What in the World Were They Thinking?

As I write this, the Houston area is dealing with the aftermath of a 500-year flood that has left several feet of water in areas that have never flooded before.  Some areas received 15- to 20-inches of rain in less that 6-hours which left all of the creeks and bayou’s overflowing their banks and inundating residential areas, displacing several thousand people and shutting down travel in much of the area.  As I watched live television coverage of this event from my non-flooded home I was saddened by the impact on the lives of so many, but initially struck by the “stupidity” of those who made decisions that put their lives at risk and in a few cases cost them their lives.  I began to try to make sense of why these individuals would make what appeared to be such fool-hearty decisions.  What could they have been thinking when they drove past a vehicle with flashing lights right into an underpass with 20 feet of water in it?  What could they have been thinking when three people launched their small flat-bottom, aluminum boat to take a “sight-seeing” trip down a creek that was overflowing with rushing waters and perilous undercurrents only to capsize, resulting in them floating in the chilly water for 2+ hours before being rescued by the authorities?  As I reflected on it, and after my initial incredulous reaction, my conclusion was that it made perfect sense to each of them to do what they did.  In the moment, each of their contexts led them to make what to me seemed in hindsight to be a very foolish and costly decision.  You may be asking yourself….” What is he talking about?  How could it make sense to do something so obviously foolish?”  Let me attempt to explain. Context is powerful and it is the primary source we have when making decisions.  Additionally, it is individual-centric.  My context, your context and the context of the individual who drove around a barricade into twenty feet of water are all very different, but they are our personal contexts.  In my context where I am sitting in my living room, watching TV, sipping a cup of coffee, with no pressure to get to a certain location for a specific purpose is most likely completely different from the man who drove around a police vehicle, with flashing lights, in a downpour, with his windshield wipers flashing, on his way to check on someone he cares about and who could be in danger from the rising water.  What is salient to me and what was salient to him are very different and would most likely lead to different decisions.  His decision was “locally rational”, i.e. it made perfect sense in the moment.  We will never know, but it is very likely that his context precluded him from even noticing the flashing lights of the police vehicle or the possibility of water in the underpass.  It is also possible that “human error” was present in the tragic deaths of at least 6 people during the flood, but human error is not a sufficient explanation.  We can never really understand what led to their decisions to put themselves at risk without understanding the contexts that drove those decisions.

This is what we really need to focus on when we are investigating incidents in the workplace so that we can impact the aspects of contexts that become salient to our workers.  The greater impact we have on minimizing the salience of contextual factors that lead to risk taking and increasing the salience of contextual factors that minimize risk, the greater opportunity we will have to end “senseless” injury and death in the workplace, and on rain swollen highways.  This approach will have a lot more positive impact than just chalking it up to “stupidity”!

“March Madness”, Salience and Safety Intervention

I can’t claim to be an avid follower of college basketball. In fact, until this past Sunday I had not watched an entire game all season and certainly couldn’t tell you who the top teams or any of the players were. But that was until I discovered that my undergraduate alma mater (Stephen F. Austin) was playing Notre Dame in the second round of the NCAA basketball tournament. “March Madness” had struck me! I ended up watching college basketball all afternoon and evening, yelling at the television and even though my alma mater lost (by 1-point in the last 1.5 seconds of the game) I will be watching college basketball for the next couple of weeks. While some of you who are reading this are probably die-hard college basketball fans, many of you are like me and only become interested when the stakes are high (e.g., your team is playing to advance) or something else, like sitting in a sports bar with friends, makes watching more likely. As I started thinking about writing this blog, it hit me that safety observation and intervention are a lot like “March Madness”. Both normally occur under specific contextual conditions. Both are triggered by a change in the salience of certain aspects of the context that lead to watching and responding. My interest in watching college basketball changed when I learned that SFA was playing Notre Dame. Basketball became much more salient in my context, important to me personally and as a result changed my television viewing behavior. Watching the game led me to “intervene” even if it was simply yelling at the television and talking with my wife about the “great 3-point shot” or the “terrible call by the referee”. As a matter of fact, that change in salience led to me watching continuous basketball until it ended that Sunday and increased the likelihood that I will watch the rest of the tournament. Isn’t that what we want in our workplaces……employees predictably watching each other’s backs and intervening when they see something unsafe? While this analogy doesn’t perfectly translate to the workplace, it would seem to be close enough to provide some help.

So how can we translate this to increasing safety observations and interventions in the workplace?

