Situational Awareness

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

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

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

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

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

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

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

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

Crew Resource Management (CRM) and the Energy Industry

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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

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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?

Hardwired Inhibitions: Hidden Forces that Keep Us Silent in the Face of Disaster

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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.

Human Error and Complexity: Why your “safety world view” matters

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Have you ever thought about or looked at pictures of your ancestors and realized, “I have that trait too!” Just like your traits are in large part determined by random combinations of genes from your ancestry, the history behind your safety world view is probably largely the product of chance - for example, whether you studied Behavioral Psychology or Human Factors in college, which influential authors’ views you were exposed to, who your first supervisor was, or whether you worked in the petroleum, construction or aeronautical industry. Our “Safety World View” is built over time and dramatically impacts how we think about, analyze and strive to prevent accidents.

Linear View - Human Error

Let’s briefly look at two views - Linear and Systemic - not because they are the only possible ones, but because they have had and are currently having the greatest impact on the world of safety. The Linear View is integral in what is sometimes referred to as the “Person Approach,” exemplified by traditional Behavior Based Safety (BBS) that grew out of the work of B.F. Skinner and the application of his research to Applied Behavioral Analysis and Behavior Modification. Whether we have thought of it or not, much of the industrial world is operating on this “linear” theoretical framework. We attempt to understand events by identifying and addressing a single cause (antecedent) or distinct set of causes, which elicit unsafe actions (behaviors) that lead to an incident (consequences). This view impacts both how we try to change unwanted behavior and how we go about investigating incidents. This behaviorally focused view naturally leads us to conclude in many cases that Human Error is, or can be, THE root cause of the incident. In fact, it is routinely touted that, “research shows that human error is the cause of more than 90 percent of incidents.” We are also conditioned and “cognitively biased” to find this linear model so appealing. I use the word “conditioned” because it explains a lot of what happens in our daily lives, where situations are relatively clean and simple…..so we naturally extend this way of thinking to more complex worlds/situations where it is perhaps less appropriate. Additionally, because we view accidents after the fact, the well documented phenomenon of “hindsight bias” leads us to linearly trace the cause back to an individual, and since behavior is the core of our model, we have a strong tendency to stop there. The assumption is that human error (unsafe act) is a conscious, “free will” decision and is therefore driven by psychological functions such as complacency, lack of motivation, carelessness or other negative attributes. This leads to the also well-documented phenomenon of the Fundamental Attribution Error, whereby we have a tendency to attribute failure on the part of others to negative personal qualities such as inattention, lack of motivation, etc., thus leading to the assignment of causation and blame. This assignment of blame may feel warranted and even satisfying, but does not necessarily deal with the real “antecedents” that triggered the unsafe behavior in the first place. As Sidney Dekker stated, “If your explanation of an accident still relies on unmotivated people, you have more work to do."

Systemic View - Complexity

In reality, most of us work in complex environments which involve multiple interacting factors and systems, and the linear view has a difficult time dealing with this complexity. James Reason (1997) convincingly argued for the complex nature of work environments with his “Swiss Cheese” model of complexity. In his view, accidents are the result of active failures at the “sharp end” (where the work is actually done) and “latent conditions,” which include many organizational decisions at the “blunt end” (higher management) of the work process. Because barriers fail, there are times when the active failures and latent conditions align, allowing for an incident to occur. More recently Hollnagel (2004) has argued that active failures are a normal part of complex workplaces because of the requirement for individuals to adapt their performance to the constantly changing environment and the pressure to balance production and safety. As a result, accidents “emerge” as this adaptation occurs (Hollnagel refers to this adaptive process as the “Efficiency Thoroughness Trade Off”) . Dekker (2006) has recently added to this view the idea that this adaptation is normal and even “locally rational” to the individual committing the active failure because he/she is responding to a context that may not be apparent to those observing performance in the moment or investigating a resulting incident. Focusing only on the active failure as the result of “human error” is missing the real reasons that it occurs at all. Rather, understanding the complex context that is eliciting the decision to behave in an “unsafe” manner will provide more meaningful information. It is much easier to engineer the context than it is to engineer the person. While a person is involved in almost all incidents in some manner, human error is seldom the “sufficient” cause of the incident because of the complexity of the environment in which it occurs. Attempting to explain and prevent incidents from a simple linear viewpoint will almost always leave out contributory (and often non-obvious) factors that drove the decision in the first place and thus led to the incident.

