Most organizations, especially those that manage higher risks, have a “requirement” for the workforce to stop work and get help when they are “unsure.” When you talk to managers, they believe this empowerment is what is needed to get people to stop. Sometimes after an incident you hear leaders have a discussion that contains one of these phrases… ”Why didn’t they just stop?” or “They knew to stop, and they didn’t,” or “They know the rules for stopping and getting help and they violated that rule...”
Missing the root cause
These comments stem from a manager’s belief the organization gave the workforce everything it needed, and the worker failed to execute expectations. Some organizations will even state that the “root cause” is the worker “not stopping” [when the managers think they should have].
Some go a step further and call the “root cause” a failure to recognize risk on the part of the worker.
This limited sight view blinds an organization to discover which systemic drivers were in place that made it necessary for the worker to stop and get hep to prevent an incident. In these cases, the organization tries to fix the worker instead of fixing the causes or drivers of the incident. This almost assures a repeat incident of the same or similar type. When a similar incident happens, (usually also the result of someone not stopping to get help, according to the manager) everyone seems surprised. After all we [the managers] told them to “be safer, be more careful, pay more attention and stop when unsure – why didn’t they do it?”
Empowering is step one
Empowering someone, telling them what the expectation is, and giving them the power to use it is only a first step. We know from Equilibria’s research and data on personality tendencies that of the four personality type groupings, each of them has potential limiters directly related to stopping a task or job.1
Three decades of applying human and organizational performance informs us if people are not taught the “triggers” that tell them they are under a specific risk, they often miss the risk until it is too late. After an incident, it’s easy to point out where a worker or crew should have stopped. It is quite different to be in the task with them while the risk is live. Sidney Dekker describes this as the difference between being in the tunnel and standing at the end of the tunnel looking at the outcome and judging how workers should have behaved in the tunnel.2
Enabling: knowing what to do
Enabling the workforce entails a different management expectation. Enabling makes sure the workforce knows what to do (stop and get help when unsure), when to do it (when unsure, or when you’re outside of procedures, programs, parameters, or the situation as you expected it to be, sometimes called OOPPPS) and how to do it accomplish that expectation.
The how actually has two important components to effectively enable the expectation to stop and seek out help.
- First, the worker or crew must recognize the risk. This may come in the form of a physical hazard (heat, electricity, steam, gravity, line of fire, struck by, ergonomics, etc.), or it may come in the form of a performance hazard that increases the probability of error (mental models or performance modes, error traps, etc.).
- Second, the worker or crew must overcome any cultural or individual personality tendency limiters to actually stop and get help from the right place, whether that is a person, document, or physical component. This element is often absent from organizational understanding, education, and development.
Organizations have gotten much better in the last few years at teaching their workforce the physical hazards associated with their work, and when all things go well, the workforce is pretty good at recognizing those hazards.
What limits the enabler of stopping and seeking out help is the organization’s understanding of the performance hazards.
What error traps look like.
What error traps feel like.
What the traps will do to us.
What we can do about them to either mitigate the trap or reduce the probability the trap will produce an error that could result in a consequence.
Simply telling a worker they need to stop and seek out help when they are “unsure” leaves the definition of ”unsure” in the hands of the worker. Performance mode research indicates that this mode has the highest error rate of the three major mental models.3
Critical methods of enabling
In order to enable the workforce to do something as simple as stopping to seek out help when they are unsure, an organization should consider three critical attributes:
- Ensure the workforce has been educated in the physical hazards;
- Ensure the workforce has been educated in the performance hazards;
- Ensure the organizations clearly define the criteria for being “unsure” and stopping work and seeking out help (OOPPPS).
- Barrionuevo, A. & Napper, C., 2017, Equilibria Personality Diversity Indicator (PDI), Assessment Research Report, Barrionuevo Consulting International, LLC. Available upon request – firstname.lastname@example.org
- Dekker, S. 2014, The Field Guide to Understanding Human Error, Ashgate Publishing (Third Edition)
- Reason, J., 2014, The Human Contribution, Cambridge University Press, UK