What an Idiot! – In Introduction to Systems Thinking

There’s been a lot of talk in the safety world about systems – whether it be management systems, sociotechnical systems, or system safety. However, it is our experience that most safety professionals, while understanding the surface level of systems thinking, don’t really get the implications. This makes sense, given that while the word “systems” sounds cool, it’s sort of abstract. And even if we understand what systems thinking is about, explaining it to people at any level in the organization (except systems engineers, of course) is difficult.

The problem is that systems thinking matters because the models that systems thinking give us more accurately reflect reality, particularly if we want to understand the behavior of people and of organizations. So if you want to actually have a significant impact in an organization in creating safety systems thinking is our current best bet. The only other viable option we have for understanding behavior is a model that focuses on individual action and accountability, or one that focuses on some other individual element.

Most of us know intuitively that any model that is based on only one piece of the puzzle won’t give us the whole picture. For example, most safety professionals know and understand that simply blaming workers for problems is a bad idea. But, in our experience, that’s where the understanding stops and we often see well meaning professionals fail to put this thinking into appropriate action.

This disconnect between thought and action is especially prevalent when someone is dealing with a hard case – a case where it’s really easy to see where the individual screwed up and it’s difficult to see where the system could have done any better. To illustrate this concept it’s probably best to use a case study of an injury accident involving a crane lift.

So the basic details of the incident were that during a crane lift of a heavy piece of equipment the rigger put his hand on the load to keep it from hitting a nearby wall and had his hand subsequently crushed when the load shifted and hit the wall with his hand in between the wall and the load. Now this rigger wasn’t an ordinary rigger – he was a rigging instructor for the company who taught all of his students to never do what he did. So, we can’t say that the organization didn’t train him and that the employee didn’t know better. What an idiot right?

Let’s pause for a second now and talk about systems thinking. A system is an interrelated set of elements organized to achieve a purpose. So, essentially, a system has at least three pieces – elements, interrelations, and a purpose. An interesting point about human behavior as it relates to systems, is that our tendency is to focus on the elements of the system, because they are typically the easiest to see. However, the individual elements tend to have to least influence on system behavior. Rather it’s the interrelations and the purpose of the system that most dramatically affects the system behavior.

Back to the story, our tendency is to focus on the elements of the system, the individual rigger in this case. To illustrate how this is often not as important as other parts of the system, when the safety officer for the company was asked if another employee in that company who had been similarly trained would have made the same mistake she responded “yes.” So if we changed the element to another one we get the same result – that’s not a problem with the individual, that’s a problem with the system.

What the safety officer captured in her answer was the truth that blaming and disciplining the individual in this case for a clear violation would not fix the problem by itself. Something deeper in the system led to this accident and if we really want to prevent the next accident we need to put on our Sherlock hats and find what it is. And here’s the thing, because the system is organized to achieve a purpose, what we find in the system that contributed to the accident may not be inherently bad. It may be normal organizational decisions and processes that on any other day wouldn’t have led to any problems, but today they worked together in just the wrong way. But if we can understand those interrelations we may be able to find a way to have the system still achieve it’s purpose, while at the same time not allowing the conditions that can lead to unacceptable risks come together in just the wrong way for both this accident and any other accident that may have happened.

Disaster Psychology: Part 2 – Behavior-Based Disaster Planning

In last week’s blog we introduced the topic of disaster psychology and made the point that research in human responses to disasters and emergency scenarios suggests that the concept of an anti-social, irrational panic behavior that people believe is rampant is actually rare. People do not really panic in disasters and emergencies. It is possible, as we discussed, but it’s not common.

So if people aren’t panicking, what are they doing?

Well, we should preface this discussion by saying that human behavior is never so simple as to allow us to completely describe it in a blog post. But, to oversimplify things a bit, people typically respond in pro-social and rational ways following disasters and emergencies. Think back to coverage of nearly any disaster or wide-spread emergency and you’ll often see many examples of this – people helping other people. Sure you’ll also see examples that seem irrational or anti-social, but these are often the exceptions (which is why they are being reported in the news, because they are exceptional) or they are being misunderstood (fear responses and running from disasters are often the most rational behavior given the situation if you think about it. We have to remember that we must define rational behavior using the information the person had at the time of the incident, not what we have in hindsight).

