but aim for,and was the subject of my snapping)is easily the most famous example ofa ‘nudge’ – the hugely influentialsocial psychology concept so expertlyand thoroughly detailed by JenniferLunt and Malcolm Staves in theNovember issue of the SHP.1 As ithappens, I do have lots of fun withthat picture at other conferenceswhen asking: “What rules,regulations, training, or supervisioncould match the automatic 50-per-cent reduction in splashing andassociated cleaning costs the flydelivers?”

As Lunt and Staves point out, thenudge concept has been around foryears in different guises2 – forexample, user-friendly paint andsignage, and good ergonomics – andit is increasingly widely used by thecurrent government. Once you knowit’s around you, it’s easy to spot. Thenew motorway signs saying “Don’tlitter – other people don’t” (a nudgewith reference to social norms), theempty Police van parked strategicallyin the city centre, the new tax formthat asks “Before you sign this off areyou sure you didn’t forget anything?”Police being asked to wear uniformwhen travelling to work, and so on.

For what it’s worth, a significantpercentage of those just about to sign,seal and post a tax form that’s notentirely true find themselvesgrimacing, banging the table andcursing: “Bugger it – I was home freebut you got me right at the end there,you evil lot!” and reaching for thewhite-out. (Studies suggest that thisone simple question alone willgenerate tens of millions of pounds ofextra tax revenue!)

Used proactively and systemically

Dr Tim Marsh takes the concept of ‘nudge’, as introduced inour November issue, and explains how it is a key element ofthe ‘mindful organisation’ – one in which strong andproactive leadership creates a robust safety culture.

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‘nudges’ are also a key element of asafety culture concept that’s gaininggreat credence around the world: theAustralian writer Andrew Hopkins’concept of “the mindfulorganisation”.3 He refers to the“shadow” that leadership throws,where apparently little things canhave a big impact – for example, anevent that generates the comment“and they stopped the job?!” or “andthey still didn’t stop the job?!” Inmany respects, such critical incidentswork as big nudges.

‘Mindfulness’ is not a technique,or a theory – it’s a practical andrealistic mindset that can (andshould) be applied to all aspects of anorganisation’s safety culture andmanagement. Following is adiscussion of several key elements ofa safety culture, starting withleadership and including incidentanalysis, communication andprocurement, and concluding withhow this mindset should be appliedto them all.

The leadership shadowThe idea of a leadership ‘shadow’ isn’tnew either, of course – I have writtenbefore in these pages on the subjectof weak leadership.4,5,6 For example:starting a meeting by announcing“safety is our number-one priority”but in a manner that means “let’s getit out of the way then crack on withthe important stuff”; using the word‘but’ in the middle of a sentence suchthat it means “ignore what I’ve justsaid, as the important stuff’s comingup”; and the way that “do it safely butdo it by Friday” means somethingentirely different to “do it by Fridaybut do it safely”.

I mean, has anyone ever heard thewords “you’re really nice and I reallylike you but…” without their heartautomatically sinking?!

Whether they are aware of nudgeor ‘mindful’ concepts or not, manycompanies train their managers notto undermine the message in suchways, and then follow up the trainingto make sure they don’t. Some others,that are aware of the concepts, arebeing more proactive than that,however, and are actively looking foropportunities to throw a positiveshadow (or nudge), as they know itcan take years to change a company’sculture.

This is because it takes that lengthof time for a genuine change insenior-management attitude topercolate down and becomeembedded (e.g. “You’ve been saying itfor years, I know, but only now am Ibeginning to realise you actuallymean it”). Basically, a few well-designed nudges can really helpaccelerate this process.

Shell Scandinavia, for example, onplatforms, has stopped asking thequestion: “Why did you feel it wasnecessary to switch off?” Instead, itasks: “Why did you feel it was safe toswitch back on?” When you thinkabout it, the technical information inthe report generated in response tothe question will be exactly the samebut the shadow it throws is verydifferent. Indeed, it’s also not somuch a nudge but an almighty shovein the right direction!

I have written previously in thesepages about “transactionalleadership”,5 and the mindful leaderis, by definition, a transactional one:always mindful to lead by example, tomaximise the use of praise, to coachand involve rather than to tell anddictate, and absolutely always awarethat even the little things they do orsay throw a big shadow.

‘Just culture’ and mindful analysisHopkins makes specific reference toboth “why?” and ABC analyses6 in hiswork and, in doing so, encouragescompanies to make that vital leap –from spotting that something iswrong to a mindset that always seeksto understand why it’s wrong.

For example, at the IOSH RailConference 2011, East Midland trainsproduced some graphs showingimpressive safety improvements, andcommented:“For us, the key was tostop treating SPADs (signals passed atdanger) and the like as events inthemselves but as symptoms of amore underlying issue. That shift inmindset was vital to ourimprovement.”

Sidney Decker, in his hugelyinfluential Field Guide toUnderstanding Human Error,7 makesthis point really bluntly, saying:“Human error is not the cause but theeffect. Whatever the label (loss ofsituational awareness, inadequateresources, even complacency) humanerror can never be the conclusion of

your investigation. It is the startingpoint.”