Why Does it Matter?

Thinking of human error as a normal and adaptive component of complex workplace environments leads to a different approach to preventing the incidents that can emerge out of those environments. It requies that we gain an understanding of the many and often surprising contextual factors that can lead to the active failure in the first place. If we are going to engineer safer workplaces, we must start with something that does not look like engineering at all - namely, candid, informed and skillful conversations with and among people throughout the organization. These conversations should focus on determining the contextual factors that are driving the unsafe actions in the first place. It is only with this information that we can effectively eliminate what James Reason called “latent conditions” that are creating the contexts that elicit the unsafe action in the first place. Additionally, this information should be used in the moment to eliminate active failures and also allowed to flow to decision makers at the “blunt end”, so that the system can be engineered to maximize safety. Your safety world view really does matter.

Diagnostic Tools for Poor Performance

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In our May Newsletter we described a Contextual Model designed to help us understand how people make decisions that impact their performance. You will recall that we focused on four general contextual factors (Self, Others, Surroundings and Systems) as primary contributors to determining performance success or failure. The salience or "relative weightiness" of specific factors within these general factors create what we called “local rationality”. Local rationality is a term to describe the fact that individuals perceive and interpret the contextual factors weighing on them in a way that is uniquely their own and makes total sense to them, irrespective of how "irrational" the interpretation appears to an onlooker. This locally perceived and vetted interpretation of the contextual factors weighing on a person, in turn, determines how the person decides, behaves, or performs.

Therefore, to accurately (and thus effectively) hold someone accountable for performance requires that we examine their context before we attempt to “fix” their performance.

Four Skills

We suggest four skills that when applied during an “accountability discussion”, or what we also refer to as a “re-direction” discussion, will help you get an accurate picture of the person’s context.

We have a natural tendency to want to understand and explain what we see as quickly as possible, so we have a tendency to make a guess about the causes of poor performance.

Thus the first skill:

“Don’t Guess”

Whether you are right or wrong in your guess, you are likely to create defensiveness and we have already talked about the negative impact that defensiveness can have on communication (Read the Blog: Dealing with Defensiveness in Relationships).

Additionally, when you guess you can unintentionally influence the person to agree with your assessment even if it is incorrect. So, instead of guessing, become curious and think to yourself...”I wonder why it makes sense to him to do that?”.

This question also weakens the influence of the Fundamental Attribution Error and allows you to entertain factors other than motivation as a cause for failure.

This leads to the second skill:

“Ask Opening Questions”

Start by making sure that your tone of voice is respectful and not accusatory which would most likely be interpreted as a guess and lead to defensiveness.

Don’t ask “Yes” or “No” type questions which would also be seen as guessing, rather simply ask the person to help you understand why they did what they did (a reflection of your curiosity question above).

For example “Can you help me understand why you are doing it this way?”

If you show genuine curiosity and not judgement you will be much more likely to get at the real reason behind the decision and behavior.

Sometimes you will only be able to identify a general contextual factor with your Opening Question, so this brings the third skill into play:

“Ask Drill Down Questions”

Remember, the objective of this discussion is to determine the real reason or reasons behind the poor performance so that you can fix it. If you didn’t get enough information from your first question, then just ask a second, more specific question (i.e., Drill Down Question).

For example Let’s say the person used the wrong tool for the job and when you ask them why they say they didn’t have the right tool. You might drill down by asking something like...”Why didn’t you have the right tool?”.

Just telling them to use the right tool might not fix the problem if the reason they don’t have the right tool is because there is only one available and someone else is using it!” Remember, drill down far enough to find the real reason(s) before you attempt to fix it.