This pro-social and rational behavior is not without it’s challenges. For example, a part of disaster and emergency response that people often take for granted is determining if there really is a threat, known as the “risk identification” phase. Although safety professionals and emergency planners try to drill into people that whenever you hear an alarm such as a fire alarm that means action, such as immediate evacuation, is necessary. People often spend the first few seconds or minutes following an alarm looking for confirmation, particularly by consulting those nearby or with loved ones, before acting (think about the last time you were in a building where the alarm went off as an example of this). The fact is we’ve heard too many false-alarms to take things seriously.  

There are many more subtle but important points about human behavior in emergencies. For more information we encourage you to look at our article in Professional Safety, which goes into more detail and also has references to spur you on to looking at the research. Additionally, a great and accessible book on the topic was released recently that we recommend, called The Unthinkable by Amanda Ripley.

So how can we incorporate human behavior into our disaster and emergency planning? Three areas in particular deserve consideration:

Emergency System Design – The most important element of disaster planning is to identify what behavior you want out of people, and then figure out how to make it easy for people to do what you want them to do and hard for them to do what you don’t want to do. For example, in a fire scenario we want people to move toward the exit, sound the alarm, and use a fire extinguisher if the situation calls for it and they are properly trained. If that’s the case why would you not have a fire extinguisher and a fire alarm station near every exit? To put it anywhere else is making it easy for people to do what we don’t want them to do and hard to do what is right.

Look at signage. Look at procedures. Look at evacuation paths. Use a Prevention through Design Mentality. Consider all aspects of how the emergency plans should work and how you can design the work environment to make the plans work.

Training – A huge mistake people make in emergency training is assuming that telling someone something in a class will make the person do the right things in an emergency. The fact is that, in a manner of speaking, the brain you use in training is different than the brain you use in an emergency. This is the root of the problem people deal with when they talk about the issue with confined space rescue fatalities.

To fix this, we need to try and access that part of our brain that we are more likely to use in an emergency – the instinctual, muscle memory part. The key is to practice, practice, and practice some more! Rote tasks should not require thought. The fact is that in an emergency your brain is overloaded so you need to ensure that cognitive resources are not wasted on simple things like trying to remember where the evacuation meeting place is. Make the training as realistic as possible as well. Don’t be afraid to hit emotional chords as well. People remember emotional events better than non-emotional ones.

You also might consider conducting drills with others in your immediate vicinity. For example, when was the last time you did a drill with your local fire department or police department (e.g. for active shooter scenarios)? What about your neighboring businesses? In a real disaster research shows that the first responders are the “walking wounded,” which means that the people around your organization may be the first responders, and your employees may be first responders for them. Perhaps some coordination, site-familiarization, and even some cross-training is in order.

A last point on training – beware training people inadvertently by giving them the wrong message. By this we mean, always avoid conducting alarm tests without having your employees do the thing you want them to do if it was a real alarm (e.g. evacuate). If you have an alarm test and the only thing your employees are to do is ignore the alarm and keep working, what are you training your employees to do?

Leadership – Leaders in emergencies are not always the same leaders in non-emergency situations. Research shows that leaders in emergencies and disasters are those who are credible (i.e. look and sound like they know what they are doing) and who offer novel solutions to the problems people are facing. This means, if you want good leaders in emergencies make them look the part and train them thoroughly in problem solving so that they learn to think outside of the box, particularly in high stress situations.

Additionally, leaders must be clear communicators. A big mistake organizations and governments have done in the past is either not communicated or poorly communicated risk information to people (usually because of a misguided hope of avoiding mass panic). Make sure your leaders know how to communicate clearly in these sorts of high stress scenarios.

The bottom line is that, like most other aspects of management, rather than creating a plan and hoping that our employees conform to the plan, a more successful approach would be to understand how people will behave in a disaster or emergency and make our plans conform to that behavior. When we do that we often find that rather than being the biggest problem, people are often a solution to many of our problems following a disaster or emergency.

Disaster Psychology: Part 1 – The Myths of Panic

One of our recent blog posts discussed the common mistake that people make when they describe human behavior as “stupid” or something similar after someone makes a mistake of some sort. This line of thinking doesn’t only apply to normal operations, but also applies to human behavior in emergency and disaster scenarios. One of the enduring beliefs people have regarding people’s behavior in these types of situations can be summed up with the word panic.

