The Weekly Reflektion 27/2023

Investigations into incidents and accidents are essential to find direct and underlying causes and to initiate measures to prevent recurrence and improve performance. The failure of processes and systems is demonstrated by the fact that an incident has occurred, and the incident and its circumstances give pointers on where to look for improvements. Just as important is looking for measures to improve where there is no incident to guide you. Sometimes it feels like looking for a needle in a haystack.

What methods do you use to find out how to improve safety?

The term ‘needle in a haystack’ is used to describe something that is difficult to find. Needles were originally made of wood or bone and would have been almost indistinguishable fromthe hay strands in the stack. The origin of this term literally, may well be an old farmer’s tale. The saying was used in the tale of ‘One Thousand and One Nights’ in 900 CE and probably was taken from the Ancient Middle East.

Jim Moran, an American eccentric, put a lot of effort into disproving popular fallacies. He unloaded 50 tons of hay in Washington and had someone bury a needle in it. After 82 hours and 35 minutes he found it. There are other examples of Morans’ attempts to disprove established sayings. He sold fridges to the Inuit in 1938, and the following year took a bull into a New York china shop. Moran was not the only one that liked to challenge popular sayings. Timothy Dexter, an American businessman, was once challenged jokingly by friends to ‘ship coals to Newcastle’ and he did so. When his ship arrived in Newcastle there was an ongoing miners strike,and he sold the load at great profit.

So, is finding improvements in your organisation when everything appears to be OK, just like trying to find a needle in a haystack? Do the management need to spend a significant amount of time searching through the hay, as Jim Moran did? Is there a way to achieve an acceptable balance between time spent and improvements achieved? 

With just a little knowledge of what you are looking for then great strides can be made in a limited time frame.

Modern needles are manufactured from high carbon steel wire and are nickel- or 18K gold-plated for corrosion resistance. The use of a magnet and/or metal detector should speed up the search process significantly. For needles made of other materials the material characteristics need to be studied to find the best way to distinguish these from the hay in the haystack. Knowledge and preparation are the prerequisites to an effective search process.

What knowledge and preparation are required when you try to find improvements in your organisation? What characteristics will separate the areas that will really make a difference from the areas that are unlikely to succeed? What should you do yourself and what should you use others for? Reflekt has several Reflektions that illustrate the importance of ‘outside eyes’ to give you an insight into your organisation that you may not get yourself.

In almost all the Major Accidents that we have studied there are needles that were never found and in some cases needles that were never looked for. The needles emerge during the investigation and seem so obvious with the benefit of hindsight. We do not have the luxury of Major Accidents to find our needles. We need to find them before people get hurt.