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.

Why Rule Breaking Makes Sense

Complexity & Rationality

by Ron Ragain, Ph.D. and Phillip Ragain

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.

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.