What is Panic?

One of the problems with the concept of panic is that the word doesn’t have a very good definition. Many times people mean “fear” when they talk about panic. So, for example, if you say that everyone was panicking, that typically means that everyone was very afraid and was reacting to that fear.

Panic is also used to describe what people believe is extreme irrational, anti-social behavior that they see following an emergency or disaster. So, for example, irrational running away (known as flight behavior), disregard for others, and even looting or other criminal behaviors get described as “panic” by some.

This latter definition of panic is the one we want to focus on in this blog, because if this is true it has significant implications. The first definition is very meaningful or surprising (saying that people get really scared in disasters isn’t telling us anything we couldn’t have guessed at). However, if people do typically respond in emergencies and disasters in irrational and anti-social ways that means that people become part of the problem following a disaster and effective planning would require protecting people from themselves. For example, we would see withholding information from the public until they “need to know,” emergency planning would be based on public response agencies saving the day for the helpless citizens, and a need for significant command and control, including law enforcement, to stop anti-social behaviors.

Do People Panic?

Well, research in emergency and disaster scenarios and people’s behaviors shows that panic does happen, but nearly as often as people think. Panic, again, defined as irrational and anti-social behavior, is the exception, but not the rule. Research shows that panic is typically an individual behavior, not a group behavior, and that individuals are likely to panic when three conditions exist:

• There is a perception of an immediate threat,
• The belief that escape is possible, but that the person’s ability to escape is diminishing, and
• The belief that others nearby are unable to help them and the individual does not have the resources to handle the situation themselves.

A couple notes on the above conditions. First, note that it is based not on reality but the individual’s perception of reality. So, one person may perceive an immediate threat in a situation where no real threat exists. But whether the threat exists or not, it’s the perception of the threat that matters.

Second, note that the person must perceive that there is potential to escape the situation. In situations where escape is impossible it is rare to see panic behaviors, such as in a cave in or a submarine disaster.

However, we must stress that panic is the exception, not the rule. To illustrate this, consider the following case studies:

• At the Beverley Hills Supper Club fire in 1977 the National Fire Protection Association investigation identified that there was no evidence of panic. Rather, the majority of the deaths occurred in a room where rather than evacuating a comedian continued to his act while the building was on fire.
• On September 11^th, 70% of all survivors in the World Trade Center reported that they spoke to someone before evacuating the building, taking an average of 6 minutes before deciding to leave the World Trade Center.
• During Orson Welles War of the Worlds broadcast where many reported wide spread panic, 85% of all listeners reported knowing it was a radio broadcast, not a real alien invasion.

Or, consider the following quote by a fire department official following the Oklahoma City Bombing:

Absolute, unrestrained panic was rampant in the building during the first hour to hour and half of the incident. The building had so many access points that it was very difficult to keep anyone from entering.

Look at the examples above and consider the picture that it paints. Do we see people acting in their own self-interest, anti-socially? Or do we see people responding in pro-social ways, trying to engage with and help others or hold on to some level of normalcy?

Consider these questions a bit and feel free to leave your comments and questions. We’ll go further into how people behave and how we can better plan for that behavior in next week’s blog.

The Safety Profession - Not Good Enough

Recently we were watching a TED Talk from Dr. Martin Seligman, one of the founders of positive psychology. He told a humorous story of when he was the head of the American Psychological Association. He was asked to describe the state of psychology in one word, to which he replied, “good.” Next his interviewers asked him to describe the state of psychology in two words, to which he replied, “not good.” Finally, when asked to describe the state of psychology in three words he replied, “not good enough.” He then went on to describe the “good” of psychology, what it has accomplished, but pointed out where psychology is “not good enough,” i.e. needing to improve. (To hear the whole story and his subsequent talk go here).

When we were watching this story we couldn’t help but think of the safety profession. If asked about the “good” of the safety profession I think we could point to many accomplishments. The rates of injuries, illnesses, and fatal injuries at work have dropped drastically. Our profession is more recognized than ever, due in large part because of the efforts of the ASSE, BCSP, and other similar organizations. We all have had at least some part in these accomplishments.

