Mindfulness: Realising the Benefits/media/Documents/Subject Groups/Safety_L… · Andrew Hopkins, demonstrates that ... Hopkins in his working paper (Hopkins, 2002) discussing safety

IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE

MINDFULNESS: REALISING THE BENEFITS

Phil Joyner1 and Ronny Lardner2

1FIChemE, Human Factors Advisor, The Keil Centre, Edinburgh, UK; Tel.: 0131 667 8059, e-mail: [email protected], Director, The Keil Centre Ltd, Edinburgh, UK; e-mail: [email protected]

This paper discusses individual mindfulness1, and the qualities of those who exhibit it. Furthermore

it reflects on what needs to be provided by the organisation to ensure it is understood and applied

and how the organisation and those who work in it should react and respond to individuals who

demonstrate mindfulness to ensure its sustainability.

Employees who demonstrate mindfulness have heightened situational awareness of what is

currently happening around them, and they think ahead to possible consequences. They raise

their concerns regarding operations, maintenance, procedures, conditions, design and behaviours.

They are on the look-out for weak signals, asking themselves ‘what could go wrong’, and they

are wary of jumping into action without thinking things through first. Mindfulness is as much

about what people do with what they notice as it is about the activity of noticing itself 2.

Employees who are mindful at work are a highly desirable asset. They will enhance both

process and occupational safety, the environment and health but also productivity and commercial

performance. One of the first references to the term mindfulness in this context was research into

high reliability organisations (HROs) by Carl Weick et al1.

It is not simply that individuals are born mindful, or that when an organisation asks their work-

force to act mindfully they will. Processes and tools need to be provided to encourage the sharing of

concerns or improvement ideas. Examples are near-miss or potential hazard reporting, suggestion

schemes, 2-way communications and on-the-job risk assessment. Safety representatives can often

be a conduit for mindful employees, as can a casual comment to a passing engineer, as these are less

confrontational approaches to raising concerns. Individuals are more likely to be mindful if there

are processes to support mindfulness at the organisational level2.

How people at all levels in the organisation react and respond is also crucial – they need to

demonstrate that mindfulness is of value and deal with all issues raised positively. If an individual

senses negativity, or feedback is weak or non-existent this will discourage future intervention.

The weaker the signal reported and acted on the more mindful the individual is. This also reflects

how effective the organisation has been at encouraging mindfulness.

When major accident reports of recent years are reviewed, it is evident that the lack of mindful-

ness, particularly where ill-considered practices had become routine, was a significant contributor

e.g. Texas City, Herald of Free Enterprise, Piper Alpha, Bhopal – the list goes on. There is no

doubt that mindfulness has saved the day on many many occasions, but these events are seldom

investigated or publicised. The precursors to the next major accident are already formed and are

sending out signals – mindfulness determines whether we see the signals and act.

Given the importance of mindfulness, the paper will allow the reader to identify

. whether they personally display the qualities of mindfulness.

. whether their organisation supports mindfulness.

. what needs to be done, individually and organisationally, to enhance the contribution of

mindfulness to loss prevention.

KEYWORDS: mindfulness, safety culture, high reliability organisations (HRO), risk awareness, situational

awareness, behaviour

RELEVANT THEMESThis paper is considered most relevant to the followingLP2007 themes.

. Risk Assessment and Control - e.g. Hazard Identification.

1Weick, K.E., Sutcliffe, K.M., Obstfeld, D., 1999. Organising for High

Reliability: Processes of Collective Mindfulness. Research in Organis-

ational Behaviour, vol 21, pp.81–123.2Hopkins, A. 2002. Safety Culture, Mindfulness and Safety Behaviour:

Converging Ideas. Working Paper 7. National Research Centre for

OHS. The Australian National University.

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. Human Factors and Safety Management Systems.

. Learning from Accidents and Knowledge Transfer - e.g.The identification of root causes.

INTRODUCTIONHow often does an incident investigation report concludethat a person or a group did not think through the task inhand, or that events or conditions prior to a catastrophesignalled loud and clear the inevitable outcome? Mindful-ness, demonstrated by individuals and supported by the


organisation in which they work, would help to eliminatethese all too frequent events.

This paper discusses mindfulness, the benefits it canbring and the qualities of those who exhibit it. Furthermoreit reflects on what needs to be provided by an organisationto ensure it is understood and applied and how the organis-ation and those who work in it need to react and respond toindividuals who demonstrate mindfulness, ensuring itssustainability.

