Complex Systems

Safety Intervention: A Dynamic Solution to Complex Safety Problems

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If your organization is like many that we see, you are spending ever increasing time and energy developing SOPs, instituting regulations from various alphabet government organizations, buying new PPE and equipment, and generally engineering your workplace to be as safe as possible.  While this is both invaluable and required to be successful in our world today, is it enough?  The short answer is “no”. These things are what we refer to as mechanical and procedural safeguards and are absolutely necessary but also absolutely inadequate.  You see, mechanical and procedural safeguards are static, slow to change, and offer limited effectiveness while our workplaces are incredibly complex, dynamic, and hard to predict.  We simply can’t create enough barriers that can cover every possible hazard in the world we live in.  In short, you have to do it but you shouldn’t think that your job stops there. For us to create safety in such a complex environment we will have to find something else that permeates the organization, is reactive, and also creative.  The good news is that you have the required ingredient already…..people.  If we can get our people to speak up effectively when they see unsafe acts, they can be the missing element that is everywhere in your organization, can react instantly, and come up with creative fixes.  But can it be that easy?  Again, the short answer is “no”.

In 2010 we completed a large scale and cross-industry study into what happens when someone observes another person engaged in an unsafe action.  We wanted to know how often people spoke up when they saw an unsafe act.  If they didn’t speak up, why not?  If they did speak up how did the other person respond?  Did they become angry, defensive or show appreciation?  Did the intervention create immediate behavior change and also long term behavior change, and much more?  I don’t have the time and space to go into the entire finding of our research (EHS Today Article) , just know that people don’t speak up very often (39% of the time) and when they do speak up they tend to do a poor job.  If you take our research findings and evaluate them in light  of a long history of research into cognitive biases (e.g. the fundamental attribution error, hindsight bias, etc.) that show how humans tend to be hardwired to fail when the moment of intervention arises we know where the 61% failure rate of speaking up comes from…… it’s human nature.

We decided to test a theory and see if we could fight human nature simply by giving front line workers a set of skills to intervene when they did see an unsafe action by one of their coworkers.  We taught them how to talk to the person in such a way that they eliminated defensiveness, identified the actual reasons for why the person did it the unsafe way, and then ultimately found a fix to make sure the behavior changed immediately and sustainably.  We wanted to know if simply learning these skills made it more likely that people would speak up, and if they did would that 90 second intervention be dynamic and creative enough to make immediate and sustainable behavior change.  What we found in one particular company gave us our answer.  Simply learning intervention skills made their workforce 30% more likely to speak up.  Just knowing how to talk to people made it more likely that people didn’t fall victim to  the cognitive biases that I mentioned earlier.  And when they did speak up, behavior changes were happening at a far great rate and lasting much longer that they ever did previously, which helped result in a 57% reduction in Total Recordable Incident Rate (TRIR) and an 89% reduction in severity rates.

I would never tell a safety professional to stop working diligently on their mechanical and procedural barriers, they should be a significant component of the foundation on which safety programs are built.  However, human intervention should be the component that holds that program together when things get crazy out in the real world.  It can be as simple as helping your workers understand their propensity for not intervening and then giving them the ability and confidence to speak up when they do see something unsafe.

Unsafe Behavior Is a Downstream Indicator

At first glance, the suggestion that behavior is a “downstream” indicator may seem ridiculous, because in the world of safety and accident prevention, behavior is almost universally viewed as an “upstream or leading” indicator.  The more unsafe behaviors that are occurring, the more likely you are to have an undesired event and thus an increase in incident rate (downstream or lagging indicator).  This view is the basis for most “behavior based safety” programs.

Over the past few years, however, there has been a great deal of research in the area of human factors which suggests that there are variables much more upstream than behavior that can help us decrease the chances of an incident.  The human factors approach views an individual’s behavior as a component of a much more complex system which includes contextual factors such as social (supervisory and peer) climate,  organizational climate (rules, values, incentives, etc.), environment climate (weather, equipment, signage, etc.), and regulatory climate (OSHA, BOEMRE, etc.).  Individuals work within these climates, evaluate action based on their interpretation of these climates and then act based on that evaluation.

Research has shown that individuals, for the most part make rational decisions based on the information that they have at their disposal in the moment.  If an individual “understands” that her boss really rewards speed, then she is more likely to pick up speed even if she is not capable of working at that speed and thus increases the likelihood of having an incident.  While speed of performance is a behavior, it is the result of the person’s knowledge of the demands of the climate and is therefore a downstream indicator.  Evaluating and impacting the climate is thus more upstream and should be the focus of our intervention programs.  When we can impact the decision making process (upstream) we can have a much better chance of creating safe/desired behavior (downstream).

Why Rule Breaking Makes Sense

Complexity & Rationality Why do employees decide to break the rules?  Do it their way?  Resist change?  It doesn’t make any sense!

It can be frustrating, and often perplexing, when employees fail to adhere to company policies and procedures, especially when those policies and procedures are in their best interest. There is a useful way to think about this issue: What employees do makes sense...to them; but the complexity of work environments makes it hard to understand why it makes sense to them.

We live and work in complex environments. It helps to think of our environments as systems with overlapping and interacting components - including people, things, rules, values, etc. - which are, in turn, complex sub-systems. One of the principles of complex systems is that the “people” component tends to respond only to the limited information that they are presented with locally. We make decisions based on our knowledge of what makes sense at the local level, which is called “local rationality”.

The policies and procedures contained in the corporate manual are only influential if they are brought to bear on the daily lives of people in the workplace. If those policies and procedures only exist in the manual and are not made a part of the local workplace, then they don’t exist in reality and will not have an impact on performance. They will lack influence.

Companies have policies and procedures for a reason - to create good, reliable results; so it is the responsibility of supervisors to bring those policies and procedures to life in the workplace. By intentionally incorporating formal policies and procedures into the “local” work environments of employees - through conversation, feedback, modeling, etc. - supervisors make it “rational” to follow the rules.