And finally, during the whole conversation apply the fourth skill:

“Listen Completely”

Listening to “what” the person is saying (their words) is only half of the process. To listen completely, you must also pay attention to “how” they are speaking, e.g. their tone of voice, their willingness to maintain eye contact, their body posture, etc. These help you understand the “real” meaning behind what they are saying and will also help you get to the real context that led them to perform as they did.

What's the Point?

Only after you have ascertained the real reason(s) do you have a sufficiently complete and accurate “accounting” of the failure. With this "accounting", you can now help find a fully informed fix that will lead to sustained improvement going forward.

The Human Factor - Missing from Behavior Based Safety

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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.

A Causation Model for Poor Performance

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We have all failed at some point to meet expectations, either our own expectations or the expectations of someone else. I would guess that most of us did not try to fail, but we did anyway. Most of us thought that we were performing well until we were either told by someone else that we weren’t or we saw the results and determined it for ourselves. The question then becomes...”Why did we fail? What caused the failure?”

Failure Failure occurs for a variety of reasons and understanding the real cause(s) of a person's failure is absolutely critical to the accountability process and to assuring future success for the individual.

Local Rationality We make decisions to perform in specific ways because it makes sense to us to do so. This is called “local rationality”. What may look ridiculous or stupid to someone else, looks perfectly correct to us because of the context that we have at that moment.

The factors that are most obvious, pressing or significant from your point of view aren’t necessarily all that obvious, pressing or significant from another person’s point of view. However, it is that very set of factors that determines what makes sense and what doesn’t.

It is these factors that determine your decision to perform in a given manner. Sometimes these factors lead to failure while other times to success.

Context is Everything Context is everything and understanding that context is absolutely required before we can apply the “Ask” skills in an accountability conversation.

So let’s take a look at look at a contextual causation model for assessing performance.

The Contextual Model We find it helpful to think of context as involving four general factors, each made up of other specific factors which can have an impact on performance.

Contextual Model

Gaining an understanding of which specific factors are affecting a person's performance will help us both understand the performance and determine how to help the person improve the performance going forward.

Self One of the general factors involves the individual and we call these the “Self” factors.

  • Motivation: Does the person actually care about success? Is the person willing to put out the energy to perform successfully? It should be noted that we have a tendency to attribute most, if not all failure to lack of motivation when in fact it is only one of serval self factors that may be at play. Remember the Fundamental Attribution Error that we discussed last month. So be careful not to guess that failure can be fixed simply by motivating the person.
  • Ability: Can the person actually engage in the performance needed for success? Do they have the skill set necessary for success or are they lacking those skills?
  • Knowledge: Does the person know how to perform correctly? Have they been given the training necessary for success?
  • Habits: Has the person done it the wrong way so many times that it has become engrained to the point that the person is on “auto pilot”?
  • Attention: Is the person failing to focus on performing correctly? Is the person distracted for some reason? Has the person done the task so many times that he/she does it without thinking?

Others A person’s performance can also be impacted by what the people around him/her do and say, and we refer to these as the “Others” factors.

  • Help: Do people in the workplace (supervisor and coworkers) provide assistance or not? Do they do things that make it difficult or easy to be successful? Do they remove or create barriers to success?
  • Pressure: Is there peer pressure to perform in an unacceptable manner? Does the boss knowingly, or unknowingly push the person to perform in a manner that leads to failure? Does the boss create an environment where one aspect of success (e.g. productivity) is seen as more important than another (e.g. safety)?
  • Modeling: Do others in the workplace perform in a manner that makes it seem normal to perform in a manner that leads to failure? Or do they perform in a manner that assures success?

Surroundings The workplace itself can also impact performance and we call these the “Surroundings” factors.

  • Equipment: Does the person have the right tools/resources to perform successfully? Or is the person forced to adapt tools that are not really fit for the job?
  • Climate: Are temperature, light, wind, or other environmental factors impacting success?
  • Layout: Are things located in such a way that they make it easier or more difficult to achieve success?

