Phil La Duke's Blog

Fresh perspectives on safety and Performance Improvement

Deadly Choices: Why Do Smart Workers Make Deadly Decisions?


By Phil La Duke

“When I was a young man I was given a check for a million dollars. I tore it up and when to the top of a mountain to contemplate the mistakes of mankind…one man in particular.” Joe Martin, Cartoonist.

When it comes to unsafe behaviors, there is a lot of ground to cover.  In some cases, these unsafe behaviors are just human errors—honest mistakes that we all unintentionally make once in a while. And despite what the mouth breathing, pig eyed brutes that fanatically claim that behavior based systems are the answer, there is scant little we can do about it.  I devoted my post last week to errors so I am disinclined to rehash it here.  Sufficed to say, we had ought to focus less on preventing mistakes and more on protecting people and process from being harmed by errors.

Misjudgments are a different story, and potentially more lethal.  For starters it is tough to get inside someone’s head and figure out exactly what they were thinking.  We love to beat up on people for making a bad call, in many cases because we just know that if put in that situation with the same information we would have decided more prudently.  We believe that we are able to make better decisions than our peers and generally avoid making stupid choices.  Unfortunately, we’re most often wrong.

Biases

The human brain (and perhaps dog brains, and bird brains, for all I know) is designed to see patterns, and to put our input into categories. In broad strokes (if you want the details read Joseph T. Hallinan’s Why We Make Mistakes: How We Look Without Seeing, Forget Things In Seconds, and Are All Pretty Sure We Are Way Above Average) our subconscious minds tend to convince us that things are true when they aren’t.  In other words, our biases fill in the blanks.  These aren’t big, ugly biases like racism, but little biases like the tendency of right handed people to turn right when entering a building even if the shortest route is to the left.

Sometimes, in fact MOST times, our biases are helpful.  Perhaps you’ve seen the email with all the letters jumbled; it expertly demonstrates that our brains can descramble letters simply because our subconscious mind is jumping to (in this case the write) conclusions. In other cases these biases are wrong and have deadly consequences.

I was working with a heavy truck manufacturer and the supplier of the fuel tanks had missed a shipment.  This forced the truck manufacturer to run production without these parts.  Running production lines during parts shortage is common, but in this case it created a problem. On one of the stations the standard operating procedure was for the operator to step out backward onto the fuel tank (the fuel tank was designed with a step for driver entry and exit—it was designed to hold the weight of a burly truck driver) and weld the exterior joints.  Even though the operators had been warned of this hazard, and contingencies were in place, an operator stepped backward from the truck and fell to the floor. Miraculously he was uninjured but had this happened another few seconds into the process he would have fallen an additional ten feet into a pit.

This wasn’t an at risk behavior.  The operator didn’t think, “well yes this is dangerous, but I will only be out there for a second.” The operator did his job the way he had been doing it for years, day-in and day-out. His mental bias made him think something was true when it wasn’t and that bias could have gotten him killed.  Should this worker be punished for his miscalculation? Hardly.  But overcoming biases—those deep-seated beliefs that are buried in our subconscious—are tough to manage.  Again, this demonstrates the importance of protecting people from their decisions instead of trying to manipulate the decision making process.

We See What We Want To See

“He’s as blind as he can be,

Just sees what he wants to see,”—John Lennon, Nowhere Man, The Beatles

Research has shown that our perceptions are intrinsically flawed.  In experiments where a stranger who approaches a pedestrian for directions and the pedestrian is distracted long enough to replace the stranger, only about 30% of the pedestrian noticed that the stranger was a completely different person.  Numerous studies were able to repeat this experiment with essentially the same results.  Researchers concluded that people saw what they were expecting to see and (at least consciously) ignored the things that didn’t seem to fit.

Imagine the implications of this study for safety, where non-standard work (situations where things aren’t the way they are supposed to be, or where there is no “normal” because of the uniqueness of the work being performed.  Our subconscious brain forces us to make decisions on what is supposed to be true and not what is actually true.

