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”!

Aligning a Complex Organizational Culture

There are a lot of organizations working hard to create an organizational culture including a safety culture that will help ensure a productive and safe workplace. The quest to build from scratch or transform your organizational culture will prove costly if the process stops at quantifying, qualifying and communicating desired results. The essential next step is to ensure alignment of all the elements of the organization that will produce the desired results. What is “Alignment”? Alignment is simply ensuring that every aspect of the organization (people, teams, surroundings, and systems) works together to create desired results.  We have previously introduced the concept of “local rationality”; i.e., people make decisions to perform in various ways as a result of the local context in which they find themselves. This context includes factors such as Self (motivation, ability, knowledge, habits, attention, emotion), Others (help, pressure, modeling), Surroundings (equipment, climate, layout) and Systems (rules, rewards/punishments, procedures). The person’s view of that context will impact how they act, which will impact the results that they get. Effective organizational leaders understand this and work to create a context (or “culture”) that increases the chances that their employees will decide to perform in ways that lead to accomplishment of the organizational mission. For example, when changing organizational policy on some issue like “incentive pay” (System), effective leaders will attempt to evaluate the impact of the policy on decision making at all organizational levels. If the policy provides incentive to produce at a higher rate, then it could lead to shortcuts in approved procedures and perhaps even create an incentive to cheat or perform in a less than safe manner. While increasing production, the policy would be “mis-aligned” with other desired results and thus become counter to overall organizational effectiveness.

Culture Alignment We have had the opportunity to help leaders evaluate this type of alignment on several occasions. We call our process “Culture Assessment & Diagnostics” and it involves three primary phases (Diagnosis, Design and Intervention).

Diagnosis If not already done, we have senior management articulate their desired “formal” organizational culture by defining the values and behaviors that they feel will support accomplishment of their mission. We then review Systems (policies and procedures) and Surroundings in light of their alignment with the desired culture. This is followed by interviewing a cross-section of employees at all organizational levels and segments to determine the real “informal” culture that exist. This information allows us to determine if “alignment” currently exists between people, systems and processes. We then deliver a report to senior management with our findings and recommendations.

Design The results of the Diagnostic Phase will provide the information needed to guide the design of any necessary change. Few organizations have perfect alignment and therefore most require some changes to achieve alignment. Management determines what changes are needed and then they design a plan to make those changes.

Intervention Every organization is different and thus needs different “interventions” to bring about the desired culture. Some organizations need training programs to impact employee knowledge and ability. Some need accountability systems to ensure consistent adherence to the desired cultural values and behaviors. Some need to change reporting structure. Once the plan has been determined, it is implemented and the appropriate changes will hopefully lead to greater alignment and thus greater effectiveness.

What’s the point? Whether you use a process like the one just described or not, continuous evaluation of alignment between formal and informal cultures is needed to remain or become an effective and safe organization. This is especially true if your organization is not currently getting the results that are expected.

“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!

Motivating Safe Performance

Have you ever observed someone acting in an unsafe manner and immediately attributed their action to lack of motivation to perform safely?  Research, including our own demonstrates that we tend to do exactly that more than 80% of the time, but when we personally act unsafely we attribute our decision to outside, situational forces rather than internal dispositional forces over 90% of the time.  Attribution theories of motivation are explanations of how we attempt to understand our environment, including the behavior of others, and ourselves, by attributing/inferring causes to behavior that we observe.  These theories are helpful in explaining how we attempt to understand performance, but the fact that we do attribute such causes to behavior is not really helpful in our personal understanding of motivation.  In fact in many cases this tendency causes us to inaccurately infer cause and then react to the action of others incorrectly, i.e. commit the Fundamental Attribution Error.  The attributional approach typically does not take into account many other potential causes of unsafe action including situational/contextual contributors. Competence theories of motivation, on the other hand are based on the premise that individuals want (are intrinsically motivated) to interact effectively with their environments.  Psychological researchers such as Albert Bandura (Social Cognitive Theory, 2001) and Edward Deci and his associates (Self-Determination Theory, 2000) have helped us understand what really produces our motivation to perform in certain ways.  They propose that we are trying to effectively engage our environments in ways that make sense given our current understanding of the components of that those environments.  Interestingly, according to Self-Determination Theory we are seen as primarily intrinsically motivated to be simultaneously autonomous and competent and the more successful we are at both of these, the more intrinsically motivated we become.