Systems And finally there may be institutional factors that impact performance and we call those the “Systems” factors.

  • Rules: Are there requirements from the company, customer, industry or government that make success difficult? Are there rules that are in conflict and force the person to make a choice of which one to follow?
  • Rewards/Punishments: Are incentives impacting performance either positively or negatively? Does the incentive program create the need to take short cuts in order to be successful? Does the incentive program reward speed over accuracy
  • Procedures: Are accepted procedures actually making success more difficult? Are there actually procedures in place that will help the person achieve success?

Think about a time when you failed to meet expectations. What factor or factors were at play to contribute to that failure? Were you held accountable and, if so, did the person holding you accountable understand why you failed? Did he/she explore your context before creating a fix for your failure?

What's the point?

Next month we will examine the four “Ask” skills that will help you use the Contextual Model to determine what exactly is contributing to an individual’s failure. This is so that you can then help them “Fix” the right things to create a context that will lead to success going forward.

Avoid Cognitive Bias to Create Workplace Accountability

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As we discussed in our January Newsletter, the first step to Accountability involves an examination of the facts/reasons underlying a specific event/result (accounting). In order for this process to bear fruit, it is important that we accurately and fairly evaluate the causes of the poor performance. To effectively examine the facts/reasons for a specific event/result requires that we understand how our biases could affect that evaluation. This is where Cognitive Biases can come into play. You may be saying to yourself…”I don’t have any biases. What are they talking about?”

Well, the truth is that we are all impacted by biases and much of the time for that matter.

What is a Cognitive Bias?

A Cognitive Bias is anything in our thought process that can distort the way we view things including the actions of another person.

There are a multitude of cognitive biases that have been identified and studied by psychologists, but there are two that directly impact accounting for the actions/results of another person.

Confirmation Bias

One of these is what is called Confirmation Bias or the tendency to search for, interpret, focus on and remember information in a way that confirms one's preconceptions. In other words, we are predisposed to look for causes that confirm what we expect.

This means, for example, that if we are predisposed to view another person as competent, a hard worker and motivated, then we will tend to look for these types of behaviors in that person and also overlook behaviors that are in conflict with our preconception. Additionally, we would be more likely to account for poor performance on the basis of external factors such as lack of resources, lack of support, etc. rather than internal factors such as knowledge, ability or motivation. In other words, we would be likely to conclude that the failure was out of the person’s control.

On the other hand, if we are predisposed to view another person as incompetent, lazy and unmotivated, then we will tend to look for support of this preconception as the cause for failure and perhaps blame the person for the failure.

The Confirmation Bias is the underlying driver for a phenomenon commonly referred to as the Self Fulfilling Prophecy. This phenomenon has been demonstrated through research and personal experience in various environments and is notably reflected in the positive correlation between a supervisor’s expectations of a subordinate and that subordinate's performance.

Low, negative expectations tend to result in poor performance, whereas high, positive expectations tend to result in good performance.

Therefore, how we view an individual not only can color how we evaluate performance, but it can also determine how the individual actually performs. To fairly hold others accountable for failure we must be aware of our predispositions/biases regarding the individual and how we may have contributed to the failure in the first place.

Fundamental Attribution Error

The second Cognitive Bias related to Accountability is called the Fundamental Attribution Error.

Have you ever been driving on a three lane highway, going the speed limit in the right hand lane (left hand lane if you are from the UK) approaching an exit that you are not taking, only to have someone cut dangerously close in front of you to take the exit? What were your thoughts about the person doing the cutting? If you are like most of us you called the person a “jerk” or something worse and honked your horn or gestured “politely”.

You just attributed the other person’s actions to an internal attribute related to carelessness or some other bad motive. In other words, we view the other person as “bad” in some way.

Now, have you ever cut someone off in a similar circumstance when you were needing to get to an exit? If you are like us, and everyone else we have asked this question, then the answer is “yes”!

So why did you do it?

Probably because that “jerk” in the right hand lane wouldn't get out of the way and let you exit. In other words, your poor performance was due to external causes and not your carelessness or bad motive.

