Something’s Missing from Behavior Based Safety - The Human Factor

by Ron Ragain, Ph.d.

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.

3 Considerations When Implementing New Policies & Procedures

by Michael Allen

Most organizations have policies and procedures that they expect employees to follow.  One difference between the best organizations and the rest is how those policies and procedures integrate with various components of the organization.  In this blog we will detail three key organizational components that the best take into consideration when evaluating and implementing new policies and procedures.  Let’s begin with an example of the impact of a new policy and its associated procedure in a normal organization.  

Company XYZ was having problems tracking expenses incurred by their employees when they were traveling on company business.  To deal with these issues, they decided to institute a policy that all employees must use a new web-based program to record all expenses, scan receipts, and track payment.  The procedure was straight forward and only required an employee to log into the system using their employee number, input requested information including the vendor name,  total amount spent, and scans of receipts.  When the information was completed the employee simply hit submit and the program took over from there.  The CFO was very excited about this new policy because it was going to make his life and his office staff’s job much easier.  Six month’s later they went back to their paper tracking system because they had continued complaints from employees and they terminated one employee who refused to use the system.  The CFO determined that it was a failure because employee’s were simply too irresponsible to use a new and simple procedure.

So how do the best avoid these types of problems?  Do they simply hire more responsible and competent employees or is there something else?  With the example above in mind, let’s examine how the best organizations look at three key factors to help develop and implement new initiatives, including policies and procedures.

1.  The Individual Employee (Self):


People are very complex and make decisions about things on the basis of a variety of factors which include knowledge and past experience.  People are also typically averse to change because it requires effort and many times is counter to the habits that they have developed over time.  The best organizations want to affect both the knowledge and habits of employees to ensure that they actually comply with new P&P.  In the case of the expense tracker, the best organizations might train employees on the proper use of the software and hardware (computer and scanner) and on the value associated with the new procedure, so that they had the necessary knowledge and skills and were therefore competent and motivated to use the new procedure.  They could also address old habits with email reminders, signage in the workplace, or other means to prompt a break in the old habits associated with the paper tracking system.

2.  Other People in the Organization and How They Affect the Individual Employee (Others):

The performance of individual employees is influenced by the people around them in significant and specific ways.  Two of the common factors exerting this influence are the “help” and “model” provided by others.  When an employee is experiencing difficulty with the execution of a new procedure because of knowledge, skill or resources, getting assistance from a coworker can provide the needed support to create success.  The best organizations create work environments where peer support and assistance is both encouraged and reinforced by management.  Modeling simply means that other people demonstrate that they are accepting change by utilizing and supporting the new policy or procedure.  When an employee sees others using the new procedure to input their expenses without complaint, they are more likely to want to comply with the policy.  If they see other employees, especially the boss, not doing so then they are more likely to see the new policy as a mere suggestion and resist or avoid the new procedure all together.

3.  The “Stuff” Around Us That Impacts Our Performance (Surroundings):

The best policies and procedures are merely good ideas without the surroundings to support their use.  Our employees work in environments that not only include other people, but also physical surroundings such as climate, equipment and the layout of that equipment.  These physical surroundings impact the ease with which people can implement new policies and procedures.  Let’s return to our expense report example.  The operations of the XYZ company are often conducted at remote sites that don’t have  the tools of a modern office.  Employees have laptops but wifi and scanners are only located at central field offices.  Employees rarely spend any significant time in these offices, rather they perform their work out in the field.  The equipment they need to use the new procedure is a resource that they would have to travel great distances, after hours to use.  For these employees, in these surroundings it was just easier to turn in paper receipts and reports hoping somebody else would log it for them.

Managers in the best organizations understand that the knowledge and habits of individual employees, the help and model provided by others, and the surroundings in which employees find themselves are significant factors in determining the successful utilization of organizational policies and procedures.  They understand that without deliberately addressing each of these contextual factors they are likely to fail in the implementation of new initiatives.

Can you work incident free without the use of punishment?

by Michael Allen

I was speaking recently to a group of mid-level safety professionals about redirecting unwanted behaviors and making change within individual and systemic safety systems.  I had one participant who was particularly passionate about his views on changing the behaviors of workers.  According to him, one cannot be expected to change behavior or work incident free without at least threatening the use of punitive actions.  In his own words, “you cannot expect them to work safely if you can’t punish them for not working safely.”  He was also quite vocal in his assertion that it is of little use to determine which contextual factors are driving an unsafe behavior.  Again quoting him, “why do I need to know why they did it unsafely?  If they can’t get it done, find somebody that can.”  

What an Idiot!

I meet managers like this from time-to-time and I’m immediately driven to wonder what it must be like to work for such a person.  How could a person like this have risen in the ranks of his corporate structure?  How could such an idiot...oh,wait.  Am I not making the same mistakes that I now, silently scold him for?  You see, when people do things that we see as evil, stupid, or just plain wrong, there are two incredibly common and powerful principles at play.  The first principle is called the Fundamental Attribution Error (FAE) and, if allowed to take over one’s thought process, it will make a tyrant out of the most pleasant of us.  The FAE says that when we see people do things that we believe to be undesirable, we attribute it to them as being flawed in some way or to them having bad intentions.  They are stupid, evil, heartless, or just plain incompetent.  If we assume these traits to be the driving factor of an unsafe act and we have organizational power, we will likely move to punish this bad actor for their evil doings.  After all, somebody so (insert evil adjective here) deserves to be punished.  The truth is that most people are good and decent people who just want to do a good job.  

Context Matters

This leads us to our second important principle, Local Rationality.  Local Rationality says that when good and decent people do things that are unsafe or break policies or rules, they usually do it without any ill-intent.  In fact, because of their own personal context, they do it because it makes sense to them to do it that way; hence the term “local rationality”.  As a matter of fact, had you or I been in their situation, given the exact same context, chances are we would have done the same thing.  It isn’t motive that normally needs to be changed, it’s context.  

With this knowledge, let’s look back at the two questions from our Safety Manager.  

1. “How can I be expected to change behavior or work incident free, without threatening to to punish the wrong-doers?” and 
2. “Why do I need to know why they did it unsafely?  If they can’t get it done, find somebody that can.”  

Once we understand that, in general, people don’t knowingly and blatantly do unsafe things or break rules, rather that they do it because of a possibly flawed work system, e.g. improper equipment, pressure from others, lack of training, etc., then we have the ability to calmly have a conversation to determine why they did what they did.  In other words, we determine the context that drove the person to rush, cut corners, use improper tools, etc.  Once we know why they did it, we then have a chance of creating lasting change by changing the contextual factors that led to the unsafe act.  

Your key take-aways: 

1. When you see what you think is a pile of stupidity, be curious as to where it came from.  Otherwise, you may find yourself stepping in it yourself.
2. Maybe it wasn’t stupidity at all.  Maybe it was just the by-product of the context in which they work.  Find a fix together and you may both come out smelling like roses.