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”.
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.
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.