Remember, I contracted “March Madness” upon learning that the stakes had increased for me, i.e. my alma mater was playing. It would seem that something analogous must happen in the workplace. First there must be an understanding that the stakes are high if we don’t watch each others’ backs. Our research indicates that this is already present in most workplaces. People consistently report that they feel a “moral responsibility" to keep each other safe, so simply reminding employees regularly of their role as a way to increase salience should be all that is necessary.

Secondly, just like I “watched” the games, we need for our employees to attend to the risks and behaviors of others in their contexts. While I don’t need to learn how to watch television, I do need to be aware of the rules of the game, pay attention to the screen and interpret what I see. This has happened for me over time, but in the workplace we need to teach employees what situations and behaviors are high risk in an attempt to increase the salience of those situations and behaviors. This requires training, but also regular reminders through safety and pre-job meetings. While watching basketball on television I have the announcers constantly predicting and interpreting play which acts to direct my attention. That should be the role of each employee, but especially the on-site supervisor. That person’s primary job is to direct attention for their employees.

But what about intervention? I don’t need any training on how to yell at the television when there is a bad call or cheer for my team when they make a good play. But our research indicates very clearly that employees for the most part, while mindful of their role in intervention, don’t necessarily feel competent to do so. They know that “yelling” at each other has a high probability of leading to defensiveness and anger. In other words, while we can get “March Madness” into our workplaces from a motivational and observational perspective, getting the right kind of intervention does not come naturally. Our research and experience demonstrate that providing employees with the right kind of intervention skills increases their competence while simultaneously leading to an increase in confidence and an increase in intervention frequency and success.

The NCAA basketball tournament only happens once a year but safety observation and intervention are a year round necessity. Maybe we can replicate the “March Madness” process to improve safety all the time!

Distracted Driving: I Teach This Stuff and I Still Mess It Up

My oldest son just turned 15 so my wife and I started researching the different avenues for teen driver’s education available in our town.  With a handful of options we decided to take the route of “parent taught driver-ed” as it was the most convenient, cost effective, and we felt we were quite capable of taking on the task.  After all, my wife is a teacher and I research and train people about performance in complex systems.  Additionally, I have developed our online training platform, which is the medium in which most of the classroom driver-ed learning will take place.  “We’ve got this,” I remember telling her. As we have progressed in our program, he has become more and more capable and comfortable in not only the rules of the road, but also driving in our small Dallas/Ft. Worth suburb.  But just a couple of days ago I was smacked in the face by reality when we stopped at a red light and he instinctively reached into his pocked to retrieve his cell phone to read a text he just received from his girlfriend.  How could he be so irresponsible with all he’s learned?  How could he possibly think this was okay to read texts while behind the wheel?  His response: “You always check your phone at red lights so I just figured it wasn’t a big deal”!

Yes, I teach this stuff and yes I mess it up on a consistent basis when I’m not intentional about what I know to be true.

For those of you that frequently read our blogs you know that we talk about complexity, the impact of context on performance, and how the model provided by others impact the performance of those around them in surprisingly unforeseen ways.  You are also aware of the studies about using cell phones to talk and text and the impact that these actions have on the ability to operate a vehicle.  We have been accustomed to seeing anti-texting commercials and even live in communities that have laws, with fines attached, preventing the use of cell phones while driving.  Yet some of you, and some of us who teach this stuff, still glance down at the phone when we hear the ding or even pick up the phone when that all important call finally comes while we are driving.

A recent study shows that after a decade of car related deaths declining year after year, a steep increase of almost 10% occurred in 2015.  Could this be an anomaly or a sign of something far more troubling occurring?  While no data has yet pointed to any trend in automobile fatality causation, I do have have my own theories and anecdotal data that I will share.

Smart phones have only been around for a little over a decade now and they are getting smarter and smarter with each launch.  We all remember the blinking red light of the blackberry that screamed out to us, “Read me!”  Today our phones have Facebook messenger, LinkedIn alerts, text, iMessage, email, and bluetooth and our cars have mobile apps and wifi hotspots.  We are constantly being alerted that somebody wants to talk to us right now.  It’s like that blinking red light on steroids.  The good news is that local governments and other organizations saw this coming years ago so they implemented laws and launched public service announcements and signage by the roads, warning us of the dangers these devices present.  And as any good safety professional knows, making new rules and putting up signs that scare people works…for awhile.