Blunders

Last week I hammered out a post for the Rockford Greene International  blog (www.rockfordgreeneinternational.wordpress.com) on Zachary Shore’s book Blunder: Why Smart People Make Bad Decisions. In Blunder Shore examines why otherwise intelligent people make really stupid decisions.  It’s worth a read, but if you prefer the equivalent of a fourth grade book report on it, read my post, it’s not my best work, but then you get what you pay for, and I haven’t seen a bunch of checks rolling in lately[1]

Shore identifies seven mental states that can cause people to make misjudgments that he calls “cognitive traps”. The cognitive traps that Shore identifies are:

  • Exposure Anxiety.  Exposure anxiety is the subconscious fear that our decisions might make us seem weak or somehow tarnish our reputations.  In these cases we will actually make a bad decision over a better option simply because we are overly concerned about how others perceive us.
    This manifests in safety when people chose to ignore safety protocols because they think coworkers will see them as foolish, unnecessarily worried about a remote possibility of injury, or even as sucking up to the boss.
    A good share of exposure anxiety is influenced by the overall cultural view of safety— if there is peer pressure to take short cuts or violate safety rules we will subconsciously make bad decisions. In other words, we will put ourselves in harms way without even realizing that we are making a decision to do so.
  • Causefusion. Causefusion (a contraction of the words “cause” and “confusion”) is the practice of ascribing cause and effect to correlation.  The best example is what we as a profession have done with the findings of the National Safety Council (and a parade of greedy, self- snake-oil salesmen) have done with the statistic that 96% of all worker injuries have a behavioral element.  That is a correlation.  In 96% of cases where a worker was injured there was also an unsafe behavior present, but that is not the same as cause and effect.  That doesn’t mean that the injuries were caused  by unsafe behaviors, only that both factors were present.

We can also see that causefusion in a lot of what we do in safety, not the least of which is incident investigation.  Far too often our incident investigations establish correlation which we mistakenly attribute a causal relationship.  Unless we can overcome this cognitive trap we create organizational superstitions around our hazards.  For all the good it will do use, we might as well be shaking a gourd over the heads of workers or sacrificing live chickens at our pre-shift huddles.  At least people would feel like we were taking action.

Shore adds more mental traps we can fall into: Flatview, Cure-Allism, Infomania, Mirror Imaging, and Static Cling; some are more applicable to safety than others but they are worth considering.  Shore isn’t a safety professional, in fact, he is primarily a historian, but his research on why we make bad decisions is compelling.  Each of these cognitive traps can be seen in the root of most of the major misconceptions of safety: that 96% of all worker injuries are caused by unsafe behavior.

There is a ton more I could say about the many factors that cause us to make bad decisions, but I am already approaching the maximum that anybody will ever read in a blog.  But sufficed to say, human behavior is a lot more variable and complex than any of the BBS yahoos will ever admit.  There is scarce little that we can do to improve our decision making because so much of it is done on a subconscious level. Once again, we have to stop trying to change human nature, and focus instead on the physical environment in which people behave and stop trying to apply Pavlovian and Skinneresque theory to workplace safety.  It doesn’t work.

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[1] Both www.philladuke.wordpress.com and www.rockfordgreeneinternational.wordpress.com are advertising free and provided to you out of the goodness of my heart, well and to get business for Rockford Greene International

Filed under: Safety, , ,

Screw Ups: Errors Are Inevitable


 By Phil La Duke

 

“It’s an imperfect world”, “To err is human”, “That’s why we put erasers on pencils”.  When it comes to screwing up, choose your idiom. We as a global society readily acknowledge that perfection is impossible and yet look with murderous intent to blame those who make mistakes.  This dichotomy isn’t always bad; consider for a moment personal injury lawsuits.  This oft-maligned practice has actually weeded out incompetent doctors, increased the urgency associated with patient safety, and increased awareness of personal responsibility. Even while many politicians deride personal injury lawsuits as single-handedly causing the sky-rocketing cost of healthcare, there are numerous cases where medical advances, improvement in the safety of machinery, and heightened awareness of preventable safety concerns were encouraged by personal injury lawsuits.

