Zero. It’s the current safety craze, particularly within those industries that have had questionable safety records. Road safety. Employee safety. Healthcare.
It goes something like this. “Wow, we’ve not been doing well. And it seems we’re all growing comfortable with it. Let’s shake things up. Set a goal of zero fatalities, even zero harm. We’ll create a list of events called ‘never events.’ After all, we’re never going to be perfect unless we first set a goal of being perfect.”
It’s a well-intentioned, but misguided, strategy.
For proof, just go to those industries that have gotten close to zero fatalities – commercial aviation and nuclear power. Ironically, they don’t set a goal of zero harm. They don’t have “never” events. Instead, in a more intellectually honest approach, they set high expectations rather than lofty goals. Loss of all flight controls at one-in-a-billion rate. Meet the expectation, or be denied FAA approval to fly.
What the aspirational zero harmers fail to recognize is what every engineer quickly learns – design trades. The Swedish government, back in 1997, set the goal of zero traffic fatalities by 2020.1 Back then, they took what they saw as the moral high ground. “It can never be ethically acceptable that people are killed or seriously injured when moving within the road transport system,” they proclaimed. Very easy to say as a marketing pitch, but not reality within the design trades.
To truly achieve zero fatalities on the road, system designers have to do one of two things. They have to prevent all accidents, or they have to make all accidents survivable. Let’s address the first. A single, inescapably fallible, heart-attack prone, physically fatigued, social texter behind the wheel. With a single loss of attention, an accident can occur. Not until we have fully autonomous vehicles with redundant computers guiding our path do we have any chance of getting close to zero. Given the prospects for fully autonomous vehicles back in 1997, it’s safe to assume preventing all accidents was not the Swedish strategy.
Make every accident survivable. That’s the only answer. There are 8 million registered motorcycles in the US, and every year roughly 5000 of them are involved in a fatal accident.2 No air bag, no crumple zone – what do they expect? Motorcyclists know the danger, yet they are willing to make the life/joy trade. To close in on zero, the Swedish government surely must have legislated those dangerous bicycles, mopeds, and motorcycles off of the road. But they did not. The right to be free to ride a two-wheeler did not neatly fit into their noble “Vision Zero.” In fact, Sweden was even unwilling to create a bicycle helmet law for adults. So, in 2015, sixty-six cyclists died on the streets of Sweden. Vision Zero, or Vision 66 you might ask?3
Every system suffers from design trades. As we asymptotically get closer to zero, the greater the burden we place on other strongly held values. Hospitals may want zero patient falls, but to get even close they’ll ask their patients to pay a price. They’ll ask them to toilet in the presence of a nurse (a significant affront to privacy), and they’ll significantly curtail patient ambulation (often clinically helpful for the healing process). Beyond that, there is always that one patient who you know is going to hop out of bed against nurse instructions. Of course, we’re just not sure which of our patients is going to be the one. So, do we staff a sitter to attend to every patient 24 hours a day, or even consider restraints, just to fulfill our proclamation of zero preventable falls?
That’s why zero ultimately becomes unachievable. Well-meaning policymakers set a goal of zero in the hopes that we humans will set aside all other competing interests or values in pursuit of their goal. Life does not work that way. Further, when policymakers realize they don’t have the cash or are unwilling to infringe upon competing values, they often shift responsibility for zero to the hands of managers and staff who have no power to change the systems around them. We don’t have the cash to fix the system, so alternatively, let’s just inspire our employees to victory. Perhaps a pizza party for the group who has zero reported injuries this quarter? One can easily imagine where that leads.
As noble as the cause may be, every zero harmer will unfortunately be proven wrong. It’s as if they’re challenging a law of nature: no matter how we string together a group of inescapably fallible human beings, they will never be able to create perfect outcomes. Just ask the Swedish Government. In 2007, to perhaps avoid the embarrassment of failure, the Swedish government recommitted to zero by 2050, a 30-year slide on a program intending to take only 23 years. Well timed, because those leaders will be long retired (or dead) by 2050. Leave it to a future legislature to tell its fallible citizens, among other constraints, that they cannot drive their own car, and that two wheeled vehicles are now outlawed.
It should be understood, the road to zero and the road to reliability are two very different roads, as we’ll attempt to show in the next issue paper. Like aviation and nuclear power, it’s better for society to take the intellectually honest road to high reliability, while still knowing we’ll never get to zero. It may not sound as noble, but it will surely deliver a better result.
David Marx
CEO Outcome Engenuity
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