There is a danger of oversimplifying mindfulness andwe need to recognise that we are dealing with complicatedsystems in terms of organisations, their processes andculture, and individuals, their beliefs and values. As adiscussion document this paper recognises these com-plexities, attempting to move the debate to a practicaloperational level.

WHAT IS MINDFULNESS?One of the first references to the term mindfulness was in thecontext of organisational studies. Research carried out intohigh reliability organisations (HRO’s) by Weick (1999)introduced it as ‘the capability to induce a rich awarenessof discriminatory detail and capacity for action’. In short,it facilitates the identification and correction of potentialunsafe conditions and mistakes.

There are a number of aspects to mindfulness. It canrelate to identifying and mitigating the risks associatedwith a task in hand or about to be carried out. Anotheraspect is very similar, but is more future-focused on whatcould go wrong rather than the immediate dangers. Bothare about what is observed, what is the persons past experi-ence and about having sufficient knowledge to assimilate the

Figure 1. A poster from Woodside Energy, Australia. One

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current status and recognise what might go wrong. Mindfulindividuals and organisations focus on the possibility offailure – they are not satisfied until proven safe. Eventhen they are wary of the unexpected and have contingencyplans should something they have not foreseen go wrong,beyond the immediate safeguards they already have inplace. They are suspicious of good news and welcome learn-ing opportunities in whatever form. The poster (figure 1)from Woodside Energy in Australia is an example of aprogressive industry campaign to heighten and maintainworkforce awareness of the need for mindfulness.

Currently the term mindfulness is not widely used in anoperational environment, but phrases such as situationalawareness or risk awareness, which are elements of mindful-ness, are. If we consider defensive driver training – thevehicle driver during his coaching is encouraged to talkthrough in real time what he observes and the additional vig-ilance or corrective action necessary e.g. a cyclist aheadwearing earphones, a tractor moving slowly and throwingup mud or a stationary school bus ahead. The same coachingcould be applied to plant operation e.g. ice on a pipelinewhich is normally clear, tower liquid level indicating lowbut bottoms pump suction pressure high or ladders next to acritical compressor noticeably vibrating. All these aremindful observations which merit further investigation. Ifunreported or ignored, they could lead to disaster.

WHY DO WE NEED MINDFULNESS?Employees who are mindful at work are a highly desirableasset. They will enhance both process and occupationalsafety, the environment and health along with reliability,productivity and commercial performance. Vogus (2003),

of the tools used in their mindful approach to operations


following a study of 186 software firms, concluded that highlevels of mindful organising among front-line employeesimproves innovation, quality and efficiency outcomes.

Mindfulness is particularly important where employ-ees face high variability and uncertainty in their taskenvironment and are required to recognise and act on emer-ging and weak signals, which could necessitate the need toidentify and analyse often obscure interdependencies. As anoperational manager with BP the first author developed aheightened awareness (mindfulness) of the complexitiesof plant operation beyond the conventional engineeringand systems approach, by reading ‘Lessons from Longford –the Esso gas plant explosion’ (Hopkins, 2000). The bookreviews a major accident in Australia in 1998 and, asa result of ground-breaking analysis carried out byAndrew Hopkins, demonstrates that the incident wassteeped in failures of mindfulness – valuable learningfor all those, at every level, associated with plantoperations.

The mindfulness existing within an organisation is areflection of its culture, demonstrated by the way itsbusiness is conducted. In developing mindfulness thesafety culture of the organisation and the benefits whichcome from that would be realised. Equally as the safetyculture develops so should mindfulness. The Health andSafety Executives human factors guidance documentHS(G)48, (HSE, 1999), characterises the key elements ofa positive safety culture. These include open communi-cations, a learning organisation, participation of staff, man-agement commitment and leadership, and balancingproductivity and safety goals. Development in these areaswould lead to a rewarding and successful organisationsupporting mindfulness.

WHAT DO MINDFUL PEOPLE DO?Employees who demonstrate mindfulness have a heightenedsituational awareness of what is currently happening aroundthem, and they think ahead to possible consequences. Theyraise their concerns regarding operations, maintenance, pro-cedures, conditions, design and behaviours. They are on thelook-out for weak signals, asking themselves ‘what could gowrong?’ and they are wary of jumping into action withoutthinking things through first. A critical point illustrated byWeick (1999), is that mindfulness is as much about whatpeople do with what they notice as it is about the activity ofnoticing itself. Do they correct the situation, do they reportensuring it has been understood, do they halt operations untilresolved? These actions require qualities of personal responsi-bility and ownership, fuelled by ‘what they stand for’.

