Leadership Perspectives Blog

Hand on This, Mind on That

by J. A. Rodriguez
May 11, 2017

Work is progressing as usual. There is a very busy day ahead with at least one hundred things to do before it ends. The time is 0600, then 1600. Time flies by and the work activity correspondingly increases to meet commitments. Hands are on the current task, but the mind is elsewhere, perhaps on the long list of things to get accomplished or perhaps on the family plans that evening. Suddenly, the unthinkable happens. There it is: an almost. A near miss. Your heart is racing. You think “what if?”  You contemplate about your family and say to yourself, “Wow! That was close! Need to be careful next time!”

Another day, another week, another month zips by. Same thing. Early mornings. Late evenings. Many things to do in a short period of time with your hands on task and your mind elsewhere. Suddenly the unthinkable happens, only this time, you suffer a serious injury. Your work comes to a halt and so does that of your team. Taking care of you is now the organizational priority, and making sure the best medical care is provided as quickly as possible is the new mission at hand. You are unaware of any of this as your stretcher carefully is loaded into the back of an ambulance and rushed off to the nearest hospital.

Family members are notified. They are on the way to the emergency room. You are now in intensive care being treated for a potentially life-altering injury. In the meantime, there is a great expanse of activity going on to stabilize the work area, determine what happened and what process changes are required to prevent recurrence. The good news is, but only after a painful while, you’ll make it with no permanent harm.

During the two long weeks in the hospital, you reflect on what happened and the personal price paid for not having mind on task in terms of your health, well-being, family and quality of life. You wish you could turn back time and do it again, except you can’t. That’s when you realize, the next time there may not be a next time. That somber thought brings serious reflection… No lapse in focus during the performance of a job is worth the unthinkable to you or your family.

According to OSHA, one worker never returns home from work to his or her family every two hours of every day due to a workplace fatality. According to the Bureau of Labor Statistics, around 2.9 million nonfatal injuries and illnesses were reported by private industry in 2015. This means that, on average, approximately 7,945 workers are injured or fall ill every day of the year. Three hundred thirty one every hour and almost six every second. While this is a decline over the last several years, the number of injuries and illnesses to our workers are way too high. More can be done. More must be done by all of us.

Always focusing on the task at hand drives higher performance and saves lives. Effectively performing your work not only means being THERE, it also means being PRESENT. It means demonstrating leadership. Deliver performance at every opportunity by keeping your attention laser-guided on working safely and avoid having to reflect back on the real price tendered for injuries.

Protect yourself and others. Keep your hands on this thought and your mind on that task to make certain there’s never a different “almost” all over again.

Discuss this Blog Entry 1

on May 14, 2017

An inescapable fact is that harmful conditions cannot be acted upon in the absence of the situational awareness of their harmfulness. Thus insufficient situational awareness is a prime suspect in the persistence of harmful situations up until their harmful consummation. Situational awareness includes being mindful of the current reality and thus relates to mindfulness.

Quotation: “Those who persist in mental vacations are seen at the bottom of six foot excavations.”-Bill Corcoran

Observation: Chernobyl is an example of insufficient situational awareness. The operators were apparently not aware that initiating the test would blow up the reactor.

Observation: The harm from the water landing of US Airways Flight 1549 was greatly mitigated by the situational awareness of the crew .

Observation: The control room operators at Three Mile Island were not aware that the reactor coolant system was in thermodynamic saturation when it should have been subcooled. They could have determined this by comparing the pressurizer steam space temperature to the hot leg temperature.

Observation: The entire cockpit crew of Eastern Airlines Flight 401 were not aware that the aircraft was descending into the Everglades .

Observation: The causation of the harmful outcomes of 2016 Cincinnati Zoo boy patron intrusion includes the absence and /or insufficiency of situational awareness of the zoo staff and the parents.

Observation: The absence or insufficiency of situational awareness is involved in the causation of most harm involving operator behavior, other than some sabotage and suicide incidents.

Observation: Since the absence or insufficiency of situational awareness always has its own causation it is never a final element of causation.

Observation: The important mitigation of the US Airways Flight 1549 goose ingestion includes impressive total situational awareness of the pilots .

Observation: Important mitigation of the harmful event aboard USS Dwight D. Eisenhower (CVN 69) that resulted in multiple sailor injuries included superb airmanship of the EC-2 Hawkeye pilot, according to the navy investigation report. Otherwise the harm may have included loss of the aircraft and crew.

Observation: The causation of the grounding of the cruise ship Royal Majesty includes the total and complete persistent lack of situational awareness of all of the ship’s officers and crew involved in navigation.

Observation: On October 21, 2003 operators unknowingly allowed the reactor at the Callaway Plant shut itself down on xenon . (Xenon is noble gas that absorbs neutrons. It builds up inside the fuel when reactor power is decreased and then decays away.) In this condition, the reactor is left hanging on the xenon and would eventually restart itself. (Positive control of reactivity is one of the basic concepts of reactor safety.) But, in this case, the operators just ignored the condition for almost two hours , indicating a mind numbing lack of situational awareness.
Observation: Cognitive impairment from sleep deficits must degrade situational awareness for all operators as it does for drivers .

Observation: Lack of situational awareness (also known as day dreaming, taking a mental vacation, wool gathering, and the like) can be a red herring that diverts attention from more egregious causation, as in the case of the 2015 AMTRAK Train 188 Crash near Philadelphia.

Recognized and Generally Accepted Good Investigation Practice (RAGAGIP):
Specify the exact attributes of the situation of which the participants were not aware as well as what actions could have been taken.

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