So why is this important?  How do these theories relate to motivating people to minimize risk and work more safely?

Simply attributing internal motivational causation (Attribution Theories) to unsafe performance creates the opportunity for execution of the Fundamental Attribution Error which is usually negative, often wrong and often leads to blame.  Additionally, it doesn’t help us understand where the motivational state came from in the first place or how to control it.  Viewing the individual as a complex entity who is actively attempting to understand and engage his environment (Competence Theories) would seem to be much more fruitful.  If we “engineer” that environment (context) to increase intrinsic motivation we would have a greater opportunity of developing employees who are competent, take initiative and work more effectively together.  Consider the following.  What if we allowed participation (autonomy) in decision making about those aspects of context that are open to input?  What if we explained the reasons for safety rules, limits, etc so that autonomy could be supported?  What if we made sure that consequences for what turns out to be intentional rule breaking are clearly understood?  The idea is to create a work context where people will adhere to safety rules and procedures, not because they are coerced to do so, but because they feel autonomous and competent in doing so; their reason for doing so is their own and they accept responsibility for doing so.  They are intrinsically motivated to be safe.  Not many people want to get hurt, so capitalizing on the intrinsic desire for safety would seem to make a lot of sense.  Deci’s research (1995) demonstrates that the more controlled people feel (i.e., the less autonomous they feel) the more likely they are to engage in risky behavior.  Isn’t it ironic that most safety programs attempt to control behavior when it is just the opposite that has been shown to motivate behaviors that lead to safety?

Overcoming Age Stereotypes: Older Workers + Younger Workers = Better Decisions

Neurological research has helped us better understand some of the developmental and age related changes in cognitive functioning and performance, including risk tolerance (see Complexity, Age and Performance).  We have proposed that these findings provide additional support for the need to have older and younger workers learn to work together so as to capitalize on their age-related strengths, i.e., older workers + younger workers = better decisions.  The problem is that there are also very strong age related stereotypes that inhibit the effectiveness of this suggestion.  Therefore, we need to understand the role that stereotypes play in the interactions of various age groups in the workplace so that we can create environments where negative stereotypes are minimized or overcome. Stop for a moment and describe the characteristics of people who are 20 years of age, 40 years of age, 60 years of age, and 75 years of age.  If you are honest with yourself, you will have some overlap in your descriptors, but you will also have differences and if you are also honest you will find that there are more negative characteristics identified for age groups to which you do not currently belong.  If you think about it you will also most likely find that your descriptions don’t necessarily accurately describe every person that you know within each of those age groups.  We all function with age related stereotypes but we also know that there are individual differences.  The problem is that until we know a given individual, our stereotypes tend to guide our perceptions and expectations of that person.  In fact, when our expectations are strong, we will overlook invalidating evidence of our stereotypes and foster what is called a “self-fulfilling prophecy (SFP)” through our actions toward the other person.  In other words, our stereotypes will tend to override our search for individual differences, or exceptions, and simultaneously help create the behavior that we expected in the other person.  For example, research has demonstrated that performance is improved when it follows an interaction driven by a positive stereotype but decreased when it follows an interaction driven by a negative stereotype (e.g., Hausdorff, et al, 1999).  Likewise, the behavior resulting from the interaction will strengthen our stereotype and if that behavior is perceived negatively, e.g., inflexible, know-it-all, etc., we will likely become less willing to work with or listen to the other person and this makes our objective of “better decisions” more difficult to attain.

So how do we overcome the negative impact of our stereotypes?