Individuals can be tempted to allow themselves, oftensubconsciously, to interpret situations and rationalise awayvalid concerns that should be acted on. Mindfulness is notsimply concerned with situational awareness ‘outside’ theperson; it is also about the individual recognising theirown psychology: their values, beliefs, prejudices, experi-ences and desire for knowledge, and how if uncheckedwill hinder their decision-making process.

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WHAT SHOULD ORGANISATIONS DO TO

SUPPORT MINDFULNESS?It is not simply that individuals are born mindful, or thatwhen an organisation asks their workforce to act mindfullythey will. Processes, tools and support need to be providedto encourage the sharing of concerns or improvementideas and any subsequent follow-up action. AndrewHopkins in his working paper (Hopkins, 2002) discussingsafety culture, mindfulness and safety behaviour assertsthat individuals are more likely to be mindful if there are pro-cesses to support mindfulness at the organisational level.Support is in reality essential – an individual’s desire to bemindful would be stifled and severely de-motivatedwithout organisational encouragement and support. Howpeople at all levels in the organisation react and respond toeach other is crucial – they need to demonstrate that mind-fulness is of value and deal positively with all issuesraised. If an individual senses negativity, or feedback isweak or non-existent this will discourage future intervention.It is not difficult to argue that the weaker the signal reportedand acted on the more mindful the individual, nor that thiswould also reflect how effective the organisation has beenat encouraging mindfulness.

As with human factors, an organisation needs a prac-tical understanding of the subject in order to take a coherentapproach to mindfulness in order to determine currentreality, identify the gaps and prioritise opportunities(Joyner, 2003). Some of the ‘mindfulness tools’ organis-ations use to varying degrees and with variable successare described in section 6. It can be argued that thedegree of success realised is dependant on the culture ofthe organisation, as described in section 3. As a trigger formindfulness Woodside Energy, Australia utilise apocket card shown in figure 2. As an organisation theyrecognise that this type of campaign or communicationmust be part of a number of tools and support activities tobe successful.

TOOLS TO ENCOURAGE MINDFULNESSThere are a number of examples of ‘mindful’ tools being usedin the workplace. In the majority of cases the organisationdoes not label them as such but rather as processes whosepurpose is to prevent accidents. In this section three topics,with associated tools, have been chosen to illustrate thetype of effective ‘mindful supporting’ tools which havebeen developed with workforce involvement. They couldbe described as behaviour modification programmesdesigned to prompt and encourage mindful behaviour(HSE, 2001).

SAFETY OBSERVATIONS – NEAR MISS, UNSAFE

CONDITIONS AND UNSAFE BEHAVIOURAs companies safety performance improves they may havefewer accidents to investigate and learn from. They willthen progress into encouraging the reporting of unsafeconditions, unsafe behaviours and near miss incidents inorder to act on the causation factors and weak signals that

Figure 2. A pocket card from Woodside Energy, Australia. One of the tools used in their mindful approach to operations


these provide and learn from them. Woodside Energy,Australia use the data they collect from such reports togood effect. Paul McCormick HS&E Manager believesthat ‘(analysing reports) . . . has increased everyone’sawareness that we will always have a chance to preventmajor incidents. It’s a question of being able to take thewarnings seriously and pursue a comprehensive solution.

Figure 3. The BP safety o

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Implementing simple processes and understanding thenaturally-occurring forms of denial that down playwarning signals is key’.

BP in Grangemouth, Scotland has provided all itsstaff and contractors with coaching in safety observationsin addition to providing each of them with guidance and areporting booklet (figure 3). Everyone who completes a

bservation booklet cover

Figure 4. The BP safety observation report form


report form (figure 4) receives prompt feedback and thewhole workforce is given a summary of the reports andwhat the key learnings are for the site each month. Thetrends and causation factors then support employee mindful-ness when they complete their on-the-job risk assessments(see next tool).

ON-THE-JOB RISK ASSESSMENTOrganisations are recognising that employees situationalawareness and risk evaluation needs to be improved justprior to and during their work. INEOS ManufacturingScotland introduced a process to encourage the workforce

Table 1. The INEOS Take 5 s

Task

Step 1 Stop, Step Back, Observe Observe work are

Step 2 Think Through Activity Consider the sequ

finish.