This is the Fundamental Attribution Error which says that we tend to attribute internal/motivational causes to the poor performance of others but not to our own poor performance. This cognitive bias can cause us to “jump to the conclusion” that the cause of the poor performance was due to motivation and thus interfere with our complete evaluation of other causes. Failure to accurately evaluate the “real” causes will most likely lead to consequences or corrections that will not lead to success in the future.

What's the Point?

Simply being aware that these two Cognitive Biases exist will help reduce or hopefully eliminate their impact on the accountability process.

As we will discuss in a future newsletter, starting your accounting of poor performance without “guesses” as to the cause(s) will almost always lead to a more accurate evaluation.

Why Rule Breaking Makes Sense

Complexity & Rationality Why do employees decide to break the rules?  Do it their way?  Resist change?  It doesn’t make any sense!

It can be frustrating, and often perplexing, when employees fail to adhere to company policies and procedures, especially when those policies and procedures are in their best interest. There is a useful way to think about this issue: What employees do makes sense...to them; but the complexity of work environments makes it hard to understand why it makes sense to them.

We live and work in complex environments. It helps to think of our environments as systems with overlapping and interacting components - including people, things, rules, values, etc. - which are, in turn, complex sub-systems. One of the principles of complex systems is that the “people” component tends to respond only to the limited information that they are presented with locally. We make decisions based on our knowledge of what makes sense at the local level, which is called “local rationality”.

The policies and procedures contained in the corporate manual are only influential if they are brought to bear on the daily lives of people in the workplace. If those policies and procedures only exist in the manual and are not made a part of the local workplace, then they don’t exist in reality and will not have an impact on performance. They will lack influence.

Companies have policies and procedures for a reason - to create good, reliable results; so it is the responsibility of supervisors to bring those policies and procedures to life in the workplace. By intentionally incorporating formal policies and procedures into the “local” work environments of employees - through conversation, feedback, modeling, etc. - supervisors make it “rational” to follow the rules.

Effective Organizations Tolerate Acceptable Risk and Learn from Success & Failure in an Attempt to Be Innovative

Risk is a natural part of life. Just about every decision that we make has some level of risk associated with it. Some risk is inconsequential, such as the decision regarding the color of the shirt that you decided to wear this morning. On the other hand, some risk can have significant impact on you and those with whom you associate, e.g., whether you ask a specific person to marry you or not. We start taking risks from a very early age and if we didn’t, we would probably never learn how to walk! Without some level of risk, things would never change or improve and effective leaders understand this.

Do You Value Initiative?

We often ask our Performance Management course participants whether they would rather have employees who show initiative or those who just do what they were told to do. They always respond with “I want employees who show initiative”.

But initiative is a form of risk-taking because the decision that the employee makes could be wrong and negatively impact desired results.

Clarify "Appropriate Risk"

Effective leaders are careful to clarify what they mean by “appropriate” risk taking and consistently encourage both initiative and innovative thinking while helping employees understand what is appropriate by helping them understand the potential results of both failure and success.

Understanding Context

We work with many organizations to help them improve performance and especially safety related performance. We know that the decisions that people make, both safety and non-safety related are driven by their understanding of contextual factors including themselves, others, the environment and the organizational systems.

Local Rationality

We have discussed before in other newsletters and articles the concept of “local rationality” in that our decisions make sense to us given our interpretation of the context and the associated risk. For example, we may make a decision to forego wearing safety glasses because we are being rushed by our supervisor to get the job done quickly and safety glasses are not readily available. We accept the risk of possible injury because the risk of displeasing the boss is seen as greater in the moment (local rationality).

Creating a New Context

Effective leaders attempt to create contexts that control factors (pressure to rush) that can lead to poor decision making (not wearing safety glasses) while increasing the chances of effective and even innovative decision making (coming up with a plan to both wear safety glasses and get the job done quickly).

They do this by encouraging active dialogue about the workplace (context) and ways to improve that context to encourage employees to take initiative (appropriate risk taking).

