Reflections... STOP Culture
APM Team,
Good execution thus far this outage season. With the exception of a rough couple days in early October when we had two craft injuries, we have kept our people 100% safe thus far this fall. There may be a number of reasons why, and I assure you we will dive deep in reviewing this fall to learn why in prep for the spring. One reason why that is on my mind right now is our STOP culture.
Recent STOP Moments
We have captured 54 STOP moments thus far in September and October. (As an aside, I am confident there are more that happen every day, yet go unreported based on your judgment of what STOP moments are impactful. I encourage you to report STOP moments, even if you don’t see much in them, as they do help us learn where our stronger defenses are weak. More on that in the end of this email.)
Not just the quantity, also the quality of STOP moments has made a difference. The detail of the events leading up to the STOP moments has been very helpful; we can stand with the crew in the moment, understanding how we got the point where a STOP moment was executed. And the detail has led to improvements in process and systems. For example, I am very proud to share that one of our customers – Exelon – recently recognized an APM crew for a STOP moment that led to a change in their LOTO process on the newer 7H fleet. Pause and think about that. Based on our crew’s confidence to STOP work based on a concern with the customer’s LOTO process, we helped a customer improve their process and the safety of their employees. Now that is a safety culture that is impacting an infinite number of lives beyond the APM family.
Recent STOP Guidance
Collin Warren, our General Counsel, recently shared an observation he had from doing site visits across the construction industry. I quote his observation below (emphasis is mine), and encourage you to incorporate his recommended countermeasure into our STOP culture.
"Findings regarding increased failures to utilize stop work authority when the “new” or “changed” work environment is not out of the norm. When people ask: Why did the crew not stop? The answer is likely the condition they planned for, versus what they actually encountered in the changed work environment, were equally within the norm. They might say we have done it like this a 1,000 times before without incident. However, the two scenarios - while equally normal - were not equally planned for. Think about moving from using a come-along to an overhead hoist. Nothing necessarily abnormal about using either, but the risks are different, yet the crew does not stop upon making the change and an incident occurs. Countermeasure - no matter how “normal” the changed situation / environment is, there must be a stop."
Relying too much on STOP?
I mentioned above that STOP moments, no matter how insignificant they may seem, help us learn where our other defenses are weak. I ask you to think about that statement. A STOP moment reveals that multiple defenses were ineffective or absent in a process or system, and thus the defense used (maybe the only defense left) was to rely on a person to STOP and not proceed. As we all know, humans err – we make mistakes every day. We will not STOP every time we should, for a number of understandable reasons. If our only defense is a strong STOP, well our entire defense is weak. For you football fans, it’s like having a great safety with a poor line and backers; the safety is making most of the tackles, 10+ yards downfield. It doesn’t take a genius to know eventually the safety will be in his end zone watching the offense score. Not a good defense.
Furthering this thought, I ask you to read the attached excerpt, particularly pages 114-117, from Workplace Fatalities: Failure to Prevent by Todd Conklin. I welcome you to share your observations with me as we think together about STOP (or START) work authority.
What do you think of the following statements:
"If your organization counts on STOP work as a prevention strategy, that means that every other prevention strategy that your organization uses failed."
Asking workers to STOP a job before the job has bad consequences feels like management is creating a "back door" that removes all responsibility from the organization.
"This crusty old mechanic looked me straight in the eye and told me, 'STOP work is at best a prevention tool, and not a good prevention tool at that.'"
"STOP work dumbs down the complex and context rich conditions that create environments that foster accidents. They make an accident look like it would be as simple to avoid as saying the word, 'STOP.'"