Overcoming the Bystander Effect

Research and personal experience both demonstrate that people are less likely to intervene (offer help) when there are other people around than they are when they are the only person observing the incident. This phenomenon has come to be known as the Bystander Effect and understanding it is crucial to increasing intervention into unsafe actions in the workplace. It came to light following an incident on March 13, 1964 when a young woman named Kitty Genovese was attacked by a knife-wielding rapist outside of her apartment complex in Queens, New York. Many people watched and listened from their windows for the 35 minutes that she attempted to escape while screaming that he was trying to kill her. No one called the police or attempted to help. As a matter of fact, her attacker left her on two occasions only to return and continue the attack. Intervention during either of those intervals might have saved her life. The incident made national news and it seemed that all of the “experts” felt that it was "heartless indifference" on the part of the onlookers that was the reason no one came to assist her. Following this, two social psychologists, John Darley and Bibb Latane began conducting research into why people failed to intervene. Their research became the foundation for understanding the bystander effect and in 1970 they proposed a five step model of helping where failure at any of the steps could create failure to intervene (Latane & Darley, 1970).

• Step 1: Notice That Something Is Happening. Latane & Darley (1968) conducted an experiment where male college students were placed in a room either alone or with two strangers. They introduced smoke into the room through a wall vent and measured how long it took for the participants to notice the smoke. What they found was that students who were alone noticed the smoke almost immediately (within 5 seconds) but those not alone took four times as long (20 seconds) to notice the smoke. Just being with others, like working in teams in the workplace can increase the amount of time that it takes to notice danger.

• Step 2: Interpret Meaning of Event. This involves understanding what is a risk and what isn’t. Even if you notice that something is happening (e.g., a person not wearing PPE), you still have to determine that this is creating a risk. Obviously knowledge of risk factors is important but when you are with others and no one else is saying anything you might think that they know something that you don’t about the riskiness of the situation. Actually they may be thinking the same thing (pluralistic ignorance) and so no one says anything. Everyone just assumes that nothing is wrong.

• Step 3: Take Responsibility for Providing Help. In another study, Darley and Latane (1968) demonstrated what is called diffusion of responsibility. What they demonstrated is that as more people are added the less responsibility each assumes and therefore the less likely any one person is to intervene. When the person is the only one observing the event then they have 100% of the responsibility, with two people each has 50% and so forth.

• Step 4: Know How to Help. When people feel competent to intervene they are much more likely to do so than when they don’t feel competent. Competence engenders confidence. Cramer et al. (1988) demonstrated that nurses were significantly more likely to intervene in a medical emergency than were non medically trained participants. Our research (Ragain, et al, 2011) also demonstrated that participants reported being reluctant to intervene when observing unsafe actions because they feared that the other person would become defensive and they would not be able to deal with that defensiveness. In other words, they didn’t feel competent when intervening to do so successfully, so they didn’t intervene.

• Step 5: Provide Help. Obviously failure at any of the previous four steps will prevent step 5 from occurring, but even if the person notices that something is happening, interprets it correctly, takes responsibility for providing help and knows how to do so successfully, they may still fail to act, especially when in groups. Why? People don’t like to look foolish in front of others (audience inhibition) and may decide not to act when there is a chance of failure. A person may also fail to act when they think the potential costs are too high. Have you ever known someone (perhaps yourself) who decided not to tell the boss that he is not wearing proper PPE for fear of losing his job?

The bottom line is that we are much less likely to intervene when in groups for a variety of reasons. The key to overcoming the Bystander effect is two fold, 1) awareness and 2) competency. 1) Just knowing about the Bystander effect and how we can all fall victim to this phenomenon makes us less likely to do so. We are wired to be by-standers, but just knowing about this makes us less likely to do so. 2) Training our employees in risk awareness and intervention skills makes them more likely to identify risks and actually intervene when they do recognize them.

Peer Pressure, Conformity and Your Safety Culture

We are social creatures. We desire and attempt to maintain relationships wherever we are. In other words, we try to fit in with other people. This is true whether we are talking about family, work or just out in public with people we don’t know. The research is pretty clear….our decisions and actions are impacted by the people around us. Take the classic research of Solomon Asch (1955; 1956) which demonstrates the power of groups (normative influence) on our decision making. The experimental task was simple….select which one of three comparison lines match the standard where one line was obviously longer and one obviously shorter. The catch was that the experimental subject was grouped with varying numbers of confederates who would select an obviously wrong answer. The results were consistent….participants were likely to go along with the group even when the answers were obviously wrong and this conformity increased as group size increased. Additional research by Asch demonstrated that conformity decreases by approximately 25% with just one dissenter, suggesting that people want to make the correct decision and they don’t need a lot of support from group members to do so. The implication is that people tend to conform to group norms if everyone agrees, but are willing to dissent if there is any sort of disagreement among group members. The reason people are willing to go along with a group even when the decision is obviously wrong is because of fear of rejection and research provides ample evidence that rejection is a very common result of dissension with group decisions (see Tata, et al, 1996). There is a second reason that people go along with the group in addition to the desire to be liked and to fit in (normative influence). Research demonstrates that we go along with the group on many occasions because we think the group knows more about the correct decision than we do (informational influence). Two types of situations produce informational influence: (1) ambiguous situations in which a decision is difficult, and (2) crisis situations in which people don’t have time to really think for themselves. While (2) is pretty uncommon, (1) is very common in the workplace, especially with new hires. Less experienced employees don’t want to be rejected by the group, but additionally don’t have the experience to make thoughtful decisions when faced with situations that they have not encountered before. This is especially true when they are observing more experienced employees who don’t view the situation as ambiguous at all and don’t seem to hesitate when making a decision, even when the decision leads to an unsafe action. These types of decisions become automatic….just the way we do it around here. While peer pressure can be a bad thing if it leads to undesired behavior, it can also be a “good” thing if it leads to positive, safe, desired behavior. Understanding the power of peer pressure and the accepted, automatic nature of responding within an organization can help you create a safety culture where peer pressure leads to safe performance and a decrease in undesired behaviors and resulting incidents.

The Brain Science of Human Performance: Part 2

In our last post, "The Brain Science of Human Performance", I described how three inherent functions of the brain affect the performance of people in very real ways.  These three functions are problem solving, automation, and generalizing.  I also introduced another mechanism of the brain that can inhibit performance, cognitive biases.  In this followup, I will propose a way to overcome the cognitive biases and use the three functions in a strategic manner to drive good performance. As I detailed before, our brains take in an enormous amount of data when we are trying to problem solve a new and/or difficult task.  This data is comprised of many factors that we call our "context".  The most salient (important) and obvious factors actually create a feeling of what makes sense in that moment and is referred to as "Local Rationality".  Once we complete the task and it seems to be successful we eventually automate this process and it becomes part of our normalized routine. We then, without even realizing it, assume that if that process worked in that case, then it must be the right thing to do in other, similar, cases and this is where the "generalizing" comes into play.  While this may seem like an inherent flaw, those that understand this process are able to actually use it to create better performance.  We know that our brains kick in when we have to start processing new context.  If we can identify the context that was previously in place (i.e., that created a moment of local rationality for performing in a flawed way) we can change that context to be more conducive to better performance.  For example, an operator at a manufacturing facility has found a way to reach around a guard and remove product that has become lodged in the machinery.  He doesn't perform lockout/tagout (LOTO) because the main power source is across the facility and it takes more time to walk over there and lock and tag than it does to perform his work-around.  He also knows just where to insert his arm to reach around the guard and pull out the product.  He's not the only person doing this, as many other operators have been performing it that way in this facility for years.  In fact, it's just how they do things around there, and after all nobody has ever been hurt doing it this way and, additionally, they have certain levels of production that they must maintain to keep their supervisors off their back.  While that may seem like a very mundane and simple example of what happens in countless facilities everyday, it is actually rooted in an incredibly complex cognitive system.  While most of you can see an immediate fix or two (move the power source and create a better guard) let's understand how that actually affects the brain.  If we are able to get budget approval (sometimes difficult) to move the power source and fabricate a better guarding system, then we would have a new and salient context.  If the operator can't reach through the guard, then he would be required to remove the guard, therefore removing the guard becomes the logical, but time consuming thing to do.  If, however, de-energizing the machinery is easier and requires less time, then it becomes far more likely that he will actually do that, not because he's lazy but because we've just impacted a cognitive bias that I'll explain later.  Once this context is changed, the cognitive automation stops and we move back to problem solving.  Based on the new context, a different way of doing things becomes locally rational and once that new, and better way of performing the task is successful, that performance will then become automated and generalized.

