One of my more unfortunate memories of my early military career is the death of a soldier on a training exercise. I was posted to a place very close to the equator … along with the heat and humidity that came with it. The soldier who died suffered from heat stroke, brought on by dehydration. And, when we looked back on what went wrong, a key issue was that the training exercise risk assessment was ‘word for word’ identical to previous risk assessments when it came to managing heat-related illnesses.
But (as was pointed out by many soldiers at the time), the training exercise in question was conducted in similar heats and humidities as the previous training exercises. So why wouldn’t the risk assessment be ‘word for word’ identical?
Many reasons.
‘Routine’ activities shouldn’t be complex and onerous … where possible.
One of the issues with this risk assessment (and risk assessments more broadly) was how ‘complex’ it was expected to be. Templates and guidance were of minimal help, but the brigade headquarters expected to see risk assessments with a lot of ‘effort.’ This created a bureaucratic symbiotic evolution where officers colloquially and collectively worked out what the headquarters expected. And the headquarters simply used the ‘last’ risk assessment as a barometer of the next.
So we had a huge bureaucratic ‘risk assessment’ liability that meant it became ‘rational’ to simply leverage as much as possible from the last risk assessment that was approved. And, in many cases, safety and risk-compliance officers simply look for remedial actions – which means that we often see risk assessments that are deliberately ‘weak’ in the first iteration so that amazing ‘improvements’ can be documented in the second.
Madness.
Break the routine by focusing on what has changed.
If we are faced with broadly similar scenarios time after time, then let’s not waste precious oxygen redoing what has already been done. But that risks simply copying what has been done in the past.
So instead, we need to focus more on what has changed. There is only so much oxygen in the world, and if we expend it on stuff that matters – we don’t waste it on stuff that doesn't matter. This might mean that we don’t need to retest the same component that has been used in the last five models of a product. It might also mean we don’t have to forensically examine another really simple component that has barely changed at all.
… but this means that routine needs to become ‘standard operations’.
This is where we need leaders to stand up.
If we are doing the same thing over and over again, then we (as an organization) can sit down and work out best practices that take into consideration lots of things – including risk. This wonderfully risk-free approach then becomes a Standard Operating Procedure (SOP), guidebook, or something else that is generally useful.
What is the guidance on how much water consumption a soldier needs to be able to operate in hot and humid conditions? What acclimatization training do newly posted soldiers need to go through as part of integration changes? What is the minimum inner radius we can tolerate on 1050 steel?
But beware of ‘reliance on compliance.’
This is where leaders need to stand up … more.
This is where we come to assume that if we do things by ‘the very archaic book’ then everything is ok. There is no single thing that you can do to guarantee this won’t happen, as a big part of this comes down to culture.
We need to continually monitor how our organization deals with risk. Is risk management onerous? Do we not give enough time to our team to do it? Do we allocate it to the least competent (or least popular) person on the team? What happens if we don’t do it properly?
We have been focusing on risk … a lot. But the issue of ‘routine’ things becoming ‘routine’ is a huge issue in lots of different ways. Whether it is risk, leadership, reliability, leadership, leadership, quality, or maintenance, we are always looking for shortcuts and efficiencies. This is fine – as long as we don’t forget what is important.
How about you? Do you have any stories that resonate with this story?