Contextual Analysis

Effective Leaders evaluate why both success and failure occur within the organizational context and do so without assuming poor motivation as a starting point. (See May newsletter for further discussion of contextual analysis and accountability).

What's the point?

Effective Organizations are filled with individuals who make good decisions about acceptable risk (initiative) because their leaders have created an organizational environment (context) that assists in that decision making.

A Best Boss Is Flexible and Willing to Change When Necessary, Is a Good Planner/Organizer, & Shows Respect to Others

The holiday season brings us to the final two installments of the Top 20 Characteristics of a Best Boss. As you prepare for the potential stress of family and out of town guests, take the time to look back at the characteristics we have described so far and imagine how they might influence your relationships with friends and family. #1 -- is a good communicator #2 -- holds himself and others accountable for results #3 -- enables success #4 -- motivates others #5 -- cares about the success of others #6 -- is honest and trustworthy #7 -- shows trust by delegating effectively #8 -- is fair and consistent #9 -- competent and knowledgeable #10 -- rewards / recognizes success #11 -- leads by example #12 -- is loyal to employees #13 -- is friendly #14 -- is a good problem solver and #15 -- is a team builder.

This month we will examine how a Best Boss:

#16 -- is flexible and willing to change when necessary #17 -- is a good planner / organizer and #18 -- shows respect to others.

Flexible and Willing to Change When Necessary

“I’m the boss and we will do it my way” is not something you would hear from a Best Boss. That being said, this a common expression heard in many workplaces and a powerful undertone in the culture of many of the organizations that don't necessarily say it out loud. The consequences of this expressed or implied sentiment are dramatic, the least of which include employee apathy, disengagement and a potentially profit forfeiting reduction in creativity.

Fear of Losing Control One of the fundamental issues is that some managers/supervisors view flexibility as a sign of weakness. Common expressions like "give them an inch and they will take a mile" and "too many chiefs and not enough indians" reinforce the belief that the supervisor must exhert unquestionable authority or risk losing control. Quite the contrary, it is often the rigid dictator that incites the desire for revolution.

Fear of not Knowing all the Answers Another driving force in the tendency toward rigidity is that many supervisors don’t want to admit that they don’t have all of the answers. I once heard a really great manager say “I am willing to learn from anyone, even the newest person on the team because they don’t have the years of bias that I have.” If you remember that the job of a supervisor is to get results from the efforts of others, it only makes sense that you would leverage the creative brains of others to get results as well. Flexibility does not mean giving in to all suggestions but rather is the willingness to entertain other views and make decisions on the basis of that evaluation.

Flexibilty & Problem Solving The ability to apply the problem solving skills that we discussed in our October Newsletter is critical to becoming flexible. Good team-based problem solvers will have the opportunity to seek input from team members and then collaborate with them on solutions, thus making flexibility much easier to demonstrate. Repeated practice with collaborative problem solving will reinforce the desire to be flexible as you observe the solution optimizing benefits of additional perspectives.

A Good Planner / Organizer

Planning/Organizing, problem solving and time management go hand-in-hand.

Expectations Good bosses know that their team members need direction so that they will know “what” is expected of them. They must have a clear understanding of the results that they must achieve. A good plan, especially as the result of collaboration, will provide those expectations for each team member.

Reading from the Same Page It really doesn’t matter if the plan is the result of problem solving or simply daily work objectives, the resulting product is the same, namely a plan that everyone understands and supports.

Time and Priorities Additionally, team members must have a clear understanding of “when” those results are expected. This is where time management comes in. Best Bosses help set priorities as part of the planning process. They gather information about the current action items for each team member and then in concert they prioritize them. This helps the team member control his/her time and as a result manage their personal stress.

Shows Respect to Others

What is respect anyway? Respect is defined as “a feeling of admiration for someone or something elicited by their abilities, qualities, or achievements.” So showing respect is a demonstration of this definition in some way.

