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Institutional Memory

Frankie Wood-Black,  Safety Expert
Frankie Wood-Black, Safety Expert

One of my former mentors used to tell me that the safety culture of any plant or organization was related to the institutional memory of the last big accident.  Think about that statement for a moment. Even in our own experience, the actions we take, our behaviors, and our plans are generally related to two things: what we were taught and what we have experienced.  But, when it comes to changing behavior to an inherently safer behavior based upon empirical evidence, we resist the change unless we have been personally impacted.

Let’s take an example to show how this works.  If you are of a certain age, you can remember riding in a car with no seatbelts, and even if you had a car with seatbelts, many of us didn’t use them.  The first US seatbelt patent for automobiles was issued in 1885 to Edward Claghorn. Nils Bohlin, at Volvo, invented the 3-point harness seatbelt in 1959.  Common usage of the seatbelt did not come until after the introduction of mandatory seatbelt laws, the first one in 1984 by the State of New York and the last states to implement mandatory laws were Maine and South Dakota in 1995.  Yet, if we know that seatbelts save lives, why were mandatory laws required before the common practice was adopted? 

Need another example?  How about helmets?  Bicycling, horseback riding, roller skating, baseball batting, etc.  It is simple physics, extend the time of impact, and the force is greatly reduced.  (This is why there are crash barriers on the highways.) Why is it so hard for individuals to wear a helmet?  You can imagine the list of excuses.  But, fundamentally, it comes down to our personal experience and the safety iceberg. The safety iceberg tells us that we can perform an “at-risk” behavior a large number of times before the one that comes up to bite us does.  How many times did you plug in the electrical appliance with wet hands and not get shocked?  You know the hazard, and you know the risk, but you do it anyway. 

Training (which hopefully creates positive habits) is one way to limit at-risk behavior.  A significant event can also change behavior, and it usually happens rapidly.  I can tell you the day; our family began wearing seatbelts all the time.  I can tell you the day that everyone in the plant began to take a hot work permit seriously.  We all remember the day when we began to submit to new screening procedures at the airport.  These are events that develop institutional memory.  There is a problem; change can have us lose that essential institutional memory that can leave us venerable.  We lose the why behind what we are doing.  

As we move forward, new policies and procedures, and new technologies are being put into place.  We have to make sure that we don’t lose that critical institutional memory.  Why does your plant need a hard telephone line?  Because when the power goes out in an emergency, you still can call for help (or the backup security systems are tied to it, or the fire alarm systems are tied to it).  Why do you need that little contact number card in your wallet?  Because when your phone is smashed or you have no battery left, do you remember what numbers to call?  

Many of us are faced with re-examining how work is accomplished, what are critical job functions, and what are critical systems.  Budgets and practices are strained.  But, we have to be careful, and we need to ask questions.  We need to understand the why behind some of our actions, policies, and procedures before we eliminate them and then find out just how important they are in an emergency.

The opinions expressed in this article are the author's own and do not necessarily reflect the view of their employer or the American Chemical Society.

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