Note: This is Part IV in a series of posts entitled "Evolving Beyond Behaviourism." To read Part III, please click here. To read Part V, please click here.
"I assert that focusing on the behavior of and pronouncing judgment on the craft worker prevented the critical learning for the people at the root cause and leadership at multiple levels of the organization. People in positions of authority and expertise create the operating structure, context and conditions in which people behave. They have the duty and responsibility to practice both excellent Safety Management and exceptional Safety Leadership."
It is clear that readers on jmj.com and in the Incident and Injury-Free™ (IIF™) LinkedIn group take differing positions on behaviorism (and on my views). In my opinion, the majority of commenters have actually evolved their thinking and their company safety programs beyond the initial promise of pure behaviorism, or the focus on changing observable behaviors to improve safety.
Behaviorism as I define it is a regressive, compartmentalized, limiting way to look at the way human beings work. Behaviorism relates to people as a problem, an unstable variable to be managed in rigid, moralistic ways.
Phrases and terms used in comments on my blogs such as “underlying drivers”, “precursors” and “understanding why” appear to be in tune with my past blogs. Not always acknowledged in these comments (granted they are all brief) is the recognition that underlying drivers, “Why” and so on are not usually observable and/or under the control of the worker.
James Reason asserted more than a decade ago that precursors, not behavior, are the avenue for safety improvement. The US Department of Energy has repeatedly published similar assertions, which have been included extensively in professional safety courses for some time.
Why are we so slow to learn and apply?
I think it is because we are not yet adapting the underlying principle which is completely counter to the behaviorism found in too many companies and their safety HSSE departments. People are the pathway to the solution, not the cause.
Readers have pointed to positive examples of moving beyond behaviorism in their comments. One example is Shell Global Solutions, who, as summarized in one reader’s comments: “… not only considers behaviour, but more importantly looks at the precursors/building blocks (or stimuli) for behaviours.”
Doug Mowle, a colleague of mine, adds, “Shell are moving toward deep causal learning to identify leadership and systemic causes. It is opening up a new conversation among senior managers: ‘How did I contribute to the culture or systems that led to the incident?’ I'm seeing the start of leaders looking in the mirror versus the subtle blame of the people on the frontline.”
Another example is Chevron, whose global report on 2013 Fatalities states “… a continuing progression within industry and Chevron away from citing behaviors and unintentional errors toward focusing on systems and culture over which leadership has more control and responsibility.”
Engineering, Construction and Project firm Bechtel are rolling out “Error Precursors” to expand upon and evolve their behavioral-based “ZAP” program. The above examples are a great start.
I believe that these companies and others are beginning to benefit from another principle of “Safety Differently”. Safety Leadership is distinct from Safety Management and must be as executed as explicitly and committedly as Safety Management.
Most of us are conversant regarding Safety Leadership. We must model good behavior. We must walk the talk. We must be visible and accessible. We must lead the safety culture. We need to be accountable. This is definitely on the right track. But few have taken on safety leadership distinct from safety management.
Furthermore, the language and examples used inside safety leadership are often shallow, providing little guidance or inspiration. In fact, the language used is often not the language of leadership, but the language of management. In my view, Safety is over-managed and under-led. It is time to give the time, energy and thinking to Safety Leadership that we give to Safety Management.
In a recent high-level leadership meeting, a safety incident was discussed. A fire destroyed an operating unit in a downstream petrochemical plant. Some months prior to the incident, a craft worker had taken matters into his own hands, re-working a leaky line with an unapproved technique and materials, sure enough, it failed later.
Root Cause Analysis revealed broken procedure, poor management of change, inadequate supervision, “Golden Rule”, “Cardinal Rule”, “Tenet” violated. Problem solved. Managers in the meeting were satisfied that their safety system, philosophy and consequences were justly applied. The discussion was closed until I spoke up, pointing out the opening sentence in the case: “A faulty pump, known to have chronically leaked for years…”. I also pointed to the fact that no one in that meeting would ever be put in a position to have to resort to fixing a leaky pump in the face of other important commitments.
“So what is the learning for you as leaders? Why did the worker fix the chronic leak the way he did?
Because he was not paying attention, making a ‘bad’ choice? Really?”. Certainly his act triggered the accident. But what smoking gun was that trigger connected to? I assert that focusing on the behavior of and pronouncing judgment on the worker prevented the critical learning for the people at the root cause and leadership at multiple levels of the organization.
People in positions of authority and expertise create the operating structure, context and conditions in which people behave. They have the duty and responsibility to practice both excellent Safety Management and exceptional Safety Leadership.
Why was a chronic leak tolerated?
Perhaps it never made the “safety critical” list or the priority maintenance list onsite or in a company that has faced constant “value-adding” initiatives. Managers assert “safety is a value,” yet are blind to chronic leaks or minor spills. They then blame worker behavior. Incidents like this one call for more from leaders at many levels. Much more.
When “something we accept” (a leaky line) becomes “acceptable” (i.e., “that’s the way it is around here”), this is a failure of Safety Leadership.
Three principles for evolving beyond behaviorism and managing “Safety Differently” are:
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