Where I have failed as a driver-ed instructor, and father, is that I kept my phone within reach.  It was in my pocket, sitting in my cup holder, or holstered on that clamp attached to my A/C vent that I bought at Best Buy so that I could use the navigation app twice a year.  Based on what we know about complexity, context, Human Factors, Human Performance, or whatever current science we want to throw out there, the answer is easy.  Turn the phone off, put it in the glove compartment and drive.  It doesn’t take any research or a consultant to come up with this idea; in fact, it’s something that a lot of people have figured out already.  Take the blinking red light, the text ding, or the “silent” buzz away from our attention and our attention remains on the road where it belongs.

I will leave you with this last thing.  Again, nothing groundbreaking here but a fun example about how those devices that are designed to make our lives so much better have effected our performance in fascinating ways.  A recent study at the Western Washington University shows that people walking and talking on their cell phones noticed a clown on a unicycle directly next to them only 25% of the time, while those walking and not on a phone noticed the clown over half of the time.  But more impressively, those walking in pairs noticed the clown 75% of the time.  If you are interested, here is a link describing this research:  https://www.youtube.com/watch?v=Ysbk_28F068

The Safety Switch℠

As our world and workplaces grow in complexity, and as failures in these complex systems become increasingly calamitous, how do we take the insights that have been given us by so many dedicated and brilliant individuals, and make things better for the people who, whether we want to think about it or not, will suffer and die if we don’t adapt? It’s a heavy question, and one that’s been on our minds for a while.

You might not have known but, between blog posts and our day jobs, we’ve been writing a book.  In fact, we are now in the final phases of writing this book called, “The Safety Switch℠,”  which aims to tie together our research and the priceless contributions made by scholars and practitioners from a wide range of disciplines.

We thought it was about time to introduce the premise.

The Safety Switch℠ is a way of thinking about how we can adapt to a new world — one in which organizations are understood as complex systems, and the ever-increasing complexity of these systems presents new challenges.

The “Switch” happens at two levels.

First, it is a micro-level, personal, in-the-moment switch between two mental Modes.  Our default setting, Mode 1, is powered by mental shortcuts (called “heuristics”) and distortions (called “biases”) and often leads us to fix upon human error as the cause of safety problems.  While we may be “wired” to stay in this default mode, we can deliberately switch to a second Mode.  When in this Mode 2, we take a rigorous, effortful, sometimes counterintuitive, and often winding path to understand and address persistent safety challenges.

Second, there is a macro-level, organizational switch.  It involves activating within the organizational system an inherently dynamic layer of protection — it’s people — positioning humans as a unique and requisite response to growing complexity.

But here’s the catch: You can’t flip the second switch until you flip the first.

We have to learn when and how to switch from Mode 1 to Mode 2 in the moment and on the fly if we are going to generate the capacity to flip the second switch, and energize within our organizations this vital, dynamic and fully integrated layer of protection — the people.

Protecting Young Workers: Bridging the Age Gap in the Workplace

In a recent blog (Protecting Young Workers from Themselves) we discussed some of the reasons for the relatively high risk tolerance of young (15-24 years old) workers compared with older workers.  We concluded that while there is still cortical structure development during this developmental period that this alone does not explain why this age group is at a higher risk of engaging in unsafe actions and suffering the consequences of those actions. The research demonstrates that the less developed limbic system which is involved in both social and pleasure seeking behavior can at times override the logical capabilities of the young workers and stimulate them to engage in risky behavior.  Because educational programs designed to provide the young workers with the knowledge necessary to effectively interpret their contexts has not proven overly successful, we proposed that one way to impact their risk taking in the workplace is to remove social stimuli such as peers from their work teams and replace them with older, more risk averse and experienced workers, especially those in the 55+ age group.  We suggested that these older workers who understand and can interpret the various workplace contexts could provide mentoring and coaching for the younger workers.  This however introduces another set of issues that must be addressed if this approach is to have the desired impact.  These issues include the perceptions/stereotypes/expectations of each cohort group by the other and the skills necessary to impact those perceptions/stereotypes/expectations. We all have a tendency to focus on actions and traits of other people that fit with our expectations and stereotypes of the groups to which that person belongs, including the person’s age.  We also tend to behave toward that person based on what we perceive them doing and they do likewise to us.  The problem is that what we “see” is driven by what we “expect to see”  and often results in a phenomenon known as the “Self-Fulfilling Prophecy (SFP)” which also reinforces our stereotypes and thus our future interactions.  For example, an older worker observes a younger worker engage in some risky behavior and because the older worker views younger workers as thinking they are “bullet proof” he immediately criticizes the younger worker for his failure to “think”.  The younger worker who did what he thought was the right thing in the situation becomes defensive toward the “judgmental/rude” older worker and “smarts off” to him.  This causes the older worker to become defensive and the cycle continues, reinforcing the SFP and strengthening the stereotypes held by both individuals (see “Your Organization’s Safety Immune System (Part 2): Strengthening Immunity” for a more in-depth discussion of defensiveness).

