Posted November 13, 2013
Mishaps aren’t necessarily the result of a one-time, flagrant error. Before mishaps, the people who caused them might be doing something that they had done repetitively and gotten away with. Or they were doing something that they had done some version of in the past except this time they pushed it too far. In either case, the results are similar: equipment gets destroyed, and people start to bleed.
Here’s a handy reference that I call the “Thin Ice Primer.” I’ve written it as dialogue, so feel free to read it aloud to someone.
• “OK, team, one guy called in sick, so we’ll just have to do this job one short. We’ll be fine as long as nothing goes wrong.”
• “I assume he took care of that, he’s usually real reliable.”
• “I don’t know what they taught you in school, but this is how we do it here. I’ve done it this way twenty times.”
• “Yeah, I know you don’t have that qual. Just pay attention and I’ll show you the basics real quick.”
• “Hey, grab that safety observer and get him to help out for a minute.”
• “Wow, this shortcut works great! Wonder why I didn’t think of it before?”
• “I don’t understand why the checklist says that step is necessary. How important could it be?”
• “I know I’m not supposed to do this, but I’ll be finished in a few seconds.”
• “Man, that blade looks sharp! Wonder where I left those work gloves. Oh, well…”
When you hear someone say something like any of the preceding, you should do several things. Call a time out. Take a few minutes for some worst-case-scenario planning. Locate the nearest first-aid kit. Make sure someone has a cell phone to call 911.
A subset of “thin ice” dialogue is preceded with sound effects. For example, sound of gravel rattling off the undercarriage of a car that has drifted off a paved road onto a shoulder. The usual dialogue for this one: “Whoa, I’m fine, no problem, I’m awake now.” The next, ominous sound effect is the snoring from the passengers after they go back to sleep.
And there’s a final, huge subset of “thin ice” situations that contains no dialogue at all. That’s where people should have spoken up, asked a question, offered a reminder, asked for an update, or suggested a double-check. But they stay silent, because they’re distracted, or make a faulty assumption, or have crappy crew-resource-management skills.
There’s really no good answer to “Why didn’t you say something?”
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