Unfortunately, our work isn't yet complete, we also have to deal with those pesky cognitive biases (distortions in how we perceive context).  I mentioned above that a person may chose to skip LOTO because it takes more time to walk across the facility than to perform the actual task.  This is rooted in a cognitive bias called "Unit Bias" where our brains are focused on completing a single task as quickly and efficiently as possible.  Or how about the "bandwagon effect" which is the tendency to believe things simply because others believe it to be true.  There is also "hyperbolic discounting" which is the tendency to prefer the more immediate payoff rather than the more distant payoff (completing a task vs. performing the task in a safe way), and the list goes on.  To overcome these cognitive biases we must first become aware that they exist.  Our brain is wired in a way that these biases are a core function.  To begin to rewire the brain and overcome these biases we must understand these biases and with this awareness we are actually less likely to fall victim to them.  When we fail to do this we are actually falling victim to yet another cognitive bias that is called "Bias blind spot".

So what is the take-away from all of this?  Our brains are wired to function as efficiently as possible.  One of the ways we do this is to automate decision making and performance to maximize efficiency.  Our decisions are driven by our contexts and the sometimes distorted way that we view that context.  If you want to change unsafe performance you have to change the context and the way we view our context so that it becomes locally rational to perform in a safe manner.  If we don't change the context we will continue to get the same performance we have always gotten because that is just the way our brains do it.

The Brain Science of Human Performance

Have you ever experienced the mental anguish of trying to perform a new and complex task?  Something that requires so much mental and maybe even physical dexterity that it takes you a while to problem solve and get it right?  I would imagine that most of us have experienced this innumerable times in our lives and, if replicated enough times, that task eventually becomes something of a second nature.  This concept was actually captured quite well by Daniel Kahneman in his book “Thinking, Fast and Slow”.  Kahneman talks about this second nature mental tasks as System I thinking and the more complex and process heavy tasks as System II.  Put simply, things that we do without even really thinking about it, like a skilled typist putting her fingers on the correct keys when she constructs an email, as System I tasks.  However, a person new to typing would have to try to remember where each key is located or maybe even look at the keyboard itself to find that ever elusive “X” key and this type of processing would be System II thinking. Understanding Kahneman’s description of System I and System II thinking, however, is only a part of the brain science of human performance.  As we like to say it, the human brain does three things repetitively and expertly; Problem Solve (System II), Automate (System I), and finally generalize, and it does all of this while interfacing with the world in a sometimes distorted manner.

Let’s see if we can break this down somewhat sequentially, although much of this happens simultaneously in the real world.  Problem solving a new task at work, as mentioned before, can be complex and mentally taxing.  You see, our brains are taking in all of the relevant information in performing this task while also trying to process extraneous context such as peer approval, time pressures, available resources, family issues, what’s for dinner, etc., etc.  Once all of this data is processed and the task is completed successfully our brain feels like the problem solving job is completed and wants to move on to the next task.  This is where automation comes in.

The human brain really isn’t capable of multi-tasking at any level of effectiveness.  While it may perform multiple tasks at the same time, it can’t really process two System II tasks simultaneously.  Therefore it wants to automate tasks (System I) so that it can be ready for the next System II task.  Automation may take time to fully take hold but once it does it is often communicated as, “this is how I’ve always done it” or “that’s just how we do things around here”, but at some point that task was new and a System II process.  The problem with automation is that we don’t realize that we are in automation.  We don’t feel the mental strain of these automated tasks and don’t even realize that we are involved in them hundreds, maybe even thousands of times a day.  But our brain isn’t finished trying to be efficient, not only does it want to automate tasks, it also wants to generalize tasks or behaviors that seem to be somewhat related.  Basically our brain says, “if that works here then it must work there as well”.  In that moment of trying to be super efficient our brains have bypassed the entire problem solving process for future tasks that seem to be related to the automated tasks that we have already problem solved.  This would seem to be highly efficient, but it can also lead to errors.  In two weeks we’ll revisit a previous topic…..the distorted view of context in the problem solving process (cognitive biases)…..and then also examine how we can make this brain science work in our favor.

Sorry, I Just Forgot!

Do you ever have trouble remembering someone’s name, or a task that you were supposed to have accomplished but didn’t, or maybe how to safely execute a procedure that you don’t do very often? I know…. you can’t remember! Well if you do forget then you are perfectly normal. Forgetting is a cognitive event that everyone experiences from time to time, but why? What causes us to forget and is there anything we can do about it? Bottom line is that when we forget, we have either failed to encode the information into long-term-memory (LTM), which means we don’t have the information stored in the first place, or we have failed to retrieve it effectively. The failure to remember the name of someone that we have just met is probably an encoding failure because we don’t move the person’s name from working memory to LTM and it just disappears or gets knocked-out because of the short-term nature of working memory. To get it into LTM we have to “elaborate” on the information in some way, maybe with a rhyme, or rehearsal, or some other mnemonic technique. The problem is that most of us either don’t expend the effort needed to transfer information like names of people we probably won’t meet again to LTM, or other information that comes in right after we hear the name interferes with transfer. But what about information that is important, like a meeting that we scheduled for 10:00 AM next Monday with a coworker about an important project that we are working on, or wearing your safety glasses when using a grinder in your home workshop? Both are important but might require different assistance to avoid forgetting. Maybe you put the meeting on your calendar but didn’t create a reminder because this is an important meeting and you will certainly not forget to check your calendar Sunday night. But you were busy watching Sunday Night Football and didn’t check your calendar and when you got a call from your coworker at 10:10 on Monday morning asking why you weren’t in the meeting, you were totally shocked that you hadn’t remembered the event. Maybe you began operating your grinder without putting on your safety glasses because the glasses weren’t readily available. These types of retrieval failures are most likely caused by something that impacts us all….interference at retrieval. There has been a lot of research into the effects of interference on memory both at encoding and at retrieval and the evidence is pretty clear…..retrieval is cue dependent (a context effect) in that it is stimulated by hints and clues from the external and internal environment (i.e., our context). If the salient cues that were present at encoding are present at retrieval, then you are less likely to forget, i.e. have a retrieval failure. The more similar the context at encoding and retrieval the greater the chances of remembering. Interference by dissimilar cues like the report that you started working on at 8:00 AM on Monday when you got to work increase the chances of forgetting the meeting. Or not having safety glasses readily available and obvious on the grinder. The way we can capitalize on the strengths of our brains and overcome it’s short comings is to better understand how our brains work. In the case of the meeting, creating cues that will be present at both encoding and retrieval is very helpful. Creating a reminder when putting the event on your calendar and then experiencing that same reminder cue before the meeting, or putting the meeting on your to-do list and then visualizing your to-do list at the beginning of the day are things that capitalize on our brain’s strengths and help avoid its weaknesses. But what about remembering to wear your safety glasses when operating a grinder? Something as simple as hanging safety glasses on the grinder switch can help. Also, research has clearly demonstrated that emotional cues tied to information at encoding increase the chances of accurate retrieval. Creating a visual image of an eye injury or hearing/reading a vivid story of a real grinder related eye injury will increase the chances that simply seeing the grinder will cause you to remember to put on your safety glasses. The bottom line is that the more we understand how we function cognitively, the better able we are to create contexts that help us remember and succeed.

Why Does Context Matter?

If you’ve been reading our blogs for some time you know that we center our approach to human performance around the idea of “context”.  Context is at the heart of the science of Human Factors, also referred to as “ergonomics”.  Human Factors involves understanding and integrating humans with the systems that they must use to succeed and context is central to that understanding.  To say that we are a product of our environment is accurate, but far too simplistic for those attempting to be more intentional in changing performance.  A practical way to look at context is to think of the world around us as composed of pieces of information that we must process in order to successfully interact with our environment.  These pieces of information include the other people, physical surroundings, weather, rules, laws, timing, and on and on and on. The breakdown in this process is when it comes time for us to crunch that data and react to it.  Our brains, at the time of this writing, still have the edge on computers in that we can intentionally take in data rather than passively waiting for something else to give us the data, and we can then decide how we behave with respect to that data where a computer is programmed to behave in predictable ways.  However, at times, that unpredictability could also be a weakness for humans.