Irrespective of your feelings on lawsuits, or even blame, you can probably agree that mistakes cause a significant number of problems, not the least of which, are injuries and workplace deaths.

Before we go much farther, I should define what I see as the categories of behaviors that I would describe under the blanket term, “mistakes”.  Mistakes can run the gamut from simple errors to, misjudgments, risk taking, and catastrophic breakdowns.

 

Errors

Errors are unintentional actions that produce an unwanted result; they are accidents.  Because errors are unintentional we can’t really blame the person who makes them.  That’s not to say that we can’t hold those who make errors accountable.  If your neighbor breaks your window accidentally you may not call the police, but you probably will expect him to cover the repair costs. We generally don’t expect to mete out justice for someone who causes an accident, at least that is, if we categorize it as an honest mistake. Honest mistakes tend to be the mistakes others make that we could see ourselves making.

In his book, Why We Make Mistakes: How We Look Without Seeing, Forget Things In Seconds, and Are All Pretty Sure We Are All Well Above Average, Pulitzer prize winning author Joseph T. Hallinan explores the nature of mistake making.  Hallinan’s book is an incredible collection of facts relative to mistake making, and it has profound implications for worker safety. I encourage all safety professionals to read and internalize this work.

Distraction

One of the key causes of errors, according to Hallinan (and the many studies he cites) is distraction. In today’s increasingly demanding workplaces workers are called upon to do more work with less resources and sadly, more distractions.  According to Hallinan, even a two second distraction can increase the likelihood of an error tenfold.  Multiply that by the multitudes of distractions we have face every day in the course of our workday and the virtual certainty of not just an error, but many errors.  An increasing number of studies have linked texting while driving with highway accidents. But several studies have shown that texting is no more dangerous than dialing a cellphone, entering information into global positioning systems, or referencing written directions.

The Myth Of Multi-Tasking

In addition to distractions, most of us are expected to multitask. Multitasking was a term coined by computer programmers to describe how a computer processes information in tandem to create the illusion of multiple tasks being completed simultaneously.  Unfortunately, it is truly an illusion, computers (except those that contain multiple processors) don’t really do two tasks at once; instead they rapidly switch between the two tasks so quickly that it appears to happen at the same time.  Studies on multitasking have shown that the practice is equally impossible. People who appear to successfully multi-tasks simply have greater short-term memory. Each time a person switches between the two (or more) tasks he or she is completing, the probability of an error increases significantly.

Cognitive Overload

More and more of our jobs require us to keep track of an increasing volume of information.  According to Hallinan, people can only retain and retrieve a fixed amount of information and once that amount of information has been exceeded errors are inevitable and unavoidable. As long we run our operations as lean as we traditionally have, we can expect cognitive overload to lead to poor decision-making, errors and injuries.

Stress

Stress directly impedes our ability to make good decisions and increases the probability that we will make mistakes (from misjudgments to errors to catastrophic breakdowns.) One of the most dangerous things about stress is that it can cause cognitive overload by lowering the threshold at which we can retain and act on information.  Stress also reduces our ability to accurately switch between multiple tasks, which makes even the illusion of multi-tasking, impossible.

But beyond it’s obvious effects, stress also increases our subconscious mind’s likelihood of mistake making.  Our brains are designed to see patterns and to resist change.  Biologically speaking, change is stupid and dangerous.  If a species has found an environment ideally suited to it’s continued survival (ample food supply, low predators, good mating prospects, etc.) than any change can lead to disaster and extinction.  Our central nervous systems are hardwired to interpret changes in our environments as potential threats, the adrenal gland releases 37 toxins into our body which effect every major body system.

But resisting change in a dynamic, every changing environment is equally deadly.  Our subconscious minds therefore test the safety of adapting by creating experiments; we act without thinking. Sometimes this unconscious exploration leads to serendipitous discovery and sometimes it gets into trouble; we commit errors.

Errors represent the single greatest threat to worker safety, and what’s more, there is little that can be done to prevent them.  The best we can hope for is to protect workers from their, and other’s, errors.  In next week’s post I will explore another cause of worker injuries: misjudgments.

