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.

Unsafe Behavior Is a Downstream Indicator

by Phillip Ragain

At first glance, the suggestion that behavior is a “downstream” indicator may seem ridiculous, because in the world of safety and accident prevention, behavior is almost universally viewed as an “upstream or leading” indicator.  The more unsafe behaviors that are occurring, the more likely you are to have an undesired event and thus an increase in incident rate (downstream or lagging indicator).  This view is the basis for most “behavior based safety” programs.  

Over the past few years, however, there has been a great deal of research in the area of human factors which suggests that there are variables much more upstream than behavior that can help us decrease the chances of an incident.  The human factors approach views an individual’s behavior as a component of a much more complex system which includes contextual factors such as social (supervisory and peer) climate,  organizational climate (rules, values, incentives, etc.), environment climate (weather, equipment, signage, etc.), and regulatory climate (OSHA, BOEMRE, etc.).  Individuals work within these climates, evaluate action based on their interpretation of these climates and then act based on that evaluation.      

Research has shown that individuals, for the most part make rational decisions based on the information that they have at their disposal in the moment.  If an individual “understands” that her boss really rewards speed, then she is more likely to pick up speed even if she is not capable of working at that speed and thus increases the likelihood of having an incident.  While speed of performance is a behavior, it is the result of the person’s knowledge of the demands of the climate and is therefore a downstream indicator.  Evaluating and impacting the climate is thus more upstream and should be the focus of our intervention programs.  When we can impact the decision making process (upstream) we can have a much better chance of creating safe/desired behavior (downstream).

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.

The Safety Side Effect

Things Supervisors do that, Coincidentally, Improve Safety

by Phillip Ragain

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...

1. consistently steps up to the failure and deals with it immediately or as soon as possible after it occurs;
2. honestly explores the many possible reasons WHY the failure occurred, without jumping to the simplistic conclusion that it was one person’s fault; and
3. 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:

1. do not so quickly become defensive when others stop their unsafe behavior
2. focus more on resolving problems than protecting themselves from blame, and
3. freely offer ideas for improving their own safety performance.

Your Culture Gap is Showing

The Gap between your Formal and Informal Cultures is as simple as 'Follow the Leader'

by Michael Allen

Companies often express frustration that their operations fail to live up to the standards set forth for itself.  These companies are essentially describing gaps between their formal (company standard) and informal (what actually happens) cultures.  While many factors contribute to this gap, such as communication, size, number of locations and hiring practices, maybe the single most prevalent force in driving informal culture is the behavior of front line managers and supervisors. 

One important characteristics of a “Best Boss” is leading by example.  On the surface, this seems like a straightforward and common characteristic of many bosses, but let’s look deeper.  How does the significance of this characteristic extend beyond just the personal esteem in which we hold the boss to the point that it actually impacts the success of the entire organization?  

A workplace is an extremely complex and dynamic organism and the workers themselves will only act in ways that make sense to them in the moment.  If the actions of supervisors suggest that certain behaviors are acceptable, even if they fly in the face of company policy, the employees will be prompted to act in the same manner as their leader.  Even worse, if the boss is allowed to pick and choose which rules to follow, he or she is giving unspoken permission for others to do the same.

Let’s look at a specific example.  There is a manufacturing company that has very high safety standards, including the proper use of PPE (Personal Protective Equipment).  The plant manager is well known to show up on the manufacturing floor wearing his Nike training shoes and a hat of his favorite football team.  While he may try to justify not wearing PPE in his own mind, what he fails to recognize is the precedent he is setting for the workforce.  After all, if the boss can wear his tennis shoes on the plant floor, why can’t the others?  Not only is he not modeling the proper standard, he has now set the precedent that the standards themselves are simply suggestions and not to be taken seriously.  

Some of you may be asking yourself, “but what if I make a simple mistake and now I’m leading the entire team down the wrong road?”  There is actually no better time to demonstrate the characteristic of leading by example than when you make a mistake.  Simply stating your mistake and the steps that you are going to take to rectify the situation shows that you do in fact care about the standards of the company, and most importantly, that you are willing to hold yourself accountable to the standards.  The resulting impact on informal culture is that the formal culture will be seen as worthy of being embraced and that everyone is able - especially leaders - and prepared to redirect and be redirected for performance that doesn't match the desired culture.  

We won’t go into detail in this post about what leaders do to redirect bad performance, in themselves or others, but you can click here to read an archived newsletter on that topic.

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.

Because I Said So! The Importance of “WHY”

by Michael Allen

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.

Is Dissent in the Workplace Good for Results?

by Mike Allen

We are inclined to conform to what we believe the people around us expect and value.  This has been demonstrated by decades of research into social conformity dating back to the Solomon Asch Line studies in the early 1950’s.  The crux of this research is that when in small groups, we tend to acquiesce (conform) to the view of the group even if it is not our natural view to begin with.  Think about how this would impact team decision making.  When the majority have one view, even when we have a different view, we are less likely to express that view because dissenters are labeled trouble-makers and most of us don’t want to be trouble-makers.

Dissent does, however, serve some very important functions.  

1.  Dissent boosts group creativity  

While conformity results in fewer variations, creativity thrives on a variety of ideas.  

2.  Dissent can prevent failures 

We conform to what we *believe* others expect and value, but sometimes people are doing things simply because they aren't aware of the possible negative consequences.  

For example, in the safety arena, dissent (which we call ‘Intervention’) helps to prevent undesired consequences by stopping an unsafe behavior.  Imagine that you see two co-workers put a tool into service that you see is compromised.  Speaking up could mean the difference between operations as normal and a catastrophic event.  Unfortunately, the group norm is to “keep quiet”, so you conform and 

don’t speak up and the tool goes into service.  

The key to capitalizing on dissent is to do it right.  If you go about it with a critical tone, unflappable confidence that you are right, or punitive intent, not only will it probably do more harm than good, but you are sure to end up with that ‘trouble-maker’ label.

Consequences of Not Speaking Up

by Phillip Ragain

     What we learned upon completing a large-scale (3,000+ employees) study of safety interventions is that employees directly intervene in only about two of five unsafe actions and conditions that they observe in the workplace.  The obvious concern is that a significant number of unsafe operations that could be stopped are not, which increases the likelihood of incidents and injuries; but this statistic is troubling for a less obvious reason - its cultural implication.

     The influence of culture on safe and unsafe employee behavior is of such concern that regulatory bodies, like OSHA in the U.S. and the Health and Safety Executive (HSE) in the U.K., have strongly encouraged organizations to foster “positive safety cultures” as part their overall safety management programs.  

     Employees are inclined to behave in a way that they perceive to be congruent (consistent) with the social values and expectations, or “norms,” that constitute their organization’s culture.  These behavioral norms are largely established through social interaction and communication, and in particular through the ways that managers and supervisors instruct, reward and allocate their attention around employees.  When supervisors and opinion leaders in organizations infrequently or inconsistently address unsafe behavior, it leads employees to believe that formal safety standards are not highly valued and employees are not genuinely expected to adhere to them.  In short, the low frequency of safety interventions in the workplace contributes to a culture in which employees are not positively influenced to work safely.

     These two implications – (1) that a significant number of unsafe operations are not being stopped, and (2) that safety culture is diminished – compound to create a problematic state of affairs.  Employees are more likely to act unsafely in organizations with diminished safety cultures, yet their unsafe behavior is less likely to be stopped in those organizations.     

(Look for the full-length article in the May/June 2011 edition of EHS Today.)