This thinking is fully in accordwith Reason’s ‘just culture’ concept.5

Hopkins himself insists that it isn’tpossible to be genuinely mindfulwithout an ongoing commitment tosuch as the “five whys” analysis. Icouldn’t agree more.

It’s a good idea to carry out‘mindful analysis’ spot checks. Forexample, we can sleep easily, assuredthat we have an excellent incidentreporting system, or we can, fromtime to time, pick an incidentmentioned in conversation andfollow it up by tracking it throughthat reporting system. How far did itget? What was learned? What wasdone with this learning? Even thebest companies with highly expensivetracking systems will often find thatthe answers to these questions areconcerning.

It’s also worth proactively lookingat the trends in the reporting system.Are there divisions, shifts, or otherdemographics that ‘hardly ever’report? If so, then we need to dig intoit and find out what the blockages areand why – because since no one everhas anything to report, there’s aproblem!

Mindfulness and ‘zero harm’No conference is complete without aheated debate about whether ‘zeroharm’ is a useful concept or genuinegoal. Reason’s cheese model,8

showing how weaknesses up anddown the chain effectively show howall accidents could have beenprevented, is very influential to thisthinking, but his recent work on the“overstretched rubber band” modelhas been very well received and, forme, clarifies the debate.

It describes how all companies areapt to be pulled from best practicesby the challenges and issues of reallife (contractors, unexpected costsand delays, etc.) so that the realisticchallenge is not to be perfect but toensure that when parts of theorganisation are stretched they do notbecome overstretched andvulnerable.

In the real world, says this model,pockets of vulnerability willinevitably pop up from time to timeand from place to place, even if theoverall culture is strong and the

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planning thorough. The trick is to begeared to spot them soon, andrespond to them effectively so thatbalance is quickly restored. This isentirely analogous to the keyprinciples of HSG48 (Human Error),which says:

Design the job/ task so that error isunlikely;Make sure you have mechanismsin place to spot error when it(inevitably) happens; andMake sure you can respondquickly.

Following on from this, Reasonsuggests that safety is then bestthought of as an ongoing guerrillawar and, like any such war, althoughwe can’t actually win it we can delaythe inevitable almost indefinitely. Todo this, we’ll need keen intelligence,good data and to use the resources atour disposal cleverly.

In other words, we’re not askingour boards to be perfect in such animperfect world – but we are askingthem to be genuinely mindful.

Mindfully ‘following the money’The Baker report into Texas City hasoften been used as a stick with whichto beat behavioural safety, pointingout, as it did, that with bonusestriggered by low accident rates theeye was taken off the process-safetyball. But the Baker report doesn’t sayanything like “behavioural safety bad,process safety good”; it actually says“don’t get the balance wrong and givetoo much weight to just one issue”.

This echoes the classic OliverStone film JFK, when the shadowybut deeply wise figure asks ourinvestigative hero: “You always haveto ask yourself, who most stood tobenefit…?” and suggests “just followthe money”.

A proactive mindful safety trick isto do exactly that. For example,where the procurement division isrewarded for cutting costs but no onechecks if any false economies resultas a consequence, we often findcheap PPE that no one actually wearsbecause it’s uncomfortable, or isn’t fitfor purpose, or that cheapcomponents fail and leak. (At TexasCity itself, bonuses were paid only onlost-time incidents, so managementfocused on these to the detriment ofprocess-safety issues.)

Of course, it’s always worth

considering how contractors andpiece workers are remunerated andselected (the term “a whole can ofworms” was coined with this issuespecifically in mind!) We all knowfull well that what the contract saysand what happens on the day are notoften in accord. An example: we allwant our airports to be safe andsecure, but how do you feel when youhear that the staff at the airport fromwhich you’ll be flying tomorrow withyour family are going to “work torule”? Is your first thought: “Great,they’ll follow all those well-designedrules and regulations and we’ll beextra safe?”

Communication and the mindfulmindsetHopkins suggests that in 2005, BPwas not a mindful organisation – infact, “the very opposite”.Underinvestment meant that pipework was old and leaky andmaintenance wasn’t being done, butin London (HQ) they were simply

unaware of the impact of theirpolicies because of the existingclimate of “only good news movedupwards” and admitted themselvesthey didn’t listen well to those on thefront line. Hopkins suggests that thisproved fatal at BP, literally andrepeatedly in combination with theaggressive cost-cutting at the time.

On a more individual level I onceasked an MD at a board meeting if heever responded negatively to a safetyissue being raised, and he wasadamant: “Never!” I asked: “Not evenwith the eyes?” and the whole roomburst into laughter, as he was, ittranspired, notorious for this. Luckilyhe wasn’t a defensive man, laughedhimself, and we were off.

So, the mindful leader will show ahealthy paranoia by losing sleep tothe thought: “How do I know XYZwon’t happen?” and this willinevitably involve lots of good,proactive communication. More thanthat, the organisation must seek outthe many examples there will be of

The key concept of

the ‘mindful’

mindset is astute

thought coupled

with some robust

digging © Alamy

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communication being poor, or evenimpossible.

