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.
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.
Hardwired Inhibitions: Hidden Forces that Keep Us Silent in the Face of Disaster
Employees’ willingness and ability to stop unsafe operations is one of the most critical parts of any safety management system, and here’s why: Safety managers cannot be everywhere at once. They cannot write rules for every possible situation. They cannot engineer the environment to remove every possible risk, and when the big events occur, it is usually because of a complex and unexpected interaction of many different elements in the work environment. In many cases, employees working at the front line are not only the first line of defense, they are quite possibly the most important line of defense against these emergent hazards. Our 2010 study of safety interventions found that employees intervene in only about 39% of the unsafe operations that they recognize while at work. In other words, employees’ silence is a critical gap in safety management systems, and it is a gap that needs to be honestly explored and resolved.
An initial effort to resolve this problem - Stop Work Authority - has been beneficial, but it is insufficient. In fact, 97% of the people who participated in the 2010 study said that their company has given them the authority to stop unsafe operations. Stop Work Authority’s value is in assuring employees that they will not be formally punished for insubordination or slowing productivity. While fear of formal retaliation inhibits intervention, there are other, perhaps more significant forces that keep people silent.
Some might assume that the real issue is that employees lack sufficient motivation to speak up. This belief is unfortunately common among leadership, represented in a common refrain - “We communicated that it is their responsibility to intervene in unsafe operations; but they still don’t do it. They just don’t take it seriously.” Contrary to this common belief, we have spoken one-on-one with thousands of frontline employees and nearly all of them, regardless of industry, culture, age or other demographic category, genuinely believe that they have the fundamental, moral responsibility to watch out for and help to protect their coworkers. Employees’ silence is not simply a matter of poor motivation.
At the heart this issue is the “context effect.” What employees think about, remember and care about at any given moment is heavily influenced by the specific context in which they find themselves. People literally see the world differently from one moment to the next as a result of the social, physical, mental and emotional factors that are most salient at the time. The key question becomes, “What factors in employees’ production contexts play the most significant role in inhibiting intervention?” While there are many, and they vary from one company to the next, I would like to introduce four common factors in employees’ production contexts:
THE UNIT BIAS
Think about a time when you were focused on something and realized that you should stop to deal with a different, more significant problem, but decided to stick with the original task anyway? That is the unit bias. It is a distortion in the way we view reality. In the moment, we perceive that completing the task at hand is more important than it really is, and so we end up putting off things that, outside of the moment, we would recognize as far more important. Now imagine that an employee is focused on a task and sees a coworker doing something unsafe. “I’ll get to it in a minute,” he thinks to himself.
BYSTANDER EFFECT
This is a a well documented phenomenon, whereby we are much less likely to intervene or help others when we are in a group. In fact, the more people there are, the less likely we are to be the ones who speak up.
DEFERENCE TO AUTHORITY
When we are around people with more authority than us, we are much less likely to be the ones who take initiative to deal with a safety issue. We refrain from doing what we believe we should, because we subtly perceive such action to be the responsibility of the “leader.” It is a deeply-embedded and often non-conscious aversion to insubordination: When a non-routine decision needs to be made, it is to be made by the person with the highest position power.
PRODUCTION PRESSURE
When we are under pressure to produce something in a limited amount of time, it does more than make us feel rushed. It literally changes the way we perceive our own surroundings. Things that might otherwise be perceived as risks that need to be stopped are either not noticed at all or are perceived as insignificant compared to the importance of getting things done. In addition to these four, there are other forces in employees’ production contexts that inhibit them when they should speak up. If we're are going to get people to speak up more often, we need to move beyond “Stop Work Authority” and get over the assumption that motivating them will be enough. We need to help employees understand what is inhibiting them in the moment, and then give them the skills to overcome these inhibitors so that they can do what they already believe is right - speak up to keep people safe.
The Human Factor - Missing from Behavior Based Safety
Since the early 1970’s, there has been an interest in the application of Applied Behavioral Analysis (ABA) techniques to the improvement of safety performance in the workplace. The pioneering work of B.F. Skinner on Operant Conditioning in the 1940’s, 50’s and 60’s led to a focus on changing unsafe behavior using observation and feedback techniques. Thousands of organizations have attempted to use various aspects of ABA to improve safety with various levels of success. This approach (referred to as Behavior Based Safety, or BBS) typically attempts to increase the chances that desired “safe” behavior will occur in the future by first identifying the desired behavior, observing the performance of individuals in the workplace and then applying positive reinforcement (consequences) following the desired behavior. The idea is that as safe behavior is strengthened, unsafe behavior will disappear (“extinguish”).
The Linear View
Traditionally, incidents/accidents have been viewed as a series of cause and effect events that can be understood and ultimately prevented by interrupting the chain of events in some way. With this “Linear” view of accident causation, there is an attempt to identify the root cause of the incident, which is often determined to be some form of “Human Error” due to an unsafe action. The Linear view can be depicted as follows:
Event “A” (Antecedent) → Behavior “B” → Undesired Event → Consequence “C”
Driven by the views of Skinner and others, Behavioral Psychology and BBS have been concerned exclusively with what can be observed. The issue is that, while people do behave overtly, they also have “cognitive” capacity to observe their environment, think about it and make calculated decisions about how to behave in the first place. While Behavioral Psychologists acknowledge that this occurs, they argue that the “causes” of performance can be explained through an analysis of the Antecedents within the environment. However, since they also take a linear view, they tend to limit the “causal” antecedent to a single source known as the “root cause”.