Step 3 Identify Hazards Identify the hazar

immediate and

Step 4 Control Hazards Implement contro

or incident, and

Step 5 Safety Complete Activity Once all control m

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as individuals and in their team to do this. Called ‘Take 5’its stated intention is to “think before you act”. It is basedon 5 prompts, shown in table 1, and a simple pocketbooklet (figure 5) with a series of questions and checkswhich drive the process of hazard identification and mitiga-tion and includes a section for any corrective actions to belisted. This completed booklet is freely available toanyone passing who may have a concern about the workbeing carried out, along with the permit to work and theformal pre-job risk assessment (where applicable).

Anne Sneddon, the INEOS Human Factors Specialist,believes that employee involvement and awareness at theworkface are essential and this is one of the many tools

teps of hazard identification

Description

a and surrounding location for actual or potential hazards.

ence of steps involved in carrying out the activity from start to

ds associated with the activity including any present within the

surrounding work area, and hazards generated by the activity.

l measures to remove the hazards or reduce the risk of an accident

communicate.

easures have been implement commence the activity.

Figure 5. The INEOS Take 5 booklet cover


available to help INEOS achieve that. Anne also believes itis important to keep reviewing, refreshing and renewingthese tools.

RAISING SAFETY CONCERNSMost organisations say they want their staff to raise safetyconcerns or stop if they feel a situation is unsafe.However they can point to examples of where failure tointervene led to a missed opportunity to prevent an incident.A common reason why people don’t intervene is amisplaced perception about hindering task progress or pro-duction pressure. Introducing a process to encourage every-one to express their concerns challenges this perception.BP’s Andrew platform in the North Sea pioneered asimple paperless process ‘Time Out for Safety’ describedand reviewed in HSE, 2001. Its aim is to encourage allstaff to raise concerns and to promote ownership of theirown and others safety. If an individual is at all uneasyabout a developing situation he or she will make a “T”sign with their hands and work will be safely suspendeduntil the concern is resolved. The effectiveness of thisprocess was enhanced by the open, trusting and involvingculture which existed on the installation.

FURTHER CHALLENGES TO BE METThe tools described in section 6, along with other mindful-ness inputs to the organisation such as accident investigation

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analysis, safety culture assessment and communicationsfeedback, provide critical information on where the nextaccident could come from, providing an opportunity forappropriate steps to be taken to prevent it. This warningmessage would be amplified if all these inputs were collatedand analysed, looking for patterns and trends, by an individ-ual or group, “the mindfulness centre”, who had account-ability to do this.

CONCLUSIONSWhen major accident reports of recent years are reviewed, itis evident that the lack of mindfulness, particularly whereill-considered practices had become routine, was asignificant contributor e.g. Texas City, Herald of FreeEnterprise, Piper Alpha, Bhopal – the list goes on. Thereis no doubt that mindfulness has saved the day on manymany occasions, but these positive interventions areseldom investigated or publicised. The precursors to thenext major accident are already formed and are sendingout signals – the level of mindfulness, as a corner stoneof an organisations safety culture, determines whether wesee and recognise these signals and then act.

REFERENCESHealth and Safety Executive (HSE), 1999, Reducing Error and

Influencing Behaviour, HS(G)48, HSE Books, ISBN 0 7176

2452 8.

Health and Safety Executive (HSE), 2001, Behaviour modifi-

cation programmes establishing best practice, OTO 2000/048, HSE Books, ISBN 0 7176 1920 6.

Hopkins, A., 2000, Lessons from Longford – the Esso gas plant

explosion, CCH Australia Ltd, Sydney, Australia, ISBN

1 86468 422 4.

Hopkins, A., 2002, Safety Culture, Mindfulness and Safety

Behaviour: Converging Ideas, Working Paper 7, National

Research Centre for OHS, The Australian National

University.

Joyner, P., Lardner, R., 2003, Developing internal human

factors expertise on a high hazard site, Loss Prevention

2004, Prague.

Vogus, T.J. and Welbourne, T.M., 2003, Structuring for High

Reliability: HR Practices and Mindful Processes in

Reliability-Seeking Organizations, Journal of Organizational

Behavior, 24: 877–903.

Weick, K.E., Sutcliffe, K.M. and Obstfeld, D., 1999, Organis-

ing for High Reliability: Processes of Collective Mindful-

ness, Research in Organisational Behaviour, 21: 81–123.