Cardinal Rules: A Q&A with Christopher Hart, former Chairman of the NTSB.

C ardinal Rules classically target specific frontline employee behaviors regarding what is considered elevated risk work activities. They typically point to specific company policies or procedures that establish the “dos and don’ts” of performing these activities or tasks. Well intentioned managers with one or both feet still planted in the Old View of safety will say it is critical to hold employees strictly accountable to error-free performance on these tasks. Seems logical at first blush, but let’s take a further look and consider the context in which work is done. At the 2018 HOP Summit Dr. Tom Krause (The Krause Bell Group) shared research that shows that as many as 99% of pivotal safety decisions prior to an unwanted serious event are made in the days and months prior to the event by site leaders, corporate, and supervisors – not by frontline employees. This points to the importance of the context in which work gets done – the set of conditions present and information that is available at the time work is actually performed – which is largely under the control of management. If you assume that you hire good people and train them well, local rationality tells you that what employees did or did not do made sense to them at the time they had to do it, or they would not have done it.

The simple act of calling certain rules out for special treatment tends to lead somewhat inevitably to discipline for deviations. How would you answer this question – If cardinal rules are critical to safety performance, and management makes the vast majority of pivotal safety decisions, why do we generally not see cardinal rules for management? If you want to say cardinal rules apply to everyone, go take a careful look at your record of disciplinary action to see how often frontline workers are disciplined versus supervisors and management.

Secondly, there is virtually universal agreement that strong engagement with employees is critical for an effective safety program – they know “stuff” management never will about performing work, unless we talk and learn together. So, if cardinal rules are weaponized as showing where violations warrant discipline rather than a collaborative learning about how work is actually done and how to make sustainable improvements in safety, what happens to learning? Simple – when employees believe management will blame/shame/discipline it shuts down learning. Few are willing to talk for fear of reprisal.

Can cardinal rules be implemented in a way that can contribute in a positive way to improve safety? Yes. Cardinal rules must be developed with employees, kept to a minimum, and applied only in safety-critical situations. Their enforcement is best kept as a last resort rather than a first response, after careful and just inquiry warrants. However, it will take resources and care to craft them well, teach management and employees that deviations are opportunities to learn – usually not discipline, and monitor to confirm that the organization does not slip backward into the trap of weaponized cardinal rules that severely limit the opportunity for operational learning. And this commitment of resources must be maintained to orient new employees and leaders who enter the system.

Last year the NTSB issued its report on the investigation of the April 2016 AMTRAK collision in Chester, PA. The report spoke to significant insights into how cardinal rules operated in this case, and the adverse impacts they had on safety performance. So we asked Christopher Hart, former Chairman of the NTSB, to share his thoughts on a few key questions.

Question 1. Virtually everyone would agree that a strong relationship between employees and management is critical for strong safety performance. How have you seen cardinal rule systems implemented, and what impact has that had on the labor/management relationship?

Christopher Hart: As far as I know, this is the first accident that the NTSB has investigated involving the concept of cardinal rules. I cannot generalize based upon a single situation, but I can say that cardinal rules that result from a collaborative effort between management and labor can improve the relationship between them by helping to ensure that both are on the same page. If, on the other hand, management unilaterally creates and imposes the rules, as apparently occurred in this situation, labor/management relations will probably be adversely affected; and poor labor/management relations can undermine safety.

Q2. If you were advising a company that had or was considering the addition of cardinal rules, what would you tell them?

CH: Collaboration is crucial to the development of a mutually beneficial relationship. My advice is that management and labor should develop the rules collaboratively by working together to identify the safety issues that need to be addressed and the best ways to address them, and then treating the rules as guidelines for appropriate behavior. If the guidelines are not followed, management and labor should collaboratively figure out why, based upon an examination of the total situation – not with the objective of punishment (unless, of course, there is criminal or intentional wrongdoing), but with the objective of improving the situation to help prevent the problem from recurring.

Q3. If you had to identify the biggest reason operational leaders struggle with the transition from the Person Model of accidents to the System Model, what would it be and how would you recommend helping them make the transition?

CH: The System Model can be difficult for operational leaders to accept because they are often the creators of the System – including the selection and training of the employees, the design of the workplace, the development of the rules, procedures, and guidelines, and the acquisition of needed supplies. Because basic human nature is “I’m doing everything ok but you aren’t”, it is generally easier to blame an employee for a problem than to admit that the System that the operational leaders created needs improving. The best way to make the transition is collaboration – meaningfully including the employees in all stages of the process as it is being developed.

Q4. What else would you like to tell us?

CH: Collaboration can be a very powerful way to improve safety, and it can also play a major role in improving labor/management relations because it can help management realize that labor has some good ideas regarding what should be improved and how to improve it, based upon their “up close and personal” daily interaction with the system; and it can help labor realize that management actually cares about them and listens to their concerns.