The two most glaring weaknesses in processing the data are topics that we have written about just recently (Hardwired Blog and Cognitive Bias Blog).  The first of these can be explained by staying with our computer analogy.  For those of you that understand computer hardware, you would never spend your money on a new computer that has a single core processor, which means it can only process one job at a time.  While our brains aren’t exactly single core processors, they are close.  We can actually do two jobs at a time, just not very well and we bounce back and forth between these jobs more than we actually process them simultaneously.  Due to this, our brains like to automate as many jobs as possible in order to free itself up to process when the time comes.  This automatic (System 1) processing impedes our more in-depth System 2 processing and while necessary for speedy success, it can also lead to errors due to failure to include relevant data.  In other words, while living most of our lives in System I is critical to our survival, it is also a weakness as there are times that we don’t shift into System II when we should, we stay in automation.  Unfortunately we are also susceptible to cognitive biases, or distortions in the way we interact with the reality of our context.  You can read more about these biases (here) but just know that our brains have a filter in how we intake the data of our context and those distortions can actually change the way our brains work.

So what are some examples of how context has shaped behavior and performance?

- Countries that have round-a-bouts (or traffic circles) have lower vehicle mortality rates because the accidents that occur at intersections are side swipes rather than t-bones.

- People that live in rural areas tend to be more politically conservative and those in urban areas tend to be more politically liberal. The reason is that those living in smaller population densities tend to be more self-reliant and those living in higher population densities rely on others, in particularly, government services.

- People who work in creative fields, (artists, writers, musicians, etc.) are more creative when they frequently change the environment where they do their work. The new location stimulates the executive center of the brain.

- Painting the holding facilities of people arrested under the influence of alcohol a particular shade of pink has proven to lower violent outbursts. *Read the book “Drunk Tank Pink”, it’s genius.

- A person that collapses due to acute illness in a street is less likely to be provided aid by other people if that street has heavy foot traffic. The fewer people that are around the more likely one of those people will provide aid.

- As a hiring manager, I’m more likely to hire a person whose name is common and which matches my age expectation.

- School yard fights increase during the spring time when the wind blows harder causing the children to become irritable.

These are all examples of how the context around us can change our behaviors and performance.  If we can start looking at our context in more intentional ways and engineering it to be more conducive to high performance, we will ultimately be better at everything we do, at work and home.

Just Pay Attention and You Won’t Get Hurt!

I have been thinking about the role of “attention” in personal safety lately.  I can’t tell you how many times I have heard supervisors say…”He wouldn’t have gotten hurt if he had just been paying attention.”  In reality, he was paying attention, just to the wrong things.  Let me illustrate this with a brief observation.  Two of my grandsons (ages 4 and 6) play organized baseball.  The 4-year old plays what is called Tee-ball.  It is Tee-ball because the coach places the ball on a chest high Tee and the batter attempts to hit the ball into the field of play where there are players on the opposing team manning the normal defensive positions.  It is my observation of the players on defense that has helped me understand attention to a greater depth.  Most of the batters at this age can’t hit the ball past the infield and most of them are lucky to get it to the pitchers mound, so the outfielders have very little chance of actually having a ball get to them and they seem to know this.  For the most part, the “pitcher” (i.e., the person standing on the mound) and to some extent the other in-fielders watch the batter and respond to the ball.  The outfielders however are a very different story.  They spend their time playing in the dirt, rolling on the ground, chasing butterflies or chasing each other.  When, on the rare occasion that a ball does get to the outfield the coach has to yell instructions to his outfielders to get them to look for the ball, pick it up and throw it to the infield.  There is a definite difference of attention between the infield and the outfield in Tee-ball.  This is not the case in the “machine-pitch” league that my 6-year old grandson plays in however.    For the most part all of the defensive players seem to attend to the batter and respond when the ball is hit.  So what is the difference?  Obviously there is a maturational difference between the 4/5-year olds and the 6/7-year olds but I don’t think this explains all of the attentional difference because even Tee-ball players seem to pay more attention when playing the infield.  I think much of it has to do with expectations and saliency.  Attention is the process of selecting among the many competing stimuli that are present in one’s environment and then processing some while inhibiting the processing of others.  That selection process is driven by the goals and expectations that we have and the salience of the external variables in our environment.  The goal of a 4-year old “pitcher” is to impress her parents, grandparents and coach and she expects the ball to come her way, thus attention is directed to the batter and the ball.  The 4-year old outfielder has a goal of getting through this inning so that he can bat again and impress his audience knowing that the probability of having a ball come his way is very small.  The goals and expectations are different in the infield and outfield so the stimuli that are attended to are different.  The same is true in the workplace.  What is salient, important and obvious to the supervisor (after the injury occurred) are not necessarily what was salient, important and obvious to the injured employee before the injury occurred.  We can’t attend to everything, so it is the job of the supervisor (parent; Tee-ball coach) to make those stimuli that are the most important (e.g., risk in the workplace, batter and ball in the Tee-ball game) salient.  This is where the discussions that take place before, during and after the job are so important to focusing the attention of workers on the salient stimuli in their environment.  Blaming the person for “not paying attention” is not the answer because we don’t intentionally “not pay attention”.  Creating a context where the important stimuli are salient is a good starting point.

Stress and Human Performance

If you examine the research literature on the topic of “psychological stress” you will find that there is a lot of disagreement on a definition of that term. However, there is almost total agreement that while stress can have positive effects in some situations, it can also have very negative effects on human performance in other situations.  For our purposes we will accept the Mirriam-Webster definition of stress as “a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances.”  While this definition ignores the positive effects of moderate stress that research shows is needed for motivation and action, it does describe a state that we all have experienced, and some of you may be experiencing right now.  Stress comes in several forms, including acute stress (in an emergency situation), chronic stress (from factors such as job, family, etc), stressful life events (e.g., divorce, death of a loved one, etc) and just those daily hassles (e.g., traffic, arguments, etc).  The one common thing in all of these types of stress is that they originate as a response to context.  There’s that word again….the one that we seem to talk about in just about all of our blogs.  Not only is stress a response to various aspects of our context, stress becomes part of our context and then impacts our performance and the decisions that we make.  Stress is our physiological response to our interpretation/appraisal of our context and it directly impacts cognition, social behavior and general performance.  Salient contextual factors such as noise, peer pressure, authority pressure, task load and time pressure have been shown to have detrimental impact on performance. Research is clear that high levels of stress cause us to narrow our attention span, decrease search behavior, react slower to peripheral cues, reduce our vigilance, degrade problem solving and rely on over learned responses that may or may not be best in the current situation.  In other words, we tend to make poorer decisions that can lead to failure and even injury.  Stress also causes us to lose our team perspective and it decreases the frequency with which we provide help to others.  This is especially impactful when working in high risk environments where watching your partners back and intervening when necessary is critical to maintaining safety and stopping unsafe actions and incidents.

So how do we deal with this so that stress doesn’t negatively impact performance?

