The problem with inattention and golden rules

I was reviewing two incident reports which involved potential breaches of golden rules (under a load). Now the reports had statements saying the breach occurred and the other saying it didn’t. Overall there was no independent corroborating evidence one way and in both of these cases, punitive action was unwarranted due to the lack of evidence. The interesting part for me though was inattention was marked on the incident report. Now I had conducted my own investigation and talked to those involved and a form of inattention was involved. Inattention to the hazard. I continued reading the report to the corrective actions and this is what I found:

  • Reinforce the golden rules to the people involved,
  • Amend the SWM/JHA to state at no time to go near a load,
  • Walking under loads as the next toolbox topic.

I thought for a moment. If the actions by the individuals was due to inattention of the hazard, by definition they were thinking of something else at the time they moved under or near the load. How does restating the golden rule and work method statement (knowledge and information) to them, deal with inattention or get them to think of the hazard before or when they are moving? Here was the classic safety persons response. I’m generalising I know but most think, like the rest of society, that once a rule has been set it will drive behaviour. If we create a rule it almost magically gets into our brain and the behaviour is sorted. Unfortunately thats not how it works. Our behaviours are influenced by a range of factors and probably least of all a rule that someone else came up with. The ironic part of this thinking is the rule we should be implementing (assuming it worked) is “pay attention” and not “don’t go under a load”. My logic here is if these guys were paying attention (as the root cause was inattention) they would see the obvious hazard in front of them and our primitive defence mechanisms would have kicked in. Remember people don’t intentionally go out to hurt themselves.

The problem with this thinking and corrective action is “inattention of the hazard” is not a conscious decision made by you, rather it comes from our brains need to switch into low energy mode at every opportunity it can find. It is called autopilot and the research shows we are in autopilot for most of the day. In autopilot we are running routines in our brains that have been developed from repeating a task over and over. We do this so the cognitive function (the highest energy user part of the brain) is pretty much on idle and not really doing much apart from saving energy or in this case, definitely not thinking about rules.

Both of these incidents occurred in situations where the individuals where in autopilot and thinking about something other than the load whilst they were moving. So to fix this we need to write a routine into autopilot to look for the hazard before moving. Reprogram in a way that makes this action a habit. An action that is completed without having to use the conscious part of the brain. Like what they did in the first place but with a small addition. Look for hazards, like a load overhead or the tripping hazard on the floor! Easier said then done but if we are looking to equip people with the tools to be safe, then writing a small routine into the autopilot to be scanning or looking for hazards whilst you are moving, is one way to do that.

There is solid science behind how we can write those new routines into the autopilot and I have seen it first hand. Not for this blog but this is the future for safety and providing tools for people. We will continue to remove hazards to the best of our abilities but it is true that we cannot make a hazard free world. Providing the tools, especially the brain and how we can use its full capacity, to keep us away from things that can hurt us.




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