We have been helping supervisors and managers deal with the impact of their negative stereotypes for the past 30+ years and the process, while simple requires understanding and effort.  First, we help them evaluate and understand their stereotypes, especially their negative stereotypes and the role that they personally play in creating SFP’s.  Second, we help them think about specific individuals with whom they interact and then have them honestly evaluate the role of negative stereotyping on both their expectations of the person and the impact of their interaction on the behavior of the person.  In other words, we help them understand that because everyone is different we need to look for those individual differences rather that viewing everyone of a certain age as the same.  Third, we have them evaluate the positive aspects of these individuals, especially those characteristics that can be beneficial to other team members and the organization.  Finally, we have them commit to a regular review of their stereotypes and evaluation of how those stereotypes are impacting their relationships.  Our objective is to improve interactions and relationships by minimizing the impact of negative age related stereotypes.  If we are going to create “better decisions” through the interaction of older and younger workers we will first need to positively impact stereotypes that are currently leading to reduced respect and willingness to listen, learn and depend on each other.

Change: 3 Lessons from College Football

Change is in the air, or at least on the minds of American football fans, political junkies, and those looking at making that big New Year’s resolution.  It seems that change has always and will always be a hot topic. In other words, nothing has changed in regards to change.  So why is it that change is so intriguing yet elusive to us all?  Oddly enough, the answer may be found in a topic at the forefront of American culture, college football. While there is a long history of teams in the Midwest, particularly the Big Ten, being powerhouses, this hasn’t been the case in recent years.  In fact, most recently the landscape of college football has been dominated by a couple of teams on the West Coast and, to a larger extent, in the Deep South.  Looking at the era from 1998-2013, the national champions have resided either in Southern California or the South 15 of 16 years, with the lone exception being Ohio State in 2002.  If you asked the experts, this was less of a cyclical trend and more of a shift into what the future of college football would look like from now on.  However, the last two years shows that may be changing.

What’s Behind It?

One reason that so many struggle with change is that they fail to understand the basic mechanisms behind it, simply floating adrift in the winds of change with no means for navigation.  Let’s looks at three very basic mechanisms of change and how we can use them in driving change in our own lives and organizations.

Acceptance of Change

We all tend to be change adverse at some level.  Some of the best organizations in the world have entire departments who do nothing more than manage change within the company.  One of their main functions is to determine when people are resistant to change and how to compel them to accept the change the organization is wanting to make.  We’ve all had that moment in our own lives that we realized that we simply can’t keep doing things the way we’ve always done them and expect to get different results, but that doesn’t make it any easier to accept that we need to make big changes.

Over the last decade warm weather schools have dominated college football.  Not only did they have a deep pool of talent located close by, they were getting some of the best players from the North to come down to warmer climates.  Warm weather schools have an embarrassment of riches in talent, and they used these talents to evolve the spread offense to such impressive levels that football scores started to resemble basketball scores.  Meanwhile the Big Ten continued to lag their friends to the South in recruiting and offensive numbers.  The powers-that-be at these Big Ten institutions knew they had to make big changes or risk the game leaving them relevant only in history books.

Change is Rooted in Complexity

Anybody that tells you that making a change is simple and you need to just do one simple thing fails to understand what is driving the performance of people.  If you’ve read many of our blogs you have seen the term complexity used quite often.  Simply put, human performance happens in response to multiple stimuli.  No one thing, by itself, is salient enough to sustainably drive a change in performance, instead multiple factors are almost always at play when lasting change takes effect.  In fact, the performance itself is simply a byproduct of the stimuli in which people find themselves. In our blog Complexity and Local Rationality we detail that people don’t behave in certain ways simply because that’s what they want to do but because that’s what seems to be the logical thing to do given their context.  In other words, getting people to want to change is far less important than helping them see that change is actually the logical thing to do and helping them understand that when the change is made it will take changing several factors to make the change stick.

In 2014 Ohio State was ranked #16 in the first College Football Playoff Poll.  After an opening week loss to Virginia Tech they had become an afterthought in terms of playing for a national championship.  Two months later they soundly beat an Oregon team to win the national championship, stopping a 7 year streak of SEC teams winning the national title.  In the 2015 season not only Ohio State, but Michigan State, Iowa, and Northwestern are ranked in the top 14 teams in the country at the end of the regular season, making the Big Ten arguably the dominant conference in college football.  Where did this change come from so fast?  The answer is nebulous but can be argued that many things led to this change.  Former Northwestern Graduate Assistant coach Kenji Jackson says he saw several things happen over the last few years that has changed the way Big Ten football recruits players and performs on the field.