The question is how do we utilize the older workers as coaches for the younger workers without the negative impact of the SFP?  The key is to change the expectations that both age groups have of each other and this requires training.  Facilitated, interactive training programs that address the common impact of the SFP, help people of all ages understand the role of individual differences in performance, teach people how to deal with the Defensive Cycle™, and give them opportunity to interact successfully with each other tend to produce environments where both older and younger workers can capitalize on the strengths that each bring to the table.  While younger workers bring less socioemotional maturity and experience, they also bring creativity, physical strength and a fresh view of the work context.  Older workers bring the experience and a broader understanding of the work context that can help younger workers make better, less risky decisions.  The key is mutual understanding and mutual respect which come from less stereotyping, less defensiveness and more teamwork.

Are Safety and Production Compatible?

Can we all agree that people tend to make fewer mistakes when they slow down and, conversely, make more mistakes when they speed up?  And people tend to increase their speed when they feel pressure to produce?  Personal experience and research both support these two contentions.  Deadlines and pressure to produce literally change the way we see the world.  Things that might otherwise be perceived as risks are either not noticed at all or are perceived as insignificant compared to the importance of getting things done. Pressure and Perception

A famous research study by Darley & Batson (1973), sometimes referred to as “The Good Samaritan Study”, demonstrated the impact of production pressure on people’s willingness to help someone in need:

Participants were seminary students who were given the task of preparing a speech on the parable of the Good Samaritan — a story in which a man from Samaria voluntarily helps a stranger who was attacked by robbers.  The participants were divided into different groups, some of which were rushed to complete this task.  They were then sent from one building to another, where, along the way, they encountered a shabbily dressed “confederate” slumped over and appearing to need help.  The researchers found that participants in the hurry condition (production pressure) were much more likely to pass by the person in need, and many even reported either not seeing the person or not recognizing that the person needed help.

Even people’s deeply held moral convictions can be trumped by production pressure, not because it has eroded those convictions, but because it makes people see the world differently.

The Trade Off

One reason for this is that many of our decisions are impacted by what is known as the Efficiency-Thoroughness Trade-off (ETTO) (Hollnagel, 2004, 2009).  It is often impossible to be both fast and completely accurate at the same time because of our limited cognitive abilities, so we have to give in to one or the other.

When we give in to speed (efficiency) we tend to respond automatically rather than thoughtfully. We engage what Daniel Kahneman (see Hardwired to Jump to Conclusions) refers to as “System 1” processing — we utilize over-learned, quickly retrieved heuristics that have worked for us in the past, even though those approaches cause us to overlook risks and other important subtleties in the current situation.  This is how we naturally deal with the ETTO while under pressure from peers, supervisors or organizational systems to increase efficiency.

Conversely, when we are not under pressure to increase efficiency, but, rather, pressure to be completely accurate (thorough), we have a greater tendency to engage what Kahneman calls “System 2” processing — we are more thorough in how we manage our efforts and account for the factors that could impact the quality of what we are producing.  In these instances, we will notice risks, opportunities and other subtleties in our environments, just as the “non-rushed” participants did in the “Good Samaritan Study.”

So what is the point?

Most of our organizations are geared to make money, so efficiency is very important; but how do we bolster the thoroughness side of the tradeoff to support safety and minimize undesired events?  To answer this, we have to take an honest look at the context in which employees work.  Which is more significant to employees, efficiency or thoroughness?  And what impact is it having on decision making?