We suggest a two-pronged approach involving (1) control of context and (2) control of how we interpret context in the moment.  Keep in mind that we are talking about normal stress reactions that we all experience, not pathological reactions that are best dealt with by trained therapists.  Let’s start with control of context and let’s set that context in the workplace.  In the workplace, context is, to a large extent under the control/influence of supervision and management.  So what should supervisors and managers do?  They should attempt to set realistic production objectives with realistic time constraints to create a context that help control stress produced by task load and time pressure.  They should minimize where possible the amount and duration of noise.  They should make sure that employees are trained so that they have the knowledge and skills required to meet those production objectives.  Simply being aware of the negative impact of stress, the relationship between stress and context, and the impact that they personally can have on that context will go a long way in stress control.  But what about how the individual interprets context in the moment.  Simple awareness that we can control stress reactions through our interpretation of context is a very good starting point.  In our February 25, 2015 blog we discussed how we are “Hardwired to Jump to Conclusions”.  In that discussion we saw how research supports the involvement of two different cognitive “Systems” in decision making and that System 1 tends to make quick decisions based on past experience and System 2 tends to be more rational and analytic.  Research demonstrates that the more stress we are experiencing, the more likely we are to engage in System 1 thinking which increases the likelihood that we will make less informed and perhaps less effective decisions.  We suggest that you use the initial physiological stress reactions as a “trigger” to stop, engage System 2 cognitive functions and evaluate your current context to determine what, if anything, can be done to create a different, less stressful context.  But what if you can’t change the context?   As we all know, there are times when we have a deadline and we are stuck in traffic and we can’t change that.  But we can stop, engage System 2 thinking, slow down our physiological response, realize that stressing out is not going to change the situation and figure out the best way out of this situation.  This of course takes practice and there are times when we won’t be successful, but understanding stress and how to respond to it can become an effective strategy to help us perform effectively in stressful conditions.

Lone Workers and “Self Intervention”

We work with a lot of companies that have Stop Work Authority policies and that are concerned that their employees are not stepping up and intervening when they see another employee doing something that is unsafe.  So they ask us to help their employees develop the skills and the confidence to do this with our SafetyCompass^®: Intervention training program.  Intervention is critical to maintaining a safe workplace where teams of employees are working together to accomplish results.  However, what about situations where work is being accomplished, not by teams but by individuals working in isolation…..the Lone Worker?  He or she doesn’t have anyone around to watch their back and intervene when they are engaging in unsafe actions, so what can be done to improve safety in these situations?  It requires “self intervention”.  When we train interventions skills we help our students understand that the critical variable is understanding why the person has made the decision to act in an unsafe way by understanding the person’s context.  This is also the critical variable with “self intervention”.  Everyone writing (me) or reading (you) this blog has at some point in their life been a lone worker.  Have you ever been driving down the road by yourself?  Have you ever been working on a project at home with no one around?  Now, have you ever found yourself speeding when you were driving alone or using a power tool on your home project without the proper PPE.  Most of us can answer “yes” to both of these questions.  In the moment when those actions occurred it probably made perfect sense to you to do what you were doing because of your context.  Perhaps you were speeding because everyone else was speeding and you wanted to “keep up”.  Maybe you didn’t wear your PPE because you didn’t have it readily available and what you were doing was only going to take a minute to finish and you fell victim to the “unit bias”, the psychological phenomenon that creates in us a desire to complete a project before moving on to another.  Had you stopped (mentally) and evaluated the context before engaging in those actions, you possibly would have recognized that they were both unsafe and the consequences so punitive that you would have made a different decision.  “Self Intervention” is the process of evaluating your own personal context, especially when you are alone, to determine the contextual factors that are currently driving your decision making while also evaluating the risk and an approach to risk mitigation prior to engaging in the activity.  It requires that you understand that we are all susceptible to cognitive biases such as the “unit bias”  and that we can all become “blind” to risk unless we stop, ask ourselves why we are doing what we are doing or about to do, evaluating the risk associated with that action and then making corrections to mitigate that risk.  When working alone we don’t have the luxury of having someone else watching out for us, so we have to consciously do that ourselves.  Obviously, as employers we have  the responsibility to engineer the workplace to protect our lone workers, but we also can’t put every barrier in place to mitigate every risk so we should equip our lone workers with the knowledge and skills to self intervene prior to engaging in risky activities.  We need to help them develop the self intervention habit.

Are Safety Incentive Programs Counterproductive?

In our February 11, 2015 blog we talked about “How Context Impacts Your Motivation” and one of the contextual aspect of many workplaces is a Safety Incentive Program designed to motivate employees to improve their safety performance. Historically the “safety bonus” has been contingent on not having any Lost Time Injuries (LTI’s) on the team during a specified period of time. The idea is to provide an extrinsic reward for safe performance that will increase the likelihood of safe behavior so that accidents will be reduced or eliminated. We also concluded in that blog that what we really want is people working for us who are highly intrinsically motivated and not in need of a lot of extrinsic “push” to perform. Safety Incentive Programs are completely based on the notion of extrinsic “push”. So do they work? We know from research dating back to the 1960’s that the introduction of an extrinsic reward for engaging in an activity that is already driven intrinsically will reduce the desire to engage in that activity when the reward is removed. In other words, extrinsic reward can have the consequence of reducing intrinsic motivation. I don’t know about you, but I don’t want to get hurt and I would assume that most people don’t want to get injured either. People are already intrinsically motivated to be safe and avoid pain. We also know that financial incentives can have perverse and unintended consequences. It is well known that Safety Incentive Programs can have the unintended consequence of under reporting of incidents and even injuries. Peer pressure to keep the incident quiet so that the team won’t lose it’s safety bonus happens in many organization. This not only leads to reduced information about why incidents are occurring, but it also decreases management’s ability to improve unsafe conditions, procedures, etc. resulting in similar incidents becoming more likely in the future. Because of this, the Occupational Safety and Health Administration (OSHA) has recently determined that safety incentive programs based on incident frequency must be eliminated because of these unintended consequences. Their suggestion is that safety bonuses should be contingent on upstream activities such as participation in safety improvement efforts like safety meetings, training, etc. On a side note, in some organizations, the Production Incentive Program is in direct conflict with the Safety Incentive Program so that production outweighs safety from a financial perspective. When this happens production speed can interfere with focus on safety and incidents become more likely. Our View

It is our view that Safety Incentive Programs are not only unnecessary, but potentially counterproductive. Capitalizing on the already present intrinsic motivation to be safe and creating an organizational culture/context that fosters that motivation to work together as a team to keep each other safe is much more positive and effective than the addition of the extrinsic incentive of money for safety. We suggest that management take the money budgeted for the safety incentive program and give pay increases while simultaneous examining and improving organizational context to help keep employees safe.

Hardwired to Jump to Conclusions

Have you ever misinterpreted what someone said, or why they said it, responded defensively and ended up needing to apologize for your response? Or, have you ever been driving down the freeway, minding your own business, driving the speed limit and gotten cut off by someone? If you have, and you are like me then you probably shouted something like “jerk” or “idiot”. (By the way, as my 6-year old grandson reminded me from the back seat the other day….the other driver can’t hear you!) As it turns out, we are actually cognitively hardwired to respond quickly with an attributional interpretation of what we see and hear. It is how we attempt to make sense of our fast paced, complex world. Daniel Kahneman in his 2011 book, “Thinking, Fast and Slow” proposes that we have two different cognitive systems, one designed for automatic, rapid interpretation of input with little or no effort or voluntary control (System 1) and the other designed for conscious, effortful and rational interpretation of information (System 2). We spend most of our time utilizing System 1 in our daily lives because it requires much less effort and energy as it helps us make sense of our busy world. The problem is that System 1 analysis is based on limited data and depends on past experience and easily accessible knowledge to make interpretations, and thus is often wrong. When I interpreted the actions of the driver that cut me off to be the result of his intellect (“idiot”), it was System 1 processing that led to that interpretation. I “jumped to a conclusion” without sufficient processing. I didn’t allow System 2 to do it’s work. If I stay with my System 1 interpretation, then the next time I get cut off I am even more likely to see an “idiot” because that interpretation is the most easily accessible one because of the previous experience, but if I allow System 2 to operate I can change the way I perceive future events of this nature. System 2 allocates attention and effortful processing to alternative interpretations of data/events. It requires more time but also increases the probability of being right in our interpretation of the data. Asking myself if there could be other reasons why the driver cut me off is a System 2 function. Identifying and evaluating those possibilities is also a System 2 function. Engaging in System 2 cognitive processing can alter the information stored in my brain and thus affect the way I perceive and respond to similar events in the future.

So how can we stop jumping to conclusions?

It would be great if we could override our brains wiring and skip System 1 processing but we can’t. Actually, without System 1 we would not be very efficient because we would over analyze just about everything. What we can do is recognize when we are jumping to conclusions (guessing about intent for example) and force ourselves to focus our attention on other possible explanations, i.e. activate System 2. You need to find your “guessing trigger” to signal you to call up System 2. When you realize that you are thinking negatively (“idiot”) about someone or feeling a negative emotion like anger or frustration, simply ask yourself…. “Is there something I am missing here?” “Is there another possible explanation for this?” Simply asking this will activate System 2 processing (and also calm you down) and lead to a more accurate interpretation of the event. It will help override your natural tendency to jump to conclusions. It might even keep you from looking like an “idiot” when you have to apologize for your wrong interpretation and action.

