Following publication of my book, Paper Safe, I have put together a couple of articles linked to the issue of bureaucracy in safety management. One article was about checklists and another was about “proving safety”.
In this article, I want to consider all of those concepts and look at how we might minimise bureaucracy and process in a (potentially) safety critical element – in this case pre-start equipment checks. Specifically, getting rid of the signed, dated and documented checklist which workers complete, hand in and organisations collate and count as a key performance indicator and measure of safety.
I do not doubt that in many cases conducting a pre-start check of equipment is important to ensure equipment is safe to use. The traditional approach to a pre-start equipment check is to provide a worker with a booklet of pre-formatted forms, typically some sort of checklist, which they will go through and tick off each of the relevant items, making a comment where they think it is appropriate. On completion, the worker will sign and date the form. Increasingly, the form is transitioning from paper-based to electronic and workers are completing pre-start inspections on mobile phones or other devices
Importantly, if the worker identifies a fault or a hazard with the piece of equipment they report the hazard and take the piece of equipment out of service.
History has shown us there are weaknesses in this process. For example, there are ample cases which demonstrate workers are not qualified to make the assessments contained in a checklist. Another problem is that the checklist process can often deteriorate into a simple “tick and flick” process with no real scrutiny being applied to the equipment.
These two problems, confidence and “tick and flick”, can occur with or without a piece of paper. A completed checklist is not evidence the pre-start inspection was done or that it was done well, any more than a worker saying they did the pre-start inspection.
As a piece of evidence, a documented pre-start checklist is at best neutral – providing no evidence – or positively harmful, being evidence that the employer did not pay attention to their own systems of work (see for example Queensland Coroner, Non-inquest findings into the deaths of Jamie Christopher ADAMS and Gary Robert WATKINS, page 8).
So, setting aside for the moment the issue of “evidencing” our process for pre-start inspections, if we start with the “purpose” in mind, how might we go about building a pre-start inspection regime?
First, what is the purpose of the pre-start inspection regime? It may be different for different organisations, but in this article I am simply going to assume it is to ensure that the piece of equipment is safe to use. Within that broad statement of purpose, it seems to me there are three key objectives. First, that the equipment is inspected. Second, that identified faults or hazards are reported and rectified. Third, that unsafe equipment is taken out of service until it is safe to use.
None of this needs a signed, dated and documented checklist.
So, what are the processes we need to achieve the purpose? Again, it seems to me there are three requirements.
First, training and competence. We need to make sure the people we expect to use the equipment, and by necessity conduct the pre-start inspections, have the training and competence necessary to perform the task.
Second, guidance. Even when people are trained and competent, it makes sense to provide them with information and guidance material to help them complete tasks. This might be in the form of a checklist, or a list of items to review. A list of items to review might even include highlighted safety critical areas and what to look for.
Third, assurance. We need to have assurance that our process works. Historically, this means seeking assurance that the checklist had been completed, but this does not demonstrate purpose. In a safety management system that is not held captive by bureaucracy, assurance is checking the achievement of purpose – in this case, assurance means knowing:
The equipment is safe; and/or
Hazards and faults have been reported; and/or
Unsafe equipment has been taken out of service.
It is possible to assure purpose without a signed, dated, and documented checklist, and all the associated bureaucracy that goes along with – collection, collation, reporting, filing and so on. And keep in mind, the signed, dated, and documented checklist is neutral – it does not provide the assurance we need.
The basic premise here is that we give people the training and competence they need to perform the task, and any guidance material and information they need to complete the task, and we trust them to perform the task and to communicate with us if there is an issue. We do not undermine training, confidence and trust by demanding people sign and document checklists and measuring or recording whether they do one every day.
So, what might assurance look like?
First, it might consider the number of hazard reports or defects. If we are receiving regular hazard or defect reports, and those hazard and defect reports both in terms of content and volume, are consistent with what we would expect to see, then we can point to this as an indicator that the pre-start checks are being done.
Second, it involves supervision. There would be an expectation that supervisors would regularly conduct pre-start inspections on equipment. This would not just be when workers pre-start their equipment, but at any time during the shift supervisors should stop work and conduct an inspection of the equipment with the worker. This provides in two benefits. It can help confirm a worker’s level of understanding of the equipment and its hazards, and it also provides ongoing checks.