Human Factors
The field of Human Factors Psychology has provided a body of research that has demonstrated that many, if not most, accidents evolve out of complex systems that are not necessarily linear. Some researchers call this a “Systemic” view of incidents. The argument is that incidents occur in complex environments, characterized as involving multiple interacting systems rather than just simple linear events. That is, multiple interacting events (Antecedents) combine to create the “right” context to elicit the behavior that follows.
In such complex environments, individuals are constantly evaluating multiple contextual factors to allow them to make decisions about how to act, rather than simply responding to single Antecedents that happen to be present. In this view, the decision to act in a specific (safe or unsafe) manner is directed by sources of information, some of which are only available to the individual and not obvious to on-lookers or investigators who attempt to determine causation following an incident.
Local Rationality
This is referred to as “Local Rationality” because the decision to act in a certain way makes perfect sense to the individual in the local context given the information that he has in the moment. The local rationality principle says that people do what makes sense given the situation, operational pressures and organizational norms in which they find themselves.
People don’t want to get hurt, so when they do something unsafe, it is usually because they are either not aware that what they are doing is unsafe, they don’t recognize the hazard, or they don’t fully realize the risk associated with what they are doing. In some cases they may be aware of the risk, but because of other contextual factors, they decide to act unsafely anyway. (Have you ever driven over the speed limit because you were late for an appointment?) The key here is developing an understanding of why the individual made or is making the decision to behave in a particular way.
A More Complete Understanding
We believe that the most fruitful way to understand this is to bring together the rich knowledge provided by behavioral research and human factors (including cognitive & social psychological) research to create a more complete understanding of what goes on when people make decisions to take risks and act in unsafe ways. We believe it is time to put the Human Factor into Behavior Based Safety.
The Safety Side Effect
Things Supervisors do that, Coincidentally, Improve Safety
Common sense tells us that leaders play a special role in the performance of their employees, and there is substantial research to help us understand why this is the case. For example, Stanley Milgram’s famous studies of obedience in the 1960s demonstrated that, to their own dismay, people will administer what they think are painful electric shocks to strangers when asked to do so by an authority figure. This study and many others reveal that leaders are far more influential over the behavior of others than is commonly recognized.
In the workplace, good leadership usually translates to better productivity, efficiency and quality. Coincidentally, as research demonstrates, leaders whose teams are the most efficient and consistently productive also usually have the best safety records. These leaders do not necessarily “beat the safety drum” louder than others. They aren’t the ones with the most “Safety First” stickers on their hardhats or the tallest stack of “near miss” reports on their desks; rather, their style of leadership produces what we call the “Safety Side Effect.” The idea is this: Safe performance is a bi-product of the way that good leaders facilitate and focus the efforts of their subordinate employees. But what, specifically, produces this effect?
Over a 30 year period, we have asked thousands of employees to describe the characteristics of their best boss - the boss who sustained the highest productivity, quality and morale. This “Best Boss” survey identified 20 consistently recurring characteristics, which we described in detail during our 2012 Newsletter series. On close inspection, one of these characteristic - “Holds Himself and Others Accountable for Results” - plays a significant role in bringing about the Safety Side Effect. Best bosses hold a different paradigm of accountability. Rather than viewing accountability as a synonym for “punishment,” these leaders view it as an honest and pragmatic effort to redirect and resolve failures. When performance failure occurs, the best boss...
- consistently steps up to the failure and deals with it immediately or as soon as possible after it occurs;
- honestly explores the many possible reasons WHY the failure occurred, without jumping to the simplistic conclusion that it was one person’s fault; and
- works with the employee to determine a resolution for the failure.
When a leader approaches performance failure in this way, it creates a substantially different working environment for subordinate employees - one in which employees:
- do not so quickly become defensive when others stop their unsafe behavior
- focus more on resolving problems than protecting themselves from blame, and
- freely offer ideas for improving their own safety performance.
Because I Said So! The Importance of “WHY”
Sending a clear message, such as an assignment to an employee requires that we make sure that Six-Points are understood: WHO-WHAT-WHERE-WHEN-HOW & WHY. Sometimes we send mixed or unclear messages because we leave out one or more of these points. This can happen because we are pressed for time, we assume understanding or because we just don’t see the importance of that point. Failure to communicate any of these points could lead to failure, but one point in particular can really impact motivation. In most organizations, there are those tasks that nobody enjoys doing. They may be either repetitive or noxious, but they have to get done anyway. For example, some of our client companies use Behavior Based Safety (BBS) as a component of their comprehensive safety program. One aspect of many of these BBS programs is the requirement for employees to complete “observation cards” on a regular basis (a repetitive task). We find that many employees don’t see the importance of this task, so they put it off until the last minute and then “pencil-whip” or “make up” the observations just to satisfy the requirement. The reason this happens is because the employees don’t really understand the “WHY” behind the observation task. Supervisors assume that they understand the purpose behind the task so they don’t take the time to communicate this clearly to their employees. As you might guess, this “false” data can lead management to make safety decisions that may be misguided. We have found that simply telling employees that their observations are actually used to direct safety decision-making by management can greatly increase the validity of those observations.
People need to understand why they are being asked to do something that they don’t really like to do. Simply saying “because I said so” doesn’t work with children and it certainly doesn’t work with employees. Take the time to clearly communicate the reason behind what you are asking them to do and you will increase motivation.