May 1, 2024 | Mark Paradies

Senior Management: Can Your Investigators Tell You that Your BABY is UGLY?

ugly baby

Senior Management Needs to Read This Article

This article is for senior corporate management

Can your investigators tell you that your baby is UGLY?

What do I mean by this?

Can your investigators point out management system flaws that ONLY YOU can fix?

If you say yes … I want to know the last time they did it!

Why am I bringing this up?

Recently, I was talking to several “senior investigators” from a major company. We were discussing some serious incidents (SIFs). I recognized that there had been a series of management system failures over a period of over a decade that had not been fixed. SEVERAL generations of senior management had contributed to the problem by creating a culture of expediency … a “just get it done” culture that put cost containment and keeping the plant operating over process safety. 

I asked them if they had pointed this out to senior management. They looked at me as if I was nuts. 

That’s when I realized … THEY couldn’t tell management that their BABY was UGLY.

Ugly Baby

I also realized that management didn’t want to hear that their BABY was UGLY.

Just Make Problems Go Away!

Management just wanted problems to go away with the least muss and fuss possible. They didn’t want to confront the investments required to face the facts. They wanted the plant to continue to produce. They didn’t put process safety first.

TapRooT® Root Cause Analysis will point out the problems in management systems. But investigators must be willing to share with senior management the facts (tactfully) and show them clearly that the BABY is UGLY.

Senior management should be DEMANDING that investigators point out management system flaws and asking WHY management system flaws ARE NOT being presented if a serious incident happens.

I remember pointing out a serious management system flaw that had caused a multi-multi-million dollar accident (no one had been killed, but someone easily could have been killed). The Senior VP said:

“If anyone would have pointed out the problems
this decision caused, we wouldn’t have made it!”

What to Do?

Don’t let poor management system decisions go unchallenged and unreported. When unreasonable budgets, deferred maintenance, short staffing, unreasonable overtime, or standard violations become an issue – SAY SOMETHING! Let senior management know they have an UGLY BABY.

SENIOR MANAGEMENT – Occasionally, you need an outside opinion of how your baby looks … Especially if you continue to have significant incidents. Maybe you need to face the fact that your BABY is UGLY.

Remember … Unlike real ugly babies, management CAN DO SOMETHING about management system problems. Effective corrective actions can make the UGLY BABY beautiful.

Courses That Can Help

To learn more about Management Systems and TapRooT® Root Cause Analysis, see our courses HERE. See the dates and locations of our public TapRooT® Courses HERE. I’d suggest taking a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.

TapRooT® Course
Exercise at a 5-Day TapRooT® Course
Investigations, Process Safety, Root Cause Analysis Tips
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