Some industries (e.g. manufacturing) have opted to streamline and automate their processes so that this balance is handled by interfacing humans more effectively with the machines.  Some industries can’t do this as well because of the nature of their work (e.g., construction).  We worked with a client in this later category that had a robust safety program, experienced employees and well intentioned leaders, but which was about to go out of business because of poor safety performance…and it had everything to do with the Efficiency-Thoroughness Trade-off.  The contracts that they operated under made it nearly impossible to turn a profit unless they completed projects ahead of schedule.  As they became more efficient to meet these deadlines, the time-to-completion got shorter and shorter in each subsequent contract until “thoroughness” had been edged out almost entirely.  For this company, preaching “safety” and telling people to take their time was simply not enough to outweigh the ever-increasing, systemic pressure to improve efficiency.  The only way to fix the problem and balance the ETTO was to fix the way that contracts were written, which was much more challenging than the quick and illusory solutions that they had originally tried.

Every organization is different, so balancing the ETTO will require different solutions and an understanding of the cultural factors driving decision making at all levels of the organization.  Once you understand what is salient to people in the organization, you can identify changes that will decrease the negative impact of pressure on performance.

Your Organization’s Safety Immune System (Part 2): Strengthening Immunity

In a recent blog (Your Organization’s Safety Immune System) we talked about people being the “white blood cells” of our "safety immune system", but also that we have to help them become competent to do so.  People care about the safety of others, but most people do not have the natural ability to conduct a successful intervention discussion.   Isn’t it ironic that most organizational leaders assume that their employees have that very ability when they tell them to intervene when they see something unsafe.  It takes skill to successfully tell someone that their actions could lead to injury.  Many times people don’t intervene because they are afraid of reactance/defensiveness on the part of the other person.  Having the skills to deal with defensiveness is essential to being willing to enter into this potentially high stress conversation in the first place.  Success involves understanding where defensiveness comes from, how to deal with it before it arises and what to do when we encounter it both in others and in ourselves.  The intervention conversation is not a script, but rather a process that involves understanding the dynamics of the inhibiting forces and development of a set of skills that lead to effective communication. Defensiveness.  We have all experienced defensiveness both in ourselves and in other people.  Defensiveness arises because we perceive that we are under attack.  We are naturally inclined to defend our bodies and our property from danger, but we are also naturally inclined to protect/defend our personal dignity from criticism and our reputation from public ridicule.  When we perceive that our dignity or reputation are threatened, we defend either internally by retreating/avoiding or externally by pushing back either physically or verbally.  Thus we enter the Defensive Cycle™.

When we see someone doing something undesirable, such as acting in an unsafe manner we automatically attempt to understand why they are doing it and most of the time we automatically attribute it to something internal to the person.  This leads to the  well-documented phenomenon of the “Fundamental Attribution Error” (FAE), 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.  When you fall victim to the FAE you will likely become frustrated or even angry with the other person, and if you enter into a conversation, you will likely come across as blaming the person, whether you mean to or not.  When the other person perceives you blaming, they will most likely guess that you are attacking their dignity or reputation, whether you mean to or not.  When this happens they naturally become defensive.  In turn, if the person gets quiet (defends internally), you will guess that you were right and they took your words to heart so you will expect performance changes which may or may not occur.  If, on the other hand, the person becomes aggressive (defends externally), you will guess that they are attacking your dignity or reputation and you will then become defensive and either retreat or push back yourself.  And the cycle goes on until someone retreats, or until you are able to stop the defensiveness and focus not on the person but on the context that created the unsafe performance in the first place.  You have to change your intent from blame to understanding and you have to communicate that intent to the other person.

Recognizing that we are in the Defensive Cycle™ is the first step to controlling defensiveness and conducting a successful intervention.  It is at this point that we need to stop and remember that when people engage in unsafe actions it is because it makes sense to them (local rationality) given the context in which they find themselves.  When we commit the FAE we are limiting the possible causes of their decision to act in an unsafe manner to their motivation and/or other internal attribute and then allowing that guess to create frustration which causes us to come across as blaming the person.  Recognizing that there could be other contextual factors driving their decision will reduce our tendency to blame, stop the defensive cycle before it begins and significantly increase our chances of having a successful intervention discussion.

Over the past decade we have trained many frontline workers and supervisors/managers in the skills needed to deal with defensiveness, hold an intervention discussion and create sustained behavior change.  We have also found that following training, interventions increase and incidents decrease as a result of simply creating competence which leads to confidence, thus strengthening the “white blood cells” needed for the "safety immune system" to work.