Contrasting Observation and Intervention Programs - Treating Symptoms vs. the Cause

Our loyal readers are quite familiar with our 2010 research into safety interventions in the workplace and the resulting SafetyCompass® Intervention training that resulted from that research. What you may not know is why we started that research to begin with. For years we had heard client after client explain to us their concerns over their observation programs. The common theme was that observation cards were plentiful when they started the program but submissions started to slow down over time. In an attempt to increase the number of cards companies instituted various tactics to increase the number of cards submitted. These tactics included such things as communicating the importance of observation cards, rewards for the best cards, and team competitions. These tactics proved successful, in the short term, but didn’t have sustainable impact on the number or quality of cards being turned in. Eventually leadership simply started requiring that employees turn in a certain number of cards in a given period of time. They went on to tell us of their frustration when they began receiving cards that were completely made up and some employees even using the cards as a means to communicate their dissatisfaction with their working conditions rather than safety related observations. They simply didn't know what to do to make their observation programs work effectively. As we spoke with their employees we heard a different story. They told us about the hope that they themselves had when the program was launched. They were excited about the opportunity to provide information about what was really going on in their workplace so they could get things fixed and make their jobs safer. They began by turning in cards and waiting to hear back on the fixes. When the fixes didn’t come they turned in more cards. Sometimes they would hear back in safety meetings about certain aspects of safety that needed to be focused on, but no real fixes. A few of them even told us of times that they turned in cards and their managers actually got angry about the behaviors that were being reported. Eventually they simply stopped turning in cards because leadership wasn’t paying attention to them and it was even getting people in trouble. Then leadership started giving out gift cards for the best observation cards so they figured they would turn a few in just to see if they could win the card. After all, who couldn’t use an extra $50 at Walmart? But even then, nothing was happening with the cards they turned in so they eventually just gave up again. The last straw was when their manager told them they had to turn in 5 per week. They spoke about the frustration that came with the added required paperwork when they knew nobody was looking at the cards anyway. As one person put it, “They’re just throwing them into a file cabinet, never to be seen again”. So the obvious choice for this person was to fill out his 5 cards every Friday afternoon and turn them in on his way out of the facility. It seemed that these organizations were all experiencing a similar Observation Program Death Spiral.

The obvious question is why? Why would such a well intentioned and possibly game changing program fail in so many organizations? After quite a bit of research into these organizations the answer became clear, they weren’t intervening. Or more precisely, they weren’t intervening in a very specific manner. The intent of observation programs is to provide data that shows the most pervasive unsafe actions in our organizations. If we, as the thought goes, can find out what unsafe behaviors are most common in our organization, then we can target those behaviors and change them. The fundamental problem with that premise is that behaviors are the cause of events (near misses, LTA, injuries, environmental spills, etc.). Actually, behaviors themselves are the result of something else. People don’t behave in a vacuum, as if they simply decide that acting unsafely is more desirable than acting safely. There are factors that drive human behaviors, the behavior themselves are simply a symptom of something else in the context surrounding and embedded in our organizations. Due to this fact, trending behaviors as a target for change efforts is no different than doctors treating the most common symptoms of disease, rather than curing the disease itself.

A proper intervention is essentially a diagnosis of what is creating behavior. Or, to steal the phrase from the title of our friend Todd Conklin's newest book, a pre-accident investigation.  An intervention program equips all employees with the skills to perform these investigations. When they see an unsafe behavior, they intervene in a specific way that allows them to create immediate safety in that moment, but they also diagnose the context to determine why it made sense to behave that way to begin with. Once context is understood, a targeted fix can be put into place that makes it less likely that the behavior happens in the future. The next step in an Intervention Program is incredibly important for organizational process improvement. Each intervention should be recorded so that the context (equipment issues, layout of workplace, procedural or rule discrepancies, production pressure, etc.) that created that behavior can be gathered and trended against other interventions. Once a large enough sample of interventions is created, organizations can then see the interworking of their work environment. Rather than simply looking at the total number of unsafe behaviors being performed in their company (e.g. not tying off at heights) they can also understand the most common and salient context that is driving those behaviors. Only then does leadership have the ability to put fixes into place that will actually change the context in which their employees perform their jobs and only then will they have the ability to make sustainable improvement.

Tying it back to observation programs

The observation program death spiral was the result of information that was not actionable. Once a company has data that is actionable, they can then institute targeted fixes. Organizations that use this approach have actually seen an increase in the number of interventions logged into the system. The reason is that the employees actually see something happening. They see that their interventions are leading to process improvement in their workplace and that’s the type of motivation that no $50 gift card could ever buy.

Why It Makes Sense to Tolerate Risk

Risk-Taking and Sense-Making Risk tolerance is a real challenge for nearly all of us, whether we are managing a team in a high-risk environment or trying to get a teenager to refrain from using his cellphone while driving.  It is also, unfortunately, a somewhat complicated matter.  There are plenty of moving parts.  Personalities, past experiences, fatigue and mood have all been shown to affect a person’s tolerance for risk.  Apart from trying to change individuals’ “predispositions” toward risk-taking, there is a lot that we can do to help minimize risk tolerance in any given context.  The key, as it turns out, is to focus our efforts on the context itself.

If you have followed our blog, you are by now familiar with the idea of “local rationality,” which goes something like this: Our actions and decisions are heavily influenced by the factors that are most obvious, pressing and significant (or, “salient”) in our immediate context.  In other words, what we do makes sense to us in the moment.  When was the last time you did something that, in retrospect, had you mumbling to yourself, “What was I thinking?”  When you look back on a previous decision, it doesn’t always make sense because you are no longer under the influence of the context in which you originally made that decision.

What does local rationality have to do with risk tolerance?  It’s simple.  When someone makes a decision to do something that he knows is risky, it makes sense to him given the factors that are most salient in his immediate context.

If we want to help others be less tolerant of risk, we should start by understanding which factors in a person’s context are likely to lead him to think that it makes sense to do risky things.  There are many factors, ranging from the layout of the physical space to the structure of incentive systems.  Some are obvious; others are not.  Here are a couple of significant but often overlooked factors.

Being in a Position of Relative Power

If you have a chemistry set and a few willing test subjects, give this experiment a shot.  Have two people sit in submissive positions (heads downcast, backs slouched) and one person stand over them in a power position (arms crossed, towering and glaring down at the others).  After only 60 seconds in these positions, something surprising happens to the brain chemistry of the person in the power position.  Testosterone (risk tolerance) and cortisol (risk-aversion) levels change, and this person is now more inclined to do risky things.  That’s right; when you are in a position of power relative to others in your context, you are more risk tolerant.

There is an important limiting factor here, though.  If the person in power also feels a sense of responsibility for the wellbeing of others in that context, the brain chemistry changes and he or she becomes more risk averse.  Parents are a great example.  They are clearly in a power-position relative to their children, but because parents are profoundly aware of their role in protecting their children, they are less likely to do risky things.

If you want to limit the effects of relative power-positioning on certain individuals’ risk tolerance - think supervisors, team leads, mentors and veteran employees - help them gain a clear sense of responsibility for the wellbeing of others around them.

Authority Pressure

On a remote job site in West Texas, a young laborer stepped over a pressurized hose on his way to get a tool from his truck.  Moments later, the hose erupted and he narrowly avoided a life-changing catastrophe.  This young employee was fully aware of the risk of stepping over a pressurized hose, and under normal circumstances, he would never have done something so risky; but in that moment it made sense because his supervisor had just instructed him with a tone of urgency to fetch the tool.

It is well documented that people will do wildly uncharacteristic things when instructed to do so by an authority figure.  (See Stanley Milgram’s “Study of Obedience”.)  The troubling part is that people will do uncharacteristically dangerous things - risking life and limb - under the influence of minor and even unintentional pressure from an authority figure.  Leaders need to be made aware of their influence and unceasingly demonstrate that, for them, working safely trumps other commands.

