In his popular books on total quality management, Out of the Crisis and The New Economics, W. Edwards Deming tells us to focus our efforts on optimizing the system. Peter Senge stresses that "systems thinking" is the Fifth Discipline, and key to continuous improvement. And Stephen Covey’s discussions of interdependency, win/win contingencies, and synergy in his best seller, The Seven Habits of Highly Effective People, are founded on systems thinking.

So what is systems thinking anyway, and how can this concept be applied to industrial safety and health? Let’s address this question from the perspective of behaviors, attitudes, and commitment to safety improvement.

Every time I travel to and from the Roanoke, Va., airport on Interstate 81 I’m reminded of the interdependency inherent in a transportation system, and of the great number of people whose driving behavior demonstrates an individualistic, win/lose attitude rather than the win/win cooperative attitude needed to optimize the system. Consider drivers who dart back and forth between lanes, often without signaling, to shave a few seconds off their trip time. They’re thinking only of themselves. It doesn’t occur to them that their inconsiderate, at-risk behavior could cause a crash and shut down the entire transportation system.

How about those slow drivers clogging up the left lane, perhaps because they’ll eventually make a left-hand turn several miles ahead. They also display a win/lose perspective, perhaps unconsciously or unintentionally, which makes our transportation system less efficient.

None of these drivers probably realize their effect on the overall system, a system that works best when everyone follows the same rules, norms, and courtesies of the road. Nor do they see the interdependency, the connection, between driving behavior and the attitudes and emotions of themselves and other drivers. Discourteous and risky driving easily triggers negative emotions in other drivers, prompting them to reciprocate with dangerous actions. It’s a disruptive chain reaction.

When we consider this broad interdependency between people’s driving behaviors, attitudes, and emotions we are engaging in systems thinking. This systems perspective on driving becomes more clear to me as I peer from the window of the plane as it leaves Roanoke. I see the bigger picture below and appreciate the complex interplay between the behaviors and attitudes of the drivers operating each vehicle.

Like my view from the plane, we need a big-picture perspective of our work situation to see the many win/win interdependencies that go into a Total Safety Culture. This is systems thinking for safety. Here are seven principles that emanate from such a perspective:

There is no single root cause

Systems thinkers do not try to find one root cause of an incident or injury. At-risk behavior contributes to 95 percent or more of most injuries, whether intentional or unintentional. But this does not mean an individual’s at-risk behavior is the root cause of the injury. A number of other factors are involved.

Consider environmental, behavioral, and personal factors

These factors are interactive, dynamic, and reciprocal. For example, changes in an environmental factor affect behaviors and attitudes. And behavior change usually results in some change in the environment. When people choose to change their behavior, they adjust their attitudes and beliefs (personal factors) to be consistent with their actions. This change in attitude can influence more behavior change and then more attitude change -- a spiraling, reciprocal interdependency between our outward actions and inward feelings. And an initial change in behavior or attitude can be sparked by an environmental factor.

An organization’s management system is one environmental factor that has dramatic impact on the human factors. A top-down authoritarian approach might dictate certain behavior, but it also creates a negative attitude that might bring about contrary behaviors.

Measure these factors

As I’ve described in an earlier ISHN article (December, 1992), environmental and behavioral factors can be systematically assessed with periodic audits of workplace conditions and work practices. And perception and attitude surveys can be useful barometers of person-based factors. Traditional reactive measures of safety, such as OSHA recordkeeping, have absolutely no diagnostic value to help understand or change system variables that cause outcomes. Keep in mind that outcome measures can be influenced by numerous factors, such as punishment and reward programs that can lead to under-reporting of injuries or near-misses.

Investigate facts, not faults

Because it’s critical to investigate minor injuries and near misses, system thinkers attempt to remove any aspect of their environment that could inhibit the reporting of safety-related incidents. They also add factors to facilitate the reporting and investigating of near misses, first-aid cases, and minor injuries -- incidents that are not typically recorded but could help prevent more serious injuries.

