Systemic Organizational Failure Root Cause: Safety as a Standard, Part 1

Systems Thinking generally is evaluating a larger thing by not just the function of individual parts but also how they interact as a whole. “Thing” can be just about anything; we are interested in the multi-dimensional interaction of people, equipment, government, environment, and money flow that comprises a single organization’s place in its market.

These concepts are difficult to generalize without turning to a strongly philosophical framework. A mathematical correlation which is easier to explain is the idea of objects distributed in space. It’s easy enough to discuss how each object relates to the other; however, it’s difficult to place them without an inertial frame work. I’m talking about a coordinate system that remains fixed in which the objects form. From a safety systems perspective, the most relevant coordinate system is OSHA. While OSHA only applies to workers & under specific circumstances, it still stands as the basis for safety programmatic evaluation. OSHA is not concerned with management theories, safety procedures such as failure modes and effects analysis, etc; it simply lays out essentially a checklist for employers to demonstrate a safe workplace and expects employees to follow them.

OSHA is able to change, which is quite important for a successful organization. Occasionally standards themselves are modified (for example, the requirements regarding who pays for Personal Protection Equipment and when an injury needs to be reported). Generally, people requesting clarification will receive Letters of Interpretation, which are important for application. Is OSHA a reliable coordinate system against which to measure a systemic failure in the market for a root cause using qualitative safety concepts?

Let’s take a look at a couple of problem areas: public schools and ergonomics. Here in Texas, we do not have a state OSHA plan; therefore, none of our public school teachers are covered by OSHA. This is a red flag. In systemic failures, red flags are areas of weaknesses; when enough of them exist in a system, the likelihood of systemic failure is high. OSHA briefly adopted an ergonomic standard after significant research, including feedback from interested parties. The standard was repealed by congress shortly after its implementation date and barred from being reconsidered at the same time. Is this a red flag? It is complex, OSHA continues to use the General Duty Clause for severe ergonomic injuries, yet the method of its elimination, lobbying by profit-maximizing interests, raises a red flag. The only other red flag we’ll mention includes the silicosis initiative. With regard to COVID, it’s important to note that the OSHA response has not been studied in sufficient detail to make any judgements.

If you look at the red flags listed above, they are significantly separated in time and are located at the political/administrative boundary to the organization. The vast majority of steps taken by OSHA reveal it to be a functional organization ensuring professionalism, a critical component to effective safety programs. For example, OSHA has significantly tightened requirements that authorized trainers must adhere to. This makes OSHA a strong reference point in identifying organizational-failure red flags in the market using safety concepts built upon its objectives.

Keep in mind, however, that OSHA, like any other organization, can potentially fail. If it did, a systemic failure is almost certain due to its position in the overall system as I’ve described above.