A Parting Thought

There is certainly more to be said about minimizing risk tolerance, but a critical first step is to recognize that the contexts in which people find themselves, which are the very same contexts that managers, supervisors and parents have substantial control over, directly affect people’s risk tolerance.

So, with that “trouble” employee / relative / friend / child in mind, think to yourself, how might their context lead them to think that it makes sense to do risky things?

A Personal Perspective on Context and Risk Taking

Most of our blog posts focus on current thinking about various aspects of safety and human performance and are an attempt to not only contribute to that discussion but to generate further discussion as well. I can’t think of an instance when we took a personal perspective on the subject, but an experience that I had a couple of weeks ago got me thinking about willingness to take risk and how context really does play a crucial role in that decision. I was attending a weekend long family reunion in the Texas hill country where we had 25 family members all staying together in a lodge that we had rented. It was a terrific weekend with a lot of food, fun, reminiscing and watching young cousins really get to know each other for the first time. My nephew brought his boat so that the adventuresome could try their hand at tubing on the river that ran by the property. I decided that since I had engaged in this activity many times in the past that I would simply act as a spotter for my nephew and watch my kids and their kids enjoy the fun. (Actually I was thinking that the rough water and bouncing of the tube would probably have my body hurting for the next week. This, I contend was a good evaluation of risk followed by good decision making).

There was also a rope swing attached to a tree next to the water allowing for high flight followed by a dip in the rather cold river water that attracted everyone to watch the young try their hand at this activity. There were actually two levels from which to begin the adventure over the water, one at the level of the river and one from a wall about 10-feet higher. All of the really young and really old (i.e. my brother-in-law) tried their hand at the rope from the level of the water and all were successful including my older brother-in-law. I arrived at the rope swing shortly after he had made his plunge only to have him and his supporting cast challenge me to take part. I told them that I would think about it and this is where “context” really impacted my decision to take a risk. The last time I had swung on a rope and dropped into water was probably 20 years ago. At that time I would swing out and complete a flip before I entered the water. No reason not to do the same thing now….right? No way I could accomplish this feat in front of my wife, sister, children, grandchildren, nieces and nephews, not to mention my brother-in-law, by starting from the waters edge. It would have to be from the 10-foot launching point. In my mind, at that moment this all sounded completely reasonable, not to mention fun! As I took my position on the wall I was thinking to myself that all I needed to do was perform like I did last time (20 years ago) and everything would be great. I was successful in getting out over the water before letting go, (needless to say that I didn’t perform the flip that I had imagined…..seems that upper body strength at 65 is less than at 45). I’m not sure how it happened, but I ended up injuring the knuckle on one of my fingers and I woke up the next morning with a stiff left shoulder. By the way, two weeks later I am feeling much better as the swelling in my finger and stiffness in my shoulder are almost gone.

As I reflect on the event, I am amazed at how the context (peer pressure, past success, cheering from my grandchildren, failure to assess my physical condition, etc) led to a decision that was completely rational to me in the moment. I am pretty sure that the memory of the pain for the next several days afterwards will impact my decision making should such an opportunity arise again. Next time I will enter from the waters edge!

Sustaining Good Performance

We have spent a lot of time talking about the side of accountability that involves correcting failure. But if you will recall our discussion in January, accountability actually involves an examination of the facts/reasons underlying a specific event/result (accounting) followed by the application of appropriate consequences for those actions and results in an attempt to more predictably have success going forward. In other words, accountability involves first the identification of both failure and success, followed by an examination of the underlying reasons for the failure/success and then the determination of the appropriate consequences to help sustain the success or eliminate the failure in the future. This month we would like to discuss the appropriate application of consequences following success so that we will have a greater chance of sustaining good performance going forward. But why is this important anyway? When we ask supervisors/managers what they really want from their employees we get a very consistent response…..”We want employees who give us good results and who take initiative!” My response to this is that the two are highly interrelated. Let me explain what I mean by this. People who take initiative are people with high levels of Self-Esteem or Self-Confidence which is developed from meaningful (to the person) accomplishment followed by recognition by someone significant to the individual. In most cases the supervisor/manager has a significant level of control over both of those variables, i.e. they control the tasks that the employee is allowed to engage in, they control recognition and they are significant to their employees (in most cases). Obviously, for success to occur while engaging in meaningful tasks, there needs to be support through training, necessary resources, etc. and when success occurs there needs to be the appropriate application of recognition, or what psychologists call “reinforcement”. Reinforcement by definition is a consequence that when following a behavior increases the likelihood that the behavior will reoccur in the future. If that reinforcement is recognition by a significant person then it will also serve the function of increasing self-confidence and the likelihood of initiative. It is important that the recognition follows some important guidelines however. Let’s look at four important aspects of reinforcement; What, When, Where and How.

WHAT. The rule here is to reinforce the behavior/performance that you want to continue and not the person. This focus on behavior ties the reinforcement to that behavior in the future and is what increases it’s chances of reoccurrence. This will also act to increase self-esteem even though you do not focus on the individual. For example, saying….”Thank you. You got that report in on time and with no errors” is much more effective than, “Thank you. You are becoming a very reliable employee.” While the latter may make the person feel better, it does nothing to point out exactly what you want going forward.

WHEN. Reinforcement is not always appropriate as we will discuss below, but when it is it has been demonstrated that reinforcement that immediately follows an action is in most cases the most powerful and effective. While some delay may be necessary in some cases, waiting until the annual performance appraisal is certainly not the best option.

WHERE. While failure should always be redirected in private, success should be reinforced in public in most cases. Public recognition does two things, it makes the person look good in front of peers and at the same time demonstrates your expectations to others on your team. It must always however be appropriately done as we will discuss below.

HOW

• Keep it brief and simple. It should, in most cases take only a few words and therefore a few seconds to reinforce performance. If you feel it is necessary to explain in more detail the exact performance/result then do so, but don’t carry on forever. You will lose the person’s attention and perhaps even embarrass the person in front of peers.
• Be genuine. Let the person know that you truly appreciate their success and expect it to continue into the future. Sarcasm has no place in the application of reinforcement.
• Make it appropriate to the level of performance. Most of the time a simple “thank you” with a connection to the successful performance is appropriate, but when the result is significant and worthy of additional recognition, just make sure that it fits. For example, if the person has contributed beyond expectations and their impact has had a noticeable impact on revenue, then a bonus might be in order. Failure to evaluate the appropriateness of recognition could lead to reduced performance in the future.
• Be consistent among employees. While meaningfulness varies among employees the need for recognition doesn’t. Make sure that you find what is meaningful for each employee and apply recognition where appropriate in a consistent manner.
• Avoid scheduled or predictable recognition. Psychological research shows that variable (unpredictable) reinforcement is more effective for behaviors that have been learned. While teaching a skill the application of continuous reinforcement is best, but after the skills is learned change to a less frequent, less predictable schedule and you will find that employees will be successful for a longer period of time.

What’s the point?

Sustained successful performance accompanied by initiative requires self confidence. Meaningful accomplishment followed by recognition by a significant person helps to create that self confidence and thus sustained success. If you are a supervisor (or a parent) you have more control over this process than you might imagine.

Hardwired Inhibitions: Hidden Forces that Keep Us Silent in the Face of Disaster

Employees’ willingness and ability to stop unsafe operations is one of the most critical parts of any safety management system, and here’s why: Safety managers cannot be everywhere at once.  They cannot write rules for every possible situation.  They cannot engineer the environment to remove every possible risk, and when the big events occur, it is usually because of a complex and unexpected interaction of many different elements in the work environment.  In many cases, employees working at the front line are not only the first line of defense, they are quite possibly the most important line of defense against these emergent hazards. Our 2010 study of safety interventions found that employees intervene in only about 39% of the unsafe operations that they recognize while at work.  In other words, employees’ silence is a critical gap in safety management systems, and it is a gap that needs to be honestly explored and resolved.

An initial effort to resolve this problem - Stop Work Authority - has been beneficial, but it is insufficient.  In fact, 97% of the people who participated in the 2010 study said that their company has given them the authority to stop unsafe operations.  Stop Work Authority’s value is in assuring employees that they will not be formally punished for insubordination or slowing productivity.  While fear of formal retaliation inhibits intervention, there are other, perhaps more significant forces that keep people silent.