If factors in the system promote a fault-finding perspective toward injury investigation, then information critical to preventing injuries could be stifled. It’s been my experience that the fault-finding perspective usually begins with undue focus on outcomes rather than processes.

Feedback directs and motivates

Rarely if ever does safe behavior have a built-in feedback system to support and direct it. When we take the extra time and inconvenience to protect ourselves or others from a potential injury, we usually do not receive a natural consequence to motivate us to continue. With systems thinking, though, we see the bigger picture and realize that someday someone in the work system will gain directly from our effort.

Systems thinkers don’t need immediate quick fixes to keep them safe. They understand that cause and effect is not necessarily immediate nor linear. Taking the time to be safe today can help develop a personal habit that could pay personal dividends in the future. Or it could teach others by example and protect them now or later from injury. System thinkers realize the special need to add extra feedback to motivate and activate safe behavior. They understand that the natural feedback from convenience, comfort, or a faster outcome usually competes with the completely safe way to do something. System thinkers look for ways to support safe behavior and correct at-risk behavior. They use feedback as a consequence to motivate an individual to continue or stop a particular behavior, and they use feedback as an activator to direct improvement in particular work practices. (For more information on how to give safety feedback, please see my ISHN article last June, "20 Guidelines for Giving Feedback.")

Consistency develops commitment

When we choose to do something, we experience internal pressure to maintain a personal belief system or attitude consistent with that behavior. And when we have a certain belief system or attitude toward something, we tend to behave in ways that are consistent with such beliefs or attitudes. Commitment and total involvement result from this spiraling effect of action feeding attitude, then attitude feeding more action, which strengthens the attitude, and leads to more behavior.

Researchers have found three ways to make an initial commitment to do something lead to total involvement. First, people live up to what they write down, so ask for a signed statement of a commitment. Second, the more public the commitment, the greater the relevant attitude and behavior change, presumably because social pressures are added to the personal pressure to be consistent in word and deed.

Third, and perhaps most important, for a public and written commitment to initiate that spiraling effect of behavior supporting attitude and vice versa, the commitment must be viewed as a personal choice. When people believe their commitment was their idea, the consistency principle is activated. But when people believe their commitment was unduly pressured by outside forces, they don’t feel a need to live up to what they were coerced to write down.

Embrace reciprocity

Simply put, the reciprocity principle is reflected in the slogan, "Do for me and I’ll do for you." In other words, if you’re nice to someone, they’ll feel obligated to return the favor. And consistent with a systems perspective, the favor might be returned to someone other than the original source.

A systems thinker sees this principle as powerful rationale for going beyond the call of duty for another person’s safety. Such actively caring behavior will provoke reciprocity, and motivate the recipient of active caring to return the favor to someone else in the system.

Systems thinkers also realize that how they react to people after doing them a favor can either stifle or mobilize a spiral of reciprocity. When a person thanks them for actively caring, system thinkers do not demean the favor by saying things like, "No problem," or "It was really nothing." Anything that makes active caring seem insignificant or trivial will reduce the impetus for reciprocity. To maintain a comfortable verbal exchange that is not belittling nor stifling, systems thinkers react to a "Thank you for actively caring" with something like, "Thank you for appreciating my effort; I know you’d do the same for me." This shows genuine admiration for the thank-you, and increases the likelihood that more thanks will be given.

As you can see from these principles, a systems approach to achieving a Total Safety Culture forces us to move away from traditional safety management concepts like trying to find one root cause of a near miss or injury, or focusing on outcome-based measures of safety performance. Systems thinking also changes our perspective from linear to circular or spiraling when looking at the connection between activators, behaviors, and consequences. We can see how small changes in behavior can result in attitude change, followed by more behavior change and more desired attitude change, leading eventually to personal commitment and total involvement in the process.

Ultimately, we have interdependent work teams regularly caring for the safety of each other with a win/win attitude and a proactive vision. And it all started with systems thinking for safety.