There are a few things to keep in mind at this point. Remember, a pre-start inspection is a snapshot at a moment in time. It is entirely possible that a piece of equipment is perfectly safe at the start of the shift but deteriorates during the shift for reasons that could not be identified in the pre-start inspection. Ongoing checks throughout the working day helps ensure the equipment is safe (i.e. achievement of purpose).
It is also important to understand that if a supervisor identifies a problem that a worker did not identify, this does not mean the worker did not do the pre-start inspection, or they did it poorly. It might mean that, but it also might tell us something about the level of the workers training and competence, it might tell us something about the quality of guidance material we have provided for doing pre-start inspections or it might point to other factors which impact on the workers ability to properly conduct a pre-start inspection.
Again, it is important to note that a signed, dated and documented checklist does not tell us any of these things. Even with a completed checklist, supervision is necessary to understand whether the process is being done properly.
Your checklist is not a substitute for training, competence or supervision.
Third, assurance could involve management interactions with workers. It is certainly an increasing philosophy in safety management systems, and often part of misguided due diligence programs, that managers need to go into the field and have conversations with workers about safety. I do not doubt there is a role for this, but more often than not these management interactions are pointless exercises, completely disconnected from the safety management processes – let alone purposes – of the organisation. A colleague of mine once described management interactions is nothing more than Random Acts of Safety.
If pre-start inspections are in fact critical safety requirement in your organisation, then management interactions with workers should be directed to understanding if they work. management interactions should be directed to proving purpose.
This means managers should understand the pre-start inspection process, or work with a subject matter expert who does, and spend time talking to workers about the pre-start inspection process, and talking through a pre-start inspection with the worker, in much the same way as a supervisor would.
There is a skill to this type of conversation. it is not a mechanistic checklist approach, but an opportunity to really understand if the process works.
A final, and critical component to assurance is incident investigations. If pre-start inspections are a critical safety element, then investigating the efficacy of the pre-start process is something that should be done at every available opportunity, not just for investigations that involve failures of equipment. What I mean by this?
Ordinarily, if there is an incident that involves a failure of a piece of equipment, and that equipment ought to have been subject to a pre-start inspection, the investigation will look for the pre-start inspection form, review it and make findings about the quality of the pre-start inspection – or at least it should.
If pre-start inspections are a critical safety element, then the process should be investigated every time there is an incident, regardless of whether there was any equipment failure. For example, if a worker injured themselves dismounting from a front end loader, and that front end loader ought to have been subject to a pre-start inspection, then it is worth investigating whether a pre-start inspection was done, and the quality of that inspection, notwithstanding the incident you are investigating had nothing to do with the pre-start inspection or any equipment failure.
If pre-start inspections are critical, investigate them whenever you can.
In the same spirit, an organisation can implement a process of proactive review. Again, if pre-start inspections are critical safety element there is nothing to prevent the organisation from conducting a review of the process once or twice a year to confirm that it is achieving its purpose.
The difficulty with bureaucracy, and in particular the fascination with counting completed checklists, is that it blinds us to purpose. We take comfort in the collection of paperwork without ever turning our minds to the real question of the purpose of the pre-start inspection process and whether it is working. As both a safety initiative and a defence in legal proceedings this is the question we need to be concerned with: did the pre-start inspection process achieve the purpose of ensuring equipment was safe to use?
In this structure, we have assurance elements made up of subjective assessments (what workers say they have done, supervisor and management inspections) and objective evidence (hazard and defect reports and incident investigations). All of these elements provide evidence of whether the pre-start inspection process is achieving its purpose.
A dashboard showing 100% of pre-start inspection checklist being completed does not provide evidence of whether the pre-start inspection process is achieving its purpose. And regardless of whether you require signed, dated and documented pre-start inspection checklists all of the factors I have identified in this article, what the workers say, supervision, management interactions, hazard and defect reporting, incident investigations and reviews will be evidence. Moreover, they will be necessary evidence, and far more compelling and important than the existence of completed checklist.
This article represents a general discussion about legal principles. It is not specific advice, and you should seek your own legal advice in relation to your specific circumstances.