Some might assume that the real issue is that employees lack sufficient motivation to speak up.  This belief is unfortunately common among leadership, represented in a common refrain - “We communicated that it is their responsibility to intervene in unsafe operations; but they still don’t do it.  They just don’t take it seriously.”  Contrary to this common belief, we have spoken one-on-one with thousands of frontline employees and nearly all of them, regardless of industry, culture, age or other demographic category, genuinely believe that they have the fundamental, moral responsibility to watch out for and help to protect their coworkers.  Employees’ silence is not simply a matter of poor motivation.

At the heart this issue is the “context effect.”  What employees think about, remember and care about at any given moment is heavily influenced by the specific context in which they find themselves.  People literally see the world differently from one moment to the next as a result of the social, physical, mental and emotional factors that are most salient at the time.  The key question becomes, “What factors in employees’ production contexts play the most significant role in inhibiting intervention?”  While there are many, and they vary from one company to the next, I would like to introduce four common factors in employees’ production contexts:

THE UNIT BIAS

Think about a time when you were focused on something and realized that you should stop to deal with a different, more significant problem, but decided to stick with the original task anyway?  That is the unit bias.  It is a distortion in the way we view reality.  In the moment, we perceive that completing the task at hand is more important than it really is, and so we end up putting off things that, outside of the moment, we would recognize as far more important.  Now imagine that an employee is focused on a task and sees a coworker doing something unsafe.  “I’ll get to it in a minute,” he thinks to himself.

BYSTANDER EFFECT

This is a a well documented phenomenon, whereby we are much less likely to intervene or help others when we are in a group.  In fact, the more people there are, the less likely we are to be the ones who speak up.

DEFERENCE TO AUTHORITY

When we are around people with more authority than us, we are much less likely to be the ones who take initiative to deal with a safety issue.  We refrain from doing what we believe we should, because we subtly perceive such action to be the responsibility of the “leader.”  It is a deeply-embedded and often non-conscious aversion to insubordination: When a non-routine decision needs to be made, it is to be made by the person with the highest position power.

PRODUCTION PRESSURE 

When we are under pressure to produce something in a limited amount of time, it does more than make us feel rushed.  It literally changes the way we perceive our own surroundings.  Things that might otherwise be perceived as risks that need to be stopped are either not noticed at all or are perceived as insignificant compared to the importance of getting things done. In addition to these four, there are other forces in employees’ production contexts that inhibit them when they should speak up.  If we're are going to get people to speak up more often, we need to move beyond “Stop Work Authority” and get over the assumption that motivating them will be enough.  We need to help employees understand what is inhibiting them in the moment, and then give them the skills to overcome these inhibitors so that they can do what they already believe is right - speak up to keep people safe.

Safety Intervention: A Dynamic Solution to Complex Safety Problems

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.

They Care, Now What? A Human Factors Approach to Accountability

Over the past several months we have been proposing an approach for holding others accountable for failed performance that is grounded in a “contextual” diagnostic model. This model allows you to determine the “real” causes of failed performance prior to determining the “best” approach for improving that performance going forward. Last month we talked about how to effectively motivate an individual who is failing due to either a lack of intrinsic (self) motivation or a need for extrinsic motivation. Fixing the Motivated

This month we will explore how to improve performance for individuals who are motivated but for some other non-motivational reason are failing to perform in a manner that is acceptable. We can fail for a variety of reasons as we discussed in our May Newsletter (A Causation Model for Poor Performance), so determining the “real” cause is obviously required before a sustainable fix can be put into place. The key to finding and implementing an effective fix requires commitment on the part of the other person and the best way to get this commitment is for the person to come up with the fix himself. In other words the objective is to help the person determine the best fix himself so that he has ownership of the plan and thus more commitment. This means that you have to be a “facilitator” and not a “dictator”. To facilitate simply means to make it easier for something to happen. In this context it means to make it easier for the person to find a fix for the reason behind his own poor performance. Facilitating is really rather simple and only requires a few skills for success. You start by asking for their ideas about how to fix it by using a simple open ended question like…..” What is something we can do to fix this?” or “Do you have any ideas for fixing this?” Asking a question such as…..”Do you think we should send you to training?” is not an open ended question because it suggests a specific solution that is your idea and not the other person’s. Remember, the objective is to get his ownership and if the plan is his then he owns it. Be careful not to criticize or belittle ideas or the person will most likely become defensive and stop offering ideas. If the person offers a fix that won’t work, explore why it won’t work. Don’t just say, “That won’t work”. Ask them to think about the natural consequences, or outcomes of their plan to help them see why it might not be the best approach.

Dealing with Complexity

Remember, failure can be due to more than one reason and fixing only part of the problem will most likely not lead to sustainable success. For example, let’s assume that the person does not have the knowledge to perform successfully and they are experiencing pressure from you to perform quickly. Providing the person with training will only solve part of the issue and will require that you determine how you are creating the pressure that is effecting performance. This may require that you “drill down” by asking additional questions to determine exactly why the person is feeling undue pressure and how that pressure is helping to create failure. Remember to monitor your defensiveness here because that could stop the facilitative process in it’s tracks. One additional skill that is required is to “listen completely”. Listening is more than just “hearing” what the other person is saying, but rather is “understanding” both the words and the underlying meaning of how they are saying it. Watch for signs such as facial expression, eye contact, body posture, etc. that could indicate that the person is not saying exactly what their words are saying. Saying “that sounds good to me” while smiling and looking you in the eye is not the same as saying those same words while looking down with a “flat” expression on their face. Always ask questions to determine the real meaning of their words if you think you could be misunderstanding their true intent.

Finally, provide help in executing the plan that has been designed through facilitation. Your role as supervisor (or parent if you are applying these skills to your children) is to help the person achieve success, so following up and providing support and feedback are crucial to maintaining success going forward.

What’s the Point?

Performance issues usually stem from multiple and varying human factors. Rarely is motivation the only cause of poor performance. When we find that the performance is lacking due to factors that don't include motivation, we simply need to brainstorm ways to fix the causes. Avoid the temptation to motivate the already motivated and find a way to fix the other causes of their poor performance.

Human Error and Complexity: Why your “safety world view” matters

Have you ever thought about or looked at pictures of your ancestors and realized, “I have that trait too!” Just like your traits are in large part determined by random combinations of genes from your ancestry, the history behind your safety world view is probably largely the product of chance - for example, whether you studied Behavioral Psychology or Human Factors in college, which influential authors’ views you were exposed to, who your first supervisor was, or whether you worked in the petroleum, construction or aeronautical industry. Our “Safety World View” is built over time and dramatically impacts how we think about, analyze and strive to prevent accidents.

Linear View - Human Error

Let’s briefly look at two views - Linear and Systemic - not because they are the only possible ones, but because they have had and are currently having the greatest impact on the world of safety. The Linear View is integral in what is sometimes referred to as the “Person Approach,” exemplified by traditional Behavior Based Safety (BBS) that grew out of the work of B.F. Skinner and the application of his research to Applied Behavioral Analysis and Behavior Modification. Whether we have thought of it or not, much of the industrial world is operating on this “linear” theoretical framework. We attempt to understand events by identifying and addressing a single cause (antecedent) or distinct set of causes, which elicit unsafe actions (behaviors) that lead to an incident (consequences). This view impacts both how we try to change unwanted behavior and how we go about investigating incidents. This behaviorally focused view naturally leads us to conclude in many cases that Human Error is, or can be, THE root cause of the incident. In fact, it is routinely touted that, “research shows that human error is the cause of more than 90 percent of incidents.” We are also conditioned and “cognitively biased” to find this linear model so appealing. I use the word “conditioned” because it explains a lot of what happens in our daily lives, where situations are relatively clean and simple…..so we naturally extend this way of thinking to more complex worlds/situations where it is perhaps less appropriate. Additionally, because we view accidents after the fact, the well documented phenomenon of “hindsight bias” leads us to linearly trace the cause back to an individual, and since behavior is the core of our model, we have a strong tendency to stop there. The assumption is that human error (unsafe act) is a conscious, “free will” decision and is therefore driven by psychological functions such as complacency, lack of motivation, carelessness or other negative attributes. This leads to the also well-documented phenomenon of the Fundamental Attribution Error, whereby we have a tendency to attribute failure on the part of others to negative personal qualities such as inattention, lack of motivation, etc., thus leading to the assignment of causation and blame. This assignment of blame may feel warranted and even satisfying, but does not necessarily deal with the real “antecedents” that triggered the unsafe behavior in the first place. As Sidney Dekker stated, “If your explanation of an accident still relies on unmotivated people, you have more work to do."