A simple exercise is to asksomeone a production, or quality-related question. Check the speed ofthe response, the facts they have attheir disposal, and how keen theyappear to reassure you they haveeverything under control. Then askthem a safety-related question ofsimilar type. How do the responsestally with a genuinely ‘balancedscorecard’?

Similarly, if you really want to getto the core of a safety culture why notsit in on a formal appraisal withoutmentioning that your interest isprimarily in safety. Monitor the bodylanguage of the appraiser and theappraised. Is it as intense whentalking about safety items as whentalking about productivity? (Or doesthis look like the half-time warm-uprather than the real thing?)

You should, of course, alsoconsider the organisational structureitself. Is it easy to communicateconcerns upwards, or totallyimpossible? (For example, if you’dneed to go through the person you’reconcerned about, even though youknow for a fact they are not going tosee this as a learning opportunity!)Also, consider if the peopleresponsible for writing systems andprocedures are empowered to ensurethey are actually followed. Morefundamentally, do the people whowrite the systems and proceduresactively consult the end users as asystematic part of the design process?Any ‘no’s’ here absolutely guaranteeproblems down the line.

Finally, especially at this time, it’sworth considering any recent cost-cutting or “renegotiated” contracts.Were these risk-assessed reallythoroughly for the ‘Law ofUnintended Consequences’, or wereassumptions made that ‘all will bewell’? You’ll have got the idea by nowthat a genuinely mindful leader willbe all over any such assumptions likea bad rash.

Training and a mindful mindsetTo start to sum up, I hope I’ve made itclear that, for me, the key concept ofthe ‘mindful’ mindset is astutethought coupled with some robustdigging. For example, you’ll often seecompanies quoting lead measuresregarding the percentage ofemployees actually trained relative tothose they planned to train (and avery impressive pie chart it can make,too!).

However, no matter how sexy andglossy the pie chart, the questions arestill begged: How well designed anddelivered was the training? Were thebehaviours introduced on the coursefollowed up and embedded? If theywere, was some follow-up analysismade to ensure the change ofbehaviour genuinely benefited thecompany in some way?

In my experience, the answers tothese questions are not always what acompany would wish for. Indeed,they rarely are. There is, of course,any number of other key issues thatshould be considered but whateverthe topic, ‘mindful’ leaders don’t takeassurance from checking the files –they get out and about, talk to peoplein-depth, and genuinely dig.

Conclusion So, to re-iterate, for me the keyelement of mindfulness is to “drill”into a subject and ask probingquestions that tell you what’s reallygoing, on especially when you suspectthe answers will make youuncomfortable.

Mindfulness is alwaysremembering that safety is a guerrillawar. To fight an effective rearguardaction we need to be clever and alertand take nothing at face value,showing proactive analysis crossedwith a healthy paranoia that reflectssenior management’s genuinecommitment to get their workforceback home unharmed every day.

As with the airport securitymentioned above, much of what weare assured by in our daily lives and

work is an illusion. An unspokenaccommodation of make-pretend thathelps us through the day. Well,usually. The genuinely mindful leaderremembers this – always – becausealmost every time you dig intosomething, you’ll learn somethingworrying.

A final thought: I do wonder if theconcept is proving so popular aroundthe world because of the positivity ofthe word ‘mindful’. It’s perhaps theflip-side of the behavioural safetyburden that the word ‘behaviour’ isnearly always used when we “want totalk to you about your behaviour”. So,no Mind Games please (unless it’s theclassic John Lennon song) but can Isign off by sincerely wishing allreaders to “please do take care andmind yourselves and your colleaguesas you go”.

References1 Lunt, J & Staves M (2011): ‘Nudge,

nudge, think, think’, in SHPNovember 2011, Vol.29 No.11 –www.shponline.co.uk/features-

content/ full/cpd-article-nudge-nudge-

think-think

2 Thaler, RH and Sunstein, CR(2009): Nudge, Penguin

3 Hopkins, A (2008): Failure tolearn, CCH Australia

4 Marsh, T (2010): ‘Stretch to thelimit’, in SHP February 2010,Vol.28 No.2 –www.shponline.co.uk/features-

content/ full/safety-culture-stretch-to-

the-limit

5 Marsh, T (2010): ‘It’s A Kind ofMagic’, in SHP September 2010,Vol.28 No.9 –www.shponline.co.uk/features-

content/full/it-s-a-kind-of-magic

6 Marsh, T (2011): ‘Words to thewise’, in SHP February 2011,Vol.29 No.2 –www.shponline.co.uk/features-

content/ full/cpd-article-words-to-the-

wise

7 Dekker, S (2006): The Field Guideto Understanding Human Error,Ashgate

8 Reason, J (1997 and 2008):Managing the Risks ofOrganisational Accidents and TheHuman Contribution, Ashgate

Dr Tim Marsh is managing director of

Ryder-Marsh Safety (Ltd) – see page 4

for more information

“Mindfulness is always remembering that safety is aguerilla war – to fight an effective rearguard action,we need to be clever and alert and take nothing atface value”

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