There is a common anecdote told by leaders and safety professionals who have been involved in incident investigations: We found that people knew something was wrong prior to the incident, but no one said anything to prevent it. Why do people so often stand by and say nothing as disasters unfold? This question confounds leaders, plagues industries and underscores the frustration felt by many who have investigated incidents.
After reviewing the results of a study of safety intervention that we conducted in 2010, this paper looks closely at four different factors that keep people silent. We draw from research in multiple disciplines to formulate a better understanding of low intervention rates during operational activity, and propose a preliminary step that organizations can take to increase the likelihood that their employees will speak up about unsafe activities.
Employees' willingness and ability to talk about and stop unsafe operations is one of the most critical layers of protection against unwanted events. Managers and safety personnel cannot be everywhere at once. They cannot write rules and procedures for every possible situation, nor can they engineer the environment to remove every possible hazard. As we have learned from detailed reports on recent, high-profile events, when catastrophic failures occur, it is often the result of a complex and unexpected interaction of many different elements.
When people monitor the complex system in which they work — which includes equipment, processes, technologies, reporting structures and other people — and reliably stop both minor and major unwanted events before they occur, they function as a kind of agile layer of protection. Much like the body's immune system, which attacks harmful foreign bodies automatically and without instruction from the brain's executive system, people throughout an organization are uniquely suited to stop unwanted events without direct oversight from leadership; but this agile layer of protection is not as robust as we would like, and many unwanted events occur as people stand by silently watching them unfold.