Systemic View - Complexity

In reality, most of us work in complex environments which involve multiple interacting factors and systems, and the linear view has a difficult time dealing with this complexity. James Reason (1997) convincingly argued for the complex nature of work environments with his “Swiss Cheese” model of complexity. In his view, accidents are the result of active failures at the “sharp end” (where the work is actually done) and “latent conditions,” which include many organizational decisions at the “blunt end” (higher management) of the work process. Because barriers fail, there are times when the active failures and latent conditions align, allowing for an incident to occur. More recently Hollnagel (2004) has argued that active failures are a normal part of complex workplaces because of the requirement for individuals to adapt their performance to the constantly changing environment and the pressure to balance production and safety. As a result, accidents “emerge” as this adaptation occurs (Hollnagel refers to this adaptive process as the “Efficiency Thoroughness Trade Off”) . Dekker (2006) has recently added to this view the idea that this adaptation is normal and even “locally rational” to the individual committing the active failure because he/she is responding to a context that may not be apparent to those observing performance in the moment or investigating a resulting incident. Focusing only on the active failure as the result of “human error” is missing the real reasons that it occurs at all. Rather, understanding the complex context that is eliciting the decision to behave in an “unsafe” manner will provide more meaningful information. It is much easier to engineer the context than it is to engineer the person. While a person is involved in almost all incidents in some manner, human error is seldom the “sufficient” cause of the incident because of the complexity of the environment in which it occurs. Attempting to explain and prevent incidents from a simple linear viewpoint will almost always leave out contributory (and often non-obvious) factors that drove the decision in the first place and thus led to the incident.

Why Does it Matter?

Thinking of human error as a normal and adaptive component of complex workplace environments leads to a different approach to preventing the incidents that can emerge out of those environments. It requies that we gain an understanding of the many and often surprising contextual factors that can lead to the active failure in the first place. If we are going to engineer safer workplaces, we must start with something that does not look like engineering at all - namely, candid, informed and skillful conversations with and among people throughout the organization. These conversations should focus on determining the contextual factors that are driving the unsafe actions in the first place. It is only with this information that we can effectively eliminate what James Reason called “latent conditions” that are creating the contexts that elicit the unsafe action in the first place. Additionally, this information should be used in the moment to eliminate active failures and also allowed to flow to decision makers at the “blunt end”, so that the system can be engineered to maximize safety. Your safety world view really does matter.

Safety Culture Shift: Three Basic Steps

In the world of safety, culture is a big deal. In one way or another, culture helps to shape nearly everything that happens within an organization - from shortcuts taken by shift workers to budget cuts made by managers. As important as it is, though, it seems equally as confusing and intractable. Culture appears to emerge as an unexpected by-product of organizational minutia: A brief comment made by a manager, misunderstood by direct-reports, propagated during water cooler conversations, and compounded with otherwise unrelated management decisions to downsize, outsource, reassign, promote, terminate… Safety culture can either grow wild and unmanaged - unpredictably influencing employee performance and elevating risk - or it can be understood and deliberately shaped to ensure that employees uphold the organization’s safety values.

Pin it Down

The trick is to pin it down. A conveniently simple way of capturing the idea of culture is to say that it is the “taken-for-granted way of doing things around here;” but even this is not enough. If we can understand the mechanics that drive culture, we will be better positioned to shift it in support of safety. The good news is that, while presenting itself as extraordinarily complicated, culture is remarkably ordinary at its core. It is just the collective result of our brains doing what they always do.

Our Brains at Work

Recall the first time that you drove a car. While you might have found it exhilarating, it was also stressful and exhausting. Recall how unfamiliar everything felt and how fast everything seemed to move around you. Coming to a four-way stop for the first time, your mind was racing to figure out when and how hard to press the brake pedal, where the front of the car should stop relative to the stop sign, how long you should wait before accelerating, which cars at the intersection had the right-of-way, etc. While we might make mistakes in situations like this, we should not overlook just how amazing it is that our brains can take in such a vast amount of unfamiliar information and, in a near flash, come up with an appropriate course of action. We can give credit to the brain’s “executive system” for this.

Executive or Automatic?

But this is not all that our brains do. Because the executive system has its limitations - it can only handle a small number of challenges at a time, and appears to consume an inordinate amount of our body’s energy in doing so - we would be in bad shape if we had to go through the same elaborate and stressful mental process for the rest of our lives while driving. Fortunately, our brains also “automate” the efforts that work for us. Now, when you approach a four-way-stop, your brain is free to continue thinking about what you need to pick up from the store before going home. When we come up with a way of doing something that works - even elaborate processes - our brains hand it over to an “automatic system.” This automatic system drives our future actions and decisions when we find ourselves in similar circumstances, without pestering the executive system to come up with an appropriate course of action.

Why it Matters

What does driving have to do with culture? Whatever context we find ourselves in - whether it is a four-way-stop or a pre-job planning meeting - our brains take in the range of relevant information, come up with an effective course of action, try it out and, when it works, automate it as “the way to do things in this situation.”

For Example

Let’s imagine that a young employee leaves new-hire orientation with a clear understanding of the organization’s safety policies and operating procedures. At that moment, assuming that he wants to succeed within the organization, he believes that proactively contributing during a pre-job planning meeting will lead to recognition and professional success.

Unfortunately, at many companies, the actual ‘production’ context is quite different than the ‘new-hire orientation’ context. There are hurried supervisors, disinterested ‘old timers’, impending deadlines and too little time, and what seemed like the right course of action during orientation now looks like a sure-fire way to get ostracized and opposed. His brain’s “executive system” quickly determines that staying quiet and “pencil whipping” the pre-job planning form like everyone else is a better course of action; and in no time, our hapless new hire is doing so automatically - without thinking twice about whether it is the right thing to do.

Changing Culture

If culture is the collective result of brains figuring out how to thrive in a given context, then changing culture comes down to changing context - changing the “rules for success.” If you learned to drive in the United States but find yourself at an intersection in England, your automated way of driving will likely get you into an accident. When the context changes, the executive system has to wake up, find a new way to succeed given the details of the new context, and then automate that for the future.

How does this translate to changing a safety culture? It means that, to change safety culture, we need to change the context that employees work in so that working safely and prioritizing safety when making decisions leads to success.

Three Basic Steps:

Step 1

Identify the “taken-for-granted” behaviors that you want employees to adopt. Do you want employees to report all incidents and near-misses? Do you want managers to approve budget for safety-critical expenditures?

This exercise amounts to defining your safety culture. Avoid the common mistake of falling back on vague, safety-oriented value statements. If you aren’t specific here, you will not have a solid foundation for the next two steps.

Step 2

Analyze employees’ contexts to see what is currently inhibiting or competing against these targeted, taken-for-granted behaviors. Are shift workers criticized or blamed by their supervisors for near-misses? Are the managers who cut cost by cutting corners also the ones being promoted?

Be sure to look at the entire context. Often times, factors like physical layout, reporting structure or incentive programs play a critical role in inhibiting these desired, taken-for-granted behaviors.

Step 3

Change the context so that, when employees exhibit the desired behaviors that you identified in Step 1, they are more likely to thrive within the organization.

“Thriving” means that employees receive recognition, satisfy the expectations of their superiors, avoid resistance and alienation, achieve their professional goals, and avoid conflicting demands for their time and energy, among other things.

Give It a Try

Shifting culture comes down to strategically changing the context that people find themselves in.  Give it a try and you might find that it is easier than you expected. You might even consider trying it at home. Start at Step 1; pick one simple "taken-for-granted" behavior and see if you can get people to automate this behavior by changing their context. If you continue the experiment and create a stable working context that consistently encourages safe performance, working safely will eventually become "how people do things around here."