 

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Hardwiring Safety Into All Activities


By Phil La Duke

I’ve written several times on the hypocrisy and condescension of slogans like “Safety Is Our Number One Priority” and “Safety First”.  Such platitudes are disingenuous and the people who perpetuate them are either liars or fools or both. For some reading this, this is fairly obvious, while others will furrow their sub-simian brows and hammer out an angry email filled with mouth-breathing outrage.  So why revisit it? I am continually surprised at the shear volume of safety professionals who continue to self-righteously lie about this to his or her constituency.

Nobody likes hypocrites, of course, but the real danger here is that once a population has been lied to, it seldom believes anything else it is told.  So by perpetuating this lie, safety professionals forever diminish their abilities to ever deliver a message. I’ve talked to too many people who cite the practice of beginning a meeting with a thought about safety.  We must stop the practice of self-congratulation because we managed to finish the day without killing someone.  Safety professionals who brag about commitment to safety because every meeting begins with a word about safety diminish the world’s view of the safety professional and by extension the profession itself.

Safety is neither a priority nor a goal instead it is a criterion by which companies measure the efficacy of its efforts to be successful. There is too much word service given to safety; much ado about nothing, sound and fury signifying nothing.  Too many safety professionals mistake communication for awareness and activity with action. For safety to truly achieve any sort of capability it must be imbedded into every thing we do. Of course that is far easier said than done.  But isn’t that the essence of a so called “safety culture”?

Hardwiring safety into all activities cannot be achieved through sermons and scoldings. Hardwiring safety requires a reimagining of the nature of safety itself.

For some safety professionals, the role of the safety professional is cheerleader;  a perpetually perky advocate of all things safe.  Unfortunately, this kind of safety professional typically has only the most superficial understanding of what it takes to make a workplace safer.

Other safety professionals see their roles as parental, eternally haranguing a petulant workforce into straightening up and flying right.  Command and control approaches to safety don’t require much more awareness of the nature of safety than that required of the cheerleaders.

Some safety professionals are witnesses to business.  They walk around the workplace worrying over charts and counting boo-boos.  These safety professionals are too busy looking at what happened that they can’t ever internalize the true nature of safety. In most cases they don’t really care about the nature of safety. They content themselves with passing charts to Operations.

Until safety professionals can see safety as an expression of risk and can advocate for risk reduction through coaching Operations can safety become imbedded into all our activities. Safety has to be more about removing variation from our processes and protecting people from injury when things go wrong and our processes fail.

No operations will ever be completely without risk, and therefore nothing can ever be described as 100% safe. Safety is a strategic business element that needs to be managed as scrupulously as Quality, Delivery, Cost, and Morale.

Filed under: Safety,

Instilling Universal Ownership And Accountability For Safety


By Phil La Duke

I hear a lot of complaints from safety professionals.  Chief among them is that they are held accountable when other people get hurt.  It’s a fair bone of contention.  In so many workplaces, workers cut corners and whine about the inconvenience of the protections put in place to protect them, supervisors encourage unsafe behaviors, and Operations leadership turn a blind eye to recklessness and noncompliance.  But as soon as there’s an injury all the fingers point at the safety professionals, and an accusing eye is cast on the job done by the safety function.  It’s a thankless job to be sure.

Is it fair to hold the safety professional accountable for every injury and near miss? Hardly, but to be fair, there are those sanctimonious and sometimes ridiculous (I know a safety manager who lectures his constituency on proper condom use in his job as a safety manager at a large construction management company) safety professionals who claim single-handed responsibility for everything that goes right with safety and let’s face it, we can’t have it both ways: either our job saves lives or it doesn’t, we can’t claim responsibility on one had and deflect blame on the other.

Everyone plays a role in safety, but unless we can clearly articulate what that role is we cannot expect people to accept responsibility for the role.

