We must improve our understanding of the role behavior plays in safety performance improvement #5

Insight: We must improve our understanding of the role behaviour plays in safety performance improvement. We need to improve our focus on organizational behaviour. The decisions of senior leaders drive the culture and systems which in turn drive organizational behaviour and performance. Nobody is in a better position to influence organizational behaviours than senior management. When things go wrong it is natural to ask who is responsible. Unfortunately, some organizations are designed to produce scapegoats. Knowing the result of what happened without knowing the causes that led to it, reveals almost no useful information. A focus on the endpoints does not tell you how to improve. We need to examine the incident from the point of view of the worker and understand why it made sense to them to do what they did.

Comment: A few Human and Organizational Performance principles can be used to drive improvement in this area. Namely, organizational systems and values influence behaviour and how leaders respond to bad news matters. This involves a shift in mindset. Traditionally we begin investigations by reviewing the rules and process that the worker should have used and looking for the rule that was not followed.

As opposed to looking for who is responsible and finding someone to blame, we need to ask, why did it make sense for the workers to operate as they did? What happened and how did we allow this to happen? We need to guard against hindsight bias. One way to do this is to begin the investigation with an open mind and examine how work is normally performed. When this approach is taken we can identify and address the latent errors and organizational weakness that created the scenario for the incident.