Listen to Show Respect How does a person “show respect” to another? If your answer is “by listening to the other person” then you are in agreement with just about everyone to whom we have asked this question over the last 30-years. Listening does not require that you “respect” every “ability, quality or achievement” of the person, but it does require some very important skills.

You may recall that we discussed listening in detail in the "Good Communicator" installment that kicked-off this newsletter series.

The key is to genuinely show interest in the other person through how you listen with both your words (questions) and with your body language.

Delegation Additionally, the skills that you use as you delegate to your team members demonstrates that you respect their “abilities, qualities and achievements” and allows you to “respectfully” help them improve in those areas where improvement is needed. To refresh your memory, check out some of the blog topics we have written on Delegation. Best Boss Bottom Line

You may have noticed that these three skills are related in that flexibility, planning and respect all require that you listen effectively. Make sure that this is your top priority and you will have a much better chance of being seen as a “Best Boss”.

Complexity and Local Rationality

Why do people - like employees and children - decide to break the rules?  Do it their way?  Resist change?  It doesn’t make any sense!  Or does it? It can be frustrating and often perplexing when employees fail to adhere to company policies and procedures, especially when those policies and procedures are in the employees’ best interest. Filing a required document can legally protect managers, but they don’t file it.  Locking out a machine that is being serviced can keep a technician safe from pain, injury and even death, but he regularly services the machine without locking it out.  Your children “know” the rules, but sometimes break them anyway. There is a useful way to think about this issue:  What employees and children do makes sense...to them.

We live, work, play and make decisions in complex environments. It helps to think of our environments as systems with overlapping and interacting components - including people, things, rules, values, knowledge, etc. - which are, in turn, complex sub-systems. One of the principles of complex systems is that the “people” component tends to be driven by the limited information that is available to and impressed upon those people within their local contexts. We make decisions based on our knowledge of what makes sense at the local level, at any given moment.  We call this the principle of “local rationality.”  In other words, our decisions are rational to us because they are based on the information available within the local context (which includes knowledge residing in our brains) at a particular point in time.

As supervisors and parents, we observe behavior that is driven by the principle of local rationality, but we only have limited information about what factors the individual is using to make their decision.  Why did it make sense to the employee to do such a dangerous thing?  Why did it make sense to the child to break the curfew rule?  After all, they know the rules and we have rules to make it clear how they should behave, don’t we?

Rules are only one component of the complex environments that we live and work in.  There are also pressures from other people - including superiors, peers and even you - to make a decision to act in a certain way.  Knowledge of past successes and failures, availability of resources needed to be successful, time pressures, workplace layout and numerous other kinds of factors make it ‘make sense’ for the person. Consider for a moment the last thing you saw a person do that “irked” you.  What kinds of factors could have led the person to do what he or she did?  Why would it have made sense...or did you assume it was because the person was lazy, rude, selfish, or in some other way had poor personal motivation?

As humans, we have a tendency to assume that people do what they do because of personal motivation , and then we treat their “failures” as an opportunity to motivate them to change and make better decisions in the future.  Research shows, however, that actions are often the result of the person’s evaluation of complex input from the environment and may have nothing to do with personal motivation.  For example, we tell employees to work safely, but at the same time push them for productivity, sometimes beyond their ability. The trade-off for the employee is to “cut corners” to be productive because he thinks in the moment that safety is really not at risk and showing you how productive he can be is what is really important.  Your teenager decides to come home late because her date had a couple of drinks and she didn’t trust him to drive safely...and her cell phone was dead, so she didn’t call. It makes sense in the moment, given the information that she had at her disposal.  It doesn’t make sense to you while you sit at home worried sick and imagining all kinds of terrible things.  It doesn’t make sense because you aren’t making decisions in her context!

As parents and supervisors, we need to ask a simple question before we punish undesired behavior: “Why did making that decision make sense to the person making it?”  Why was the decision “locally rational”? If we find out it was motivation, then we can deal with that; but if it is some other factor or combination of factors, then simply motivating won’t work. Look for which contextual factors actually are at play in the decision before you try to change the person’s behavior, and you will be much more successful at creating sustained change.