Authority Pressure, Obedience and Organizational Culture

In a recent blog we discussed Peer Pressure, Conformity and Safety Culture.   As with peer pressure, authority pressure and the resulting obedience can be either good or bad.  It is hard to imagine a functioning society without obedience to police officers or successful organizations without obedience to supervisors.  It is also not hard to imagine the negative impact of power hungry, authoritarian police or over zealous, production oriented supervisors. The study of obedience to authority has its roots in the famous research of Stanley Milgram (1963).  His research was stimulated by the Nazi atrocities seen during WWII.  The question he attempted to answer was…how could seemingly moral people follow instructions to kill innocent civilians simply at the command of a superior officer?  The experimental conditions that he utilized involved a series of subjects who were required to “administer” electric shocks to a confederate when the confederate failed to answer a question correctly.  In reality no shock was actually administered but the test subjects were unaware of this and thought that they were actually administering increasingly powerful shocks to the confederate.  If the test subjects balked at administering the shocks, they were directed/commanded by the experimenter (in white lab coat) to continue.  The “shocks” began at 15-volts and progressively increased to a maximum of 450-volts which could in reality kill the confederate if actually administered.  The results indicated that a majority (62.5%) of test subjects went all the way up to the maximum shock when directed to do so by the authority figure.  Many of the test subjects showed signs of distress, indicating that they did not agree with the directive, but the majority did so anyway.

Perhaps even more concerning is recent research that indicates that even having a resistant ally did not stop others from being obedient to authority (Burger, 2009).  The power of authority pressure can be extreme.  While the Milgram studies are focused on the negative effects of bad authority pressure, obedience which leads to prosocial behavior ultimately contributes to culture and organizational success.  It is difficult to achieve success in social groups whether it be society or organizations without obedience.  Understanding the powerful influence that leaders have on the performance of their employees and establishing cultural norms and developing the leadership skills that lead to desired performance can have a profound impact on how these individuals lead and on how their employees respond when pushed to perform in an undesired manner whether that performance relates to production, ethics or safety.

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.

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.

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.

Crew Resource Management (CRM) and the Energy Industry

If you work in the airline or healthcare industries, you are probably already familiar with Crew Resource Management (CRM) training.  CRM training was an outgrowth of evaluations of catastrophic airline crashes that were deemed to be due to “human error”.  The original idea behind CRM was to capitalize on the knowledge and observations of other crew/team members when the pilot or doctor was seen doing something that could lead to an incident.  The goal is to help crew members develop the skills necessary to successfully anticipate and recognize hazards and then correct the situation. Recently, the energy industry has begun to provide guidelines for member companies to implement CRM training in an attempt to avoid catastrophic events like the Macondo and Montara blowouts.* CRM training focuses on six non-technical areas needed to reduce the chances of “human error”.  These six areas are:

1. Situation Awareness This involves vigilance and the gathering, processing and understanding of information relative to current or future risk.
2. Decision Making This involves skills needed to evaluate information prior to determining the best course of action, selecting the best option and implementing and evaluating decisions.
3. Communication This involves skills needed to clearly communicate information, including decisions so that others understand their role in implementation.  It also involves skills for speaking up when another person is observed acting in an unsafe manner.
4. Teamwork This involves an understanding of current team roles and how each individual's performance and interaction with others (including conflict resolution) can impact results.
5. Leadership This involves the skills and attributes needed to have others follow when necessary.  It also includes the ability to plan, delegate, direct and facilitate as needed.
6. Factors that impact human performance Typically this category has focused on stress and fatigue as contributors to unsafe actions or conditions.  However, drawing from the wealth of Human Factors research, we view this category more broadly and feel that it includes the many ways in which human performance is impacted by the interaction between people and their working contexts.

We have been writing on these skill areas in our blogs and newsletters for several years and thought that some of our work on these subjects might be beneficial to our readers who are either currently working to implement CRM training or evaluating the need to do so.  If you have been following our writings, you will already know that we take a Human Factors approach to performance improvement (including safety performance), which involves an understanding of the contextual factors that impact performance deemed to be “human error”.  It is our view that, while human error is almost always a component of failure, it is seldom the sufficient cause.  We hope that this link to our archive of Crew Resource Management related posts will be useful and thought-provoking.  For ease of access, you can either click on one of the six CRM skill sets described above, or the Crew Resource Management link, which includes all related writings from the six skill sets.

*OGP: Crew Resource Management for Well Operations, Report 501, April, 2014. IOGP: Guidelines for implementing Well Operations Crew Resource Management training, Report 502, December, 2014 The EI Report: Guidance on Crew Resource Management (CRM) and non-technical skills training programmes, 1st edition, 2014.

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."