Sense Making in Safety

                                                    

Jeff, the seafarer and common sense

Jeff had been into boating all his life (26 years), right from a young lad he was on the sea and never really had any accidents. Jeff was very respectful of the risks with boating and seen what boating risks could do first hand as an Air Sea Rescue Leader.

Jeff considered himself to be a very careful marine vessel operator. Jeff had no specialised training in risk management other than what he learnt in his fitter and turning trade in the early 80’s and from owning his own business in the marine industry. He always lived by, ‘it’s about having your wits about what you are doing and having boating common sense’. It was on this day where his life was taken and the lives of those who loved him would change forever.

Jeff had been staying at his holiday house on an island east of Gladstone QLD, and had a call from a boating customer asking Jeff to take him out to sea in one of the boats Jeff sold in his business. So, Jeff decided to leave the island late that afternoon to go back to main land to prepare the boat for the morning test run. Jeff had a brand new 4 plus metre aluminium tiller steer dinghy, the motor had a new safety lanyard attached to it, which wasn’t on the boats he grew up with. Jeff never wore this as it would shut the motor down if he forgot to take it off when he went to move towards the front of the boat, it was an extra thing to stuff around with.

Jeff was on his way back to main land in his dinghy and was not wearing the lanyard as he never needed one of these ever before, it saved a few minutes just by not putting it on. On this day after many years not wearing the lanyard, Jeff hit what was thought to be a dugong (sea cow), Jeff was thrown out of the boat, however the motor kept going and it was in fast mode. Jeff attempted to get into the dinghy a couple of times and on the third attempt he slipped down and the motor hit him in the head and killed him. It wasn’t until the next day that he was found.

What was not unique about Jeff’s story, is his reliance to ‘common sense’ and ‘having your wits about you’. ‘Being witted’ or ‘being careful’ are expressions for what are known as ‘micro-rules’. Jeff and most of us use micro-rules to manage risk and our safety. Many of us think that these micro-rules should be intuitively known, or objectively self-evident. Micro-rules are developed by a human process called ‘heuristics’. Heuristics is any approach to problem solving, learning, or discovery that employs a practical method not guaranteed to be optimal or perfect, but sufficient for the immediate goals. Where finding an optimal solution is impossible or impractical, heuristic methods can be used to speed up the process of finding a satisfactory solution. Heuristics can be mental shortcuts that ease the cognitive load of making a decision. Examples of this method include using a rule of thumb, an educated guess, an intuitive judgment, guesstimate, profiling, or common sense. Some of our mental shortcuts, in reality are myths, they either have no meaning or have little connection to reality, however they provide us with incredible comfort and confidence, sometimes over-confidence (hubris).

To many who heard about my brother Jeff’s story at the time did not make sense that someone would not wear a safety lanyard to save a few seconds, yet the practice to Jeff and old school boat users, it made sense. Jeff had been working on ‘common sense’ for 26 years of his life, and so the shortcut was successful and became the rule in which he and other seafarers used to save a few seconds, it was a trade-off of time for risk. Jeff like all of us did not want to associate losing his life with not wearing the lanyard, he just wanted to ‘get from A to B quickly’ and without fuss.

We can see from Jeff’s story that assigning confidence in micro-rules and shortcuts eventually brings things undone. Jeff’s rule of thumbs did not help him the day he died, why? Many micro-rules are not calculated can be misconceptions or half right which people unquestionably rely on to explain and help make sense of the world around them. In reality they provide comfort and confidence but lack any real meaning.  

         

So, what is ‘common Sense’?

Wikipedia defines common sense as: Common sense is a basic ability to perceive, understand, and judge things that are shared by ("common to") nearly all people and can reasonably be expected of nearly all people without need for debate.

The question is, ‘is sense-making common?

I created an experiment using an image & or the word ‘chocolate. I asked participants to tell me what the image or word meant to them, we got results like: yum, sweet, desert, love, valentine’s day, not many just said, ‘chocolate or block of chocolate’. All the answers were different, chocolate was interpreted and or understood so many ways. ‘Sense making on just one word was not common’, how is there common sense when managing hazards, risk, safety and documents?    

When it comes to risk there is no substitute for learning, experience, training and coaching.

Some learn from a young age, like the danger of power points, hot water, and roads, because someone taught them, or we learned some things from observation. We have also learned from ‘trial and error’, we witnessed something, we were told something or we were trained what to do. Unfortunately, there is little to no room for ‘trial and error’ when it comes to some risks in life.

It is not common sense for a kid whose ball goes on the road not to chase it. It’s not common sense for a kid who sees a fire not to want to play with it, or to want to put something into a power point unless they have learned about the risks associated with what they are doing. Some forms of knowledge are acquired, but not by all, and they certainly can’t be assumed for everyone.

Look at the story of my brother Jeff, he was not lacking intelligence when he was killed, nor did he want his life to end. He simply made sense of the situation differently, perhaps from others, because his perspective and perception were influenced by a trade-off of time for risk. All trade-offs in risk makes sense to the person who is taking the risk. They have good reason for the trade-off and feel they can manage the risk in front of them. It is only in hindsight or when things go wrong when we think the rule of thumb (shortcut) didn’t make sense. We all have our own rules of thumb and shortcuts that we use every day to save time, money of effort.

It is critical to understand that the frustration we see others have over the lack of ‘common sense’ of another person. This often becomes the device for dismissiveness and non-understanding how risk makes sense to others. So, when we have organisations telling workers they have to wear gloves at all times or not to use Stanley knives as they are too risky, what is happening to most worker’s perception? Are they becoming dismissive to the organisations sense making?

If we respect and understand that everyone makes their own sense of risk, then we are on the road to better understanding peoples judgement and decision making, and we might start to realise that ‘common sense’ is not common. People who create shortcuts in risk, think of the gain from the rule of thumb in the face of uncertainty not loss. They see any trade-off which creates some sort of gain as logical common sense.

Common understanding must be created and assessed as something all hold in common, it cannot be assumed. So, how can we create common understanding to create common sense? We know there must be some formula to this learning as organisations need common understanding with their processes and operations.

The key to learning common understanding to risk is through an infinite learning and feedback coil. We call this the, ‘Lens of Common understanding learning coil’.