People, in performing their work, generally do things that usually makes sense to them at that point in time and place. The decisions to do something are usually based on their understanding of required task performance production goals. It may also be influenced by the unavailability of the proper required tools or equipment, safe access, and appropriate information. It may also be the result of a mismatch between the task demand and the worker’s knowledge, expertise, and/or capability. 

Much of this could be addressed or minimized through the supervisor’s appropriate operational preplanning, careful organizing, and befitting directing, in order to achieve a proper balance between the task demand and worker’s qualifications. This is primarily the result of a shortcoming in the organizational, operational (policy, processes. procedure, practices), thereby creating systems driven short comings. 

The problem may be driven by some shortcoming on the worker’s part. Some of this could be minimized through supervisory intervention, mood, level of attention, and understanding of the way it is done of the situation. Therefore, to truly understand why and how things happen in the way that they do, we need to have an “inside perspective.” That is, we need to try to see things as the person involved saw, felt, and understood things which lead to the decisions they made and actions they took resulting in an unanticipated or unsatisfactory outcome. Much of this falls under the “local rationality principle.”

Risk and Accidents

As an industry, construction tends to have more accidents per man hour worked than many of the other industries. As a result, the organizations involved in this industry must do a better job in understanding and managing the risks associated with the work. Looking at the “domino effect theory” of accident causation one finds five basic sequential elements. 

1. The situation or condition the worker is in 
2. The worker’s decision and/or choice made
3. The inappropriate response (act or behavior)
4. The resulting accident (consequence)
5. The injury, outcome, or loss (result) 

An accident investigation typically is conducted after the fact to determine the what, where, when and how things progressed to find a way to keep it from happening or occurring again. This process tends to put the primary focus on the worker and his/her behavior.     

• Where was the worker working
• What was the worker doing
• How did the accident happen 

Most construction accident investigations are completed shortly after the event and usually attributed to some shortcoming of the worker’s part. Some of the more common reasons given for the accident may include:                                                                                                          

• Frustration with the task, not using the proper tools or improperly handling the materials, lack of proper knowledge, poor work practices, inattention, rushing, lack of focus, fatigue, etc.
• Rushing to get done, not following the correct safe way to perform the work. Possibly getting behind and wanting to catch up.
• Improperly dealing with physical conditions. Possibly being fatigued which slows the worker down or makes them more vulnerable to making an error.
• Complacency on the part of the worker. False sense of security, or their ability to deal with the situation. A macho attitude, resulting in inattention, not following sound work practices, or safety procedures, Taking unnecessary risk.
• Inattention and as a result “working in the line of fire,” putting oneself at risk. 
• Just plain bad luck. 

Another thing to consider is that other workers in similar situations have successfully completed similar tasks. So, this worker could have acted differently and not caused the accident. The perceived reasons may be that the worker is inexperienced, incompetent, incapable, inattentive, lacks knowledge, has poor judgement, is complacent, may have forgotten or failed to use the applicable safety standards. As a result of such thinking, human error, inappropriate action, at risk behavior, becomes the starting point of the investigation.

Human Action or Error

An adverse effect or accident can develop over a matter of minutes or possibly even seconds, yet the analysis may take many hours, sometimes days or even longer. The ultimate determination of the cause is generally based on what we know after the fact rather than what the person knew, thought or felt at the exact time and place of the event. The event may be triggered by some simple factor or event, but the analysis is made using complex tools and techniques. 

The decision made before the event’s occurrence may have been made in a matter of seconds with limited information while the evaluation made at a later time or date has the benefit of unlimited time and a plethora of facts resulting from hindsight. So, the system is predisposed to ultimately focus on the worker as being the cause of, or contributor to the unfortunate event.     

Assuming the worker is a rational person who wants to stay employed and certainly does not want to get injured while performing the work, then the fundamental question should be what caused the worker to make the decision and then engage in the behavior that led to the unexpected, unintended, and unwanted event. 

The worker’s primary objective is to perform the work and meet production expectations so as to stay employed. So, all decisions made are the result of trying to meet the above stated goals, as well as deal with the situational factors that existed at that point in time.

It is evident that rational people do things that make sense to them at the point in time that they make decisions related to what they were engaged in. Decision-making is a cognitive process and may include such things as: task goals, available information, any perceived expectations of supervision associated with the given task, the person’s focus and attention, the general understanding of the overall situation (work climate and organizational culture). Obviously rational people would not do things that did not make sense to them. For people who want to better understand this concept, they should read Field Guide to Understanding Human Error, written by Sidney Dekker. An important concept that is fully discussed in this book is that of local rationality.

Dekker contends that local rationality explains the idea that during the events leading up to accidents, or the aftermath of an unwanted negative event, people are acting in a way that makes sense to them, given their mindset, the situational context, their past experience, knowledge, capability and readiness, availability of relevant information, pressures they are under, task-related goals, objectives, agendas, politics, as well as the task’s demand and design. For some more detail on task design and demand, see my article in last month’s ISHN issue on employee morale. By understanding local rationality, people investigating unwanted negative outcomes (accidents), get a much better picture of “why” things happened the way they did leading to the outcomes they got.

Local Rationality

An important consideration underlying decision making involves cognitive factors. Different aspects of cognition will be relevant to different conditions and/or situations. At work people pursue goals that involve taking action. To do so they must assess conditions, make decisions, then take the appropriate and necessary action usually within a relatively short period of time. Decision-making requires information. Much of that information available to people is the cumulative mentally stored data which comes from daily experiences. These experiences are unique to every individual. So, all the elements of this process along with the person’s perceptions of their workplace, their relationship with others, their aspirations and values are bound by their local reality and rationality.

As workers perform their task, they invariably affect and change some of the physical conditions. This requires that they continually assess the changing conditions and make the necessary adjustments as required in order to successfully complete the task. Another overriding factor is that conditions are never exactly the same. So, if multiple workers successfully completed a similar task, it does not ensure that the next worker will successfully complete it as well. Local rationality thinking is not to say where people went wrong (that much is easy). The point is to understand why they thought they were doing things right; why it made sense to them at the time.

Conclusion

A central assumption for local rationality is that people tend to come to work expecting to do a good job and avoid creating an incident or hurt themselves, or others. Local rationality holds “what people do makes sense to them at that point in time — given their goals, situational focus and knowledge — otherwise they wouldn’t do it. Often, readers and analysts apply their rationality to a situation. This rationality has the benefit of hindsight, full overview of relevant factors, and plenty of time to analyze and reflect. All too often “behavior is contrasted against the investigator’s reality, not the reality surrounding the behavior in question at the time.”   

As supervisors, we need to ask a simple question before we criticize or punish undesired behavior: “Why did making that decision make sense to the person making it?” Why was the decision “locally rational?” If we find out it was motivation, then we can deal with that; but if it is some other factor or combination of factors, then simply motivating won’t work. Look for which contextual factors are at play in the decision before you try to change the person’s behavior, and you will be much more successful at creating sustained change.