• Several assistant coaches hired from the South brought their recruiting networks with them
• Satellite camps from Big Ten schools held in the Deep South in Summers to recruit the best from that region
• Lowering of academic standards in some Big Ten schools
• Social media and video sharing tools such as Twitter and Hudl where recruits could gain instant access to college coaches around the country
• A change in offensive philosophies in the Big Ten that has coupled the fast paced spread offense with the traditional smash mouth run game.

These were just a few of the examples that Coach Jackson immediately saw happening in the Big Ten the last few years.  While there is no measurable correlation, each of these probably have impacted the resurgence of Big 10 football.

Agents of Change

To drive change in organizations you have to have the right person/people at the wheel.  This doesn’t necessarily mean you have to have a CEO that drives the change throughout the organization, you simply have to identify the right people, the social centers of gravity, that will intentionally drive the change.  This could be senior leadership, front line supervisors, key front line employees, or any combination of the above.  However, you have to find the right person/people who know the vision of where the organization wants to go and who have the hearts and minds of the masses to make them follow.

In the case of the Big Ten nobody has driven this change more than Urban Meyer.  Coach Meyer has been successful at every stop, from Bowling Green, to Utah, to Florida, and ultimately Ohio State.  He not only brought a fresh perspective for running a cutting edge new offense to the league, he brought new blood with his coaches and players that he recruited from outside the region, and viewership that meant more TV dollars that help all of the teams in recruiting.

One of the biggest aspects of change that Coach Meyer brought to Ohio State was the willingness to change.  Braxton Miller was the starting QB when the season started in their championship season of 2014 but missed the majority of the season due to injury.  When he returned in 2015  he was asked to move to receiver and did so.  Now none of us on the outside know how that change was received at first but the change was made and Braxton Miller has played exceptionally well at the position and will probably be playing receiver in the NFL next season.  He built the blueprint for winning in the Big Ten in modern day football and other teams have benefited by following that blue print while putting their own tweaks in the plan itself.

The Real World

What does this have to do with making change in my own life or in my company you may ask.  This analogy is not just the musings of a college football fan but a case study in how we can all drive big change in performance across dynamic and complex organizations.  There are more aspects to change than just these three points but if we can start to understand how a loosely jointed group of higher learning institutions changed the way America views their football programs we can start to understand how we get our organization to be better at changing HR software programs or adhering to a new company policy on environmental record keeping.

First, understand that people tend to be resistant to change.  This isn’t merely a weakness of the human spirit, but more likely a weakness in organizational context.  We can and should compel, encourage, and reward people to accept positive change, but we can’t expect change to stick until we understand the context in which people work.

Next, understand that making change is not a one off effort.  People are doing things because the context in which they work makes it locally rational to do it that way.  You can’t change any one thing and create sustainable change.  In Step 1 above you have encouraged your team to accept change and begun to understand the context that is driving their resistance.  It will take effort and resources across the board to make changes to this context and make the change stick.

Lastly, identify the right agents of change.  It may be a senior leader, a committee of front line leaders or even your front line workers but you have to find the people who see the vision, understand the strategy for making change, and who people will follow to make the change sustainable.

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.

