Good Safety – Bad Process

Articles

Good Safety – Bad Process

13/03/2015

Do you generally achieve good outcomes in your business even though you know your processes are far from ideal? If so, chances are you are over-relying upon your team to compensate for the deficiencies in the system. 

Not unsurprisingly, we like it when our workers are flexible and help us achieve good results, but often blame them when they make a mistake, possibly as part of that earlier flexibility that we liked. 

Error Judgement 

We often hear “we’re only human”, and in the workplace we occasionally see incident reports conclude “human error” as the cause of some adverse event e.g. “he forgot to switch it off” or “she picked up the wrong box”. 

In this article we show that human error is a starting point, not an end point of investigations. If understood and used properly, this approach can rejuvenate incident investigations, and provide refreshing new insights into the underlying causes of “accidents”. 

Error judgement is a social process and is influenced by; cultural, religious, psychological and other factors. Have you ever seen someone over-react to a minor issue, but appear relaxed about other “poor” behaviour? It is likely the person had strong personal feelings about that subject and therefore reacted strongly to that particular issue. 

Similarly, some people accept many risks in their life like; smoking, over-eating and driving fast, but panic if someone mentions; “food preservative”, “shark” or “asbestos”. 

Spare the Rod and Spoil the Child

Some overseas cultures exhibit stronger expectations on individuals to “look after themselves” and to “obey rules”, whereas in Australian business we tend to hold the managers and company almost solely responsible for workplace safety, and allow wider latitude for individuals, who may occasionally forget or choose not to follow some workplace rules. 

Many of these harsh or soft attitudes to individual responsibility are not right or wrong, but are under-pinned by personal beliefs derived from family, local community or possibly from work if the organisation has a strong long-term culture. 

Hindsight Bias 

As already mentioned in earlier newsletters, another important factor which often leads us to a conclusion of human error is “hindsight bias”. 

Studies** have shown that when investigators know the outcome, as they inevitably do, all other possibilities immediately extinguish leaving a simple pathway back to an individual involved in the incident and their now obvious mistake. 

** e.g. Behind Human Error by S. Dekker, 2010 and Human Error by J. Reason, 1999 

Blame Those Closest 

Have you ever been accused of taking someone’s pen or bumping something off a table when you didn’t touch it? Chances are that you were blamed because you were the closest to the event. 

Similarly, in the workplace when a machine jams or a person is struck by a crane, we focus our attention on those in the immediate vicinity, and quickly conclude they made a mistake e.g. human error. However, stopping at this point will not identify the root causes, or prevent it happening again in the future.

Bad Outcome – Bad Person 

Ever heard of an “evil” doctor, lawyer, real estate agent or car salesman who “ripped off” their client? The media like to represent those who cause harm to have sinister motives and methods. This makes it easier for us to hate them and to create more hysteria and follow-on stories. We see this generated hatred between enemies at war, fighting married couples, and increasingly with refugees. 

At home we sometimes jump into this mode and initially accuse the motives of anyone who causes us harm e.g. why did you break my cup? Or why did you crash into my car? 

At work we tolerate poor processes as long as they give good results. Therefore many failures have been deeply imbedded in the system of work and only become evident, if at all, after an accident. 

Similarly, a procedural breach might be praised if it averts a disaster e.g. didn’t follow procedure in an emergency to deal with a previously unforseen circumstance, but a similar action which results in damage or harm is often treated harshly. 

 

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