However, when we look at our profession and look not only at how far we’ve come but also at how far we could be we have to conclude that the safety profession is currently not good enough.  This isn’t to say that we can’t get there, but rather to say that, as a profession, we need to do more to further our causes. Here specifically are some areas we think the safety profession is not good enough:

Not Exclusive Enough – Right now there exists no significant industry standard in terms of education, experience, or training for the safety profession. It’s amazing to me how many safety professionals start their safety careers in safety with literally no direct experience or education in safety at all. For example, many safety officers in construction companies were former craftsmen who were injured, couldn’t do their craft anymore, but still could work. So they were made safety officers for the company. We don’t think these people are bad or unintelligent. We just think there needs to be some sort of standard to which one must adhere to enter and stay in our profession. Society tends to expect similar (certificates, licenses, etc.) from other professions, such as hairstylists and plumbers, why not safety professionals?

We do know and readily admit that if we implemented such a standard it would inevitably be imperfect, leading to some qualified individuals not making the cut and some unqualified individuals being called “safety professionals.” Still, the number of unqualified professionals would decrease in any reasonably designed system (or, at least, the average qualification would increase). We would also rather have a system where qualified folks have to work a little harder to prove themselves than have unqualified folks have to do nothing to prove themselves. Additionally, those professions that have clear boundaries as to qualifications tend to have more respect and people tend to pay more for their services as a result.

Too Reliant on Regulation – If you want an example of this one, just ask a safety professional at what point we need to start thinking about protecting workers from falls. Most will respond with some number such as 4 feet or 6 feet. Then ask them what biomechanical calculations they performed to determine that the risk of serious injury from falling from that height was unacceptable and look at the blank stare you get in response. Most people choose fall protection not based on what is safe, but based on what is compliant.  The truth is that there is a significant risk of falling from 0 feet and dying. Obviously your risk is higher at 6 feet, but what about 5 feet? And what about the personal factors, such as health, weight, and age. Don’t those come into play?

Of course they should, but the fact is that they don’t. The problem is that as safety professionals we are spread too thin. We are supposed to understand biomechanics, injury tolerances, psychology, sociology, law and regulation, engineering, physics, and chemistry all at a level that will ensure that bad things don’t happen. No one person can be that good, so we (many times unconsciously) look for opportunities to mentally outsource our thinking. OSHA (or whatever agency we’re talking about) allows us to do that. I don’t have to do the math if OSHA has done that for me. The problem, of course, is when OSHA is wrong and the regulation is not protective.

This is one of those “easier said…” things but as a profession our gut reactions to things should not be to get to compliance and stop there. This, of course, doesn’t mean we necessarily arbitrarily go beyond compliance either. Rather, we take the emphasis off of compliance and put it on risk – are the risks acceptable and as low as reasonably practicable at the level of compliance? If not then we go beyond compliance. If yes, then we stop there. A focus on risk though is what our decisions should be based on, not compliance alone.

Not Evidence-Based Enough – What if your doctor decided to try this new treatment on you that he heard about at a conference and it sounded like a good idea, but he didn’t know of any evidence that it worked – would you be happy if he took that risk on you? Of course not! In the safety profession we are often making decisions that could literally mean the difference between injury or safety, life or death for someone, not to mention the potential economic effects of accidents. When was the last time you looked in the research literature to see if the intervention you want to implement in your organization to see if there was any evidence that it was even effective?

A large part of the problem is that most safety professionals aren’t aware of the journals available dedicated to research in safety and health issues (such as Safety Science, Journal of Safety Research, Accident Analysis & Prevention, Journal of Safety, Health, and Environmental Research, and Journal of Occupational and Environmental Hygiene, not to mention many others). Sure these journals are sometimes hard to read and understand, but part of the reason for that is because the authors don’t have to write articles for the average practitioner because the average safety practitioner doesn’t read the articles. So the academics write information for other academics, learning interesting things about safety, and the safety practitioners are none the wiser.

Of course, these issues (and more) will not be fixed or even adequately discussed in one blog post. But we as a profession need to start the discussion at least. How are we going to get better at what we do (i.e. helping organizations and people create safety on a day to day basis)? How can we be taken more seriously by decision-makers? How can the safety profession be good enough?