Behavioural Safety – The moments before the incident

When it comes to behavioural safety, the only behaviour that really matters is the action just before the injury is about to occur. This is the causation discussion I mentioned in previous blogs. In my mind, it is the holy grail. If you can get people to stay away from the hazard the moment just before they contact it, people wont get hurt…period!

Then the question is how do we do that? Deeply understanding what is going on for that person is critical. We have a few ways to do that. The most common is interview and ask. This can provide valuable information but in my experience, people tend to recall what they want to think happened rather than what actually happened. This is where the CCTV can play an important role and source of data, moments before the incident. Reviewing as much CCTV of incidents provides a telling insight into human behaviour.

Having recently spent many hours reviewing video of injuries and incidents, my two main observations are:

  1. Most people are not looking at hazard until it is too late, and
  2. Most people are not thinking about the hazard until it is too late (they are thinking about something else) .

My analysis and experience of this data is that in the moments before the incident, most people appear to be not focussing on or looking at the hazard that eventually hurts them, even though the hazard is visible. They are thinking about things other than the hazard. In terms of our thinking systems, either:

  • our cognitive capacity (system 2) is engaged in something else, limiting it to that task and therefore not to the hazard or
  • we are running routines (system 1) to do the task in autopilot but the routines don’t have looking for hazards in them.

So the program to influence behaviours just before the incident occurs, must address the two modes our brains think in. The conscious and the unconscious thinking (habits). However,  many sturdies and research into our thinking have shown we spend the vast majority of our day (approx. 90%) in the autopilot (system 1 – our habits). Helping to rewrite habits by ensuring your routines contain a look and think about hazards will give you a higher return then any action requiring a conscious thought.

Go and observe human action just before an incident. Look at what they are looking at. See if you can pick whether they are consciously aware of the hazard or thinking of something else. Then if they were thinking about the hazard, whether they could see it? What would be the one behaviour you would like to have just before the incident?

Merry Christmas – pay attention when you drive this holiday season

As I write this I see the national Christmas road toll stands at 3. I am always saddened by the number of people that die over the Christmas break, here in Australia and around the world.

At work we talk about the most dangerous activity each persons will do that day and based on actual incidents, it is without doubt the drive to the workplace and back. More people die on the roads than at workplaces these days. Why? What are we doing at work that we aren’t doing when we drive?

Well in 2015, I want to do something about the road toll. I want to explore what the universal law of personal safety can do for the driver of a vehicle. Not everyone is speeding or drunk when they have an accident. The hazards are there and we need to use the hierarchy of control where we can but what are we doing help drivers. What skills are we training them in and what happens after people get their license. What behaviours do they practice which then become habits. I will explore this field.

So please feel free to share your thoughts by leaving a comment and let’s see if we can start a revolution with road safety. Use the great stuff we learn in the workplace to reduce the devastation road trauma causes to families this and every Christmas.

Have a safe Christmas. Drive with eyes on the path and mind on the job.

How to beat our fallible memory, distraction and confirmation bias

Humans suffer from three major issues that are often found in incidents. The first is a fallible memory. Our working memory has a limited capacity to reliably remember tasks, especially when facing complex environments.

The second is distraction, especially with mundane repetitious tasks. Our ability to paying attention is also limited. Significant studies show for most people our level of attention drops dramatically after about 20 minutes. Even focussed individuals get to about 30 minutes. Once attention drops the potential to be distracted increases, steps can be missed and hence why it is appears.

The third one, and probably the most dangerous, is how we, when we do miss steps and nothing happens, can put ourselves into a false sense of security. We repeat the missed step again and again, nothing happens so it continues to be “ok” to do it. Before we know it, we are habitually missing important steps. Steps that aren’t important until they are!

I’m sure safety professionals, when they look for it, will see these issues everywhere. This is not new. The major question is how do we prevent it?

Checklists, thats how. In key areas where memory, distraction or self confirming step skipping would be catastrophic, checklists have been used with outstanding results. Take aviation for a start. The amount of complex inter-related activities that need to co-ordinated to enable an aircraft to fly for most people incomprehensible. Even highly trained pilots, with years of experience all use checklists to ensure safety. It is fair to say that we wouldn’t have the aviation safety record today, without the ubiquitous use of checklists.

Today, checklists are used again and again with great success in many industries. Medicine, Engineering, Manufacturing, Banking, Transport just to name a few. The reason why they work are:

1. The important knowledge cant be forgotten by your working memory,
2. When the inevitable distraction happens, you don’t lose important data or processes, and
3. A checklist is a visual marker when you miss a step, creating accountability to follow the process.

So if you are looking for ways to beat your brains weakenesses, try using checklists to do it.

Why admin controls will get you hurt!

The problem with administration controls is they