Your Organization's Safety Immune System

Have you ever considered that organizations in many ways are like living organisms?  While there are obvious differences between organizations and living organisms, the metaphor can be helpful in understanding how to keep people safe in the workplace.  Like a living organism, organizations are made up of complex, interacting components and systems that allow the organization to survive, flourish and grow.  One of those systems in a living organism is its immune system which is needed to help it fight off external and internal attacks.  Organizations also need an immune system to help it defend itself from danger.  An immune system is composed of many different types of barriers against disease, some static and some dynamic.  Your body’s immune system includes static components like your skin, blood vessels, thymus, spleen, bone marrow, liver, etc., each designed to act as a barrier to defend your body against various dangers that could cause damage to you.  Organizations also rely of various static barriers to defend themselves against injury.  These include rules, policies, procedures and various mechanical safeguards, such as personal protective equipment, machine guards, etc.  While unquestionably useful, these defenses are also inherently insufficient.  No matter how well designed or assimilated, these devices simply cannot prevent all incidents in complex workplaces because they are static and slow to change.  As such, there is a need for something different.  Something more naturally suited to mitigate risk in our highly complex work environments.  Something that is more agile than our usual tools.  Something ubiquitous, reactive and creative.  The immune systems of living organisms contain something that is more agile than the static structures and barriers listed above.  They include white blood cells that move around the body and create various types of antibodies needed to fight off invaders.  Our organizations also have “white blood cells”…. the people that work there.  The individuals that are moving around, observing and intervening to activate safeguards or remove others from danger.  The difference between the white blood cells of our immune system and the people in our organizations is that white blood cells “naturally” intervene when danger is observed.  People on the other hand don’t necessarily always intervene.  White blood cells have the natural ability to detect danger and intervene.  Most people on the other hand don’t have the natural ability to intervene and as we have discussed in other articles (Hardwired Inhibitions), they are actually predisposed not to intervene.  To overcome this inhibition people have to be trained.  They have to learn how to not only recognize hazards but how to effectively speak up and also deal with the possible defensiveness that can arise when they do so.  Is your organization's immune system fully functional.  Do your organization's “white blood cells” know how to intervene.  If not, then your organization is very possibly at serious risk of injury.

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.

Emails Can Be Fertile Ground for Misunderstanding & Conflict

Emails have become a valuable and indispensable part of our lives, both personally and at work.  We provide information, seek information and maintain a record of the email communications that we have had so that we can go back and remember those “conversations”.  Most of us don’t think much about the form of our emails, we just write and send them.  But have you ever received an email that made you angry, or made you feel disrespected?  I have had several conversations with people about this very issue over the past few weeks, so I thought it might be an issue that needs addressing.  I remember that when email first came on the scene it was viewed as an electronic version of a letter.  Formal business letters have a certain format including a salutation, a body and a closing.  Following this format was/is expected and as a result helped shape the individual and company image and simultaneously communicated respect to the person receiving the letter.  Emails have changed over the years and I think have taken more of a “text” or “message” format.  These latter formats are based on brevity and often include abbreviations and even acceptable “bad grammar”, and many times exclude the salutation and/or the closing.  People have come to expect that type of format in texts, but what about emails?  I think the answer to this question is that “it depends on who is communicating with whom about what”.  It goes without saying that if you have something to say to someone that has negative emotional content, don’t send it in an email, rather do it face-to-face or at least over the phone when face-to-face is impossible.  But even non-emotionally laden content can be misunderstood.  For me, the key is to always think about how the other person could interpret (or misinterpret) the message and always communicate with respect.  A salutation as simple as “Hi, Joe” or “Good Morning, Joe” can help to set the stage for a more positive reading of the content.  Likewise, clear communicative language in the message body even to the point of clarifying your intent can help to eliminate misinterpretation.  Obviously your relationship with the person receiving the email will guide the language and format that you use, but it never hurts to be polite, even with those with whom you have a good long-term relationship.  Also, when receiving an email, don’t be so quick to jump to negative interpretation of ambiguous content.  Give the person the benefit of the doubt by assuming that they did not intend to be disrespectful or otherwise negative and check it out before responding back with a short, curt email of your own that was intended to “get even”.  Emails can be a valuable, time saving tool unless they create misunderstanding and conflict that is unnecessary and counterproductive.  Take a moment to think about what you are writing in your email and then re-read what you have written before you hit send.  It could save you a lot of time and relationships if you do.

Why Does Context Matter?

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

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

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

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

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

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

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

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

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

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

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

Just Pay Attention and You Won’t Get Hurt!

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

Lone Workers and “Self Intervention”

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

Hardwired to Jump to Conclusions

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

So how can we stop jumping to conclusions?

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

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

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

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

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

Tying it back to observation programs

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

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!