The Role of the Individual

Ask a safety professional and they will tell you that an individual has the responsibility to work safely, but how realistic is that?  This expectation implies working safely is always a choice.  The first responsibility of an individual is to do his or her job as prescribed without taking unjustifiable risks; this isn’t the same as working safely.  Even the most diligent worker will make errors, take those risks that are culturally accepted (even demanded), and inadvertently drift from the standard.  So does that mean we can’t hold them accountable for allowing unsafe conditions to grow until the environment is so unsafe that injuries are all but an absolute certainty? Is it right to punish people for something they never intended just because they should have known better? The role of the individual isn’t to work safely rather it is to actively and continually look for hazards and to report these hazards to their supervisor.  Obviously, the individual must refrain from depraved indifference and recklessness, but these are responsibilities under the law and are in no way specific to the workplace.

The Role of the Supervisor

The first line supervisor has perhaps the most pivotal role in safety.  Because first line supervision has both intimate knowledge of the process and workplace and the authority to enforce safety protocols, the onus of safety falls chiefly on the shoulders of the supervisor.  This may sound unfair to some, but consider that the job of the supervisor is to support those in his or her charge.  Supervisors are responsible for ensuring that the workers have all the tools to do their jobs safely.  Supervisors are often required to make snap decisions and to modify the process when parts shortages, absenteeism, or equipment breakdowns threaten production and they have a responsibility to ensure that such ad hoc process variation doesn’t increase the risk of worker injuries.  Supervisors must always consider how their decisions and tweaks affect safety and must be trained to spot safety hazards, especially during nonstandard work. Supervisors must hold workers accountable for eliminating hazards, following safety procedures and policies, and making sound judgments rather than for the presence or absence of injuries.

Operations Leadership

Operations Leadership must value safety above production and reinforce the idea that work completed unsafely is not acceptable.  Operations Leadership must do more than pay lip service to safety and when they are identifying the criteria for success they make it clear that safety is of equal importance to quality, cost, and timing.  This is not to say that safety is our number one priority—it isn’t.  But Operations Leadership must be uncompromising in its message that it will not sacrifice safety (or delivery or quality for that matter) in the name of speed.  Good Operations Leadership would never deliver an inferior product just to meet a delivery deadline, so too must they convince everyone believe that they will not allow workers to be exposed to unreasonable risks simply to meet a deadline.

It’s important to remember that all work carries with it some risk, and it is naïve to think that the risk of injury will not increase in work that is being completed out of process.  Operations Leadership must assess the risks associated with out of process work and ensure that these risks are known, mitigated, and closely managed.

Maintenance & Facilities

One of the chief bottlenecks in making the workplace safer is invariable maintenance and/or facilities.  Identifying hazards is only a small part of the overall safety management process.  Hazards must then be appropriately contained and permanently corrected.  Unfortunately, when I have helped overhaul corporate cultures such that safety is appropriately managed it almost always results in a bottleneck at maintenance or facilities.  Maintenance has a two-fold responsibility. First, it is responsible for making sure that it quickly and appropriately responds to the hazards reported to it by the larger organization. Next, it has to proactively prevent hazards by keeping machinery, vehicles, tools, equipment and facilities in good working order through a comprehensive Total Productive Maintenance (TPM) program.  Another related responsibility is the monitoring of containment actions.  Far too often containment measures are put in place under the assumption that the measures will only be needed for a short time until a permanent solution is applied.  Years later the containment is still in place and is typically only marginally effective.

Training

Whenever I mention the training department’s role in safety people tend to nod their heads and move directly to a discussion about safety training.  The training function should be directing its focus to the area of training that will have the most impact on the safety of the work: basic job function competency.  The best defense against workplace injuries is a comprehensive job training that focuses on the skills the worker needs to do the basic tasks associated with the job.

Safety

The safety professional is responsible for informing and advising all other functions, not in a Cotton Mathers sermon from the pulpit style diatribe, but in bringing their specialized skills to bear in the most appropriate manner.  The safety professional must be a coach and mentor, not parent or policeman.

Irrespective of industry, every job and every function plays a role in ensuring workplace safety, and everyone must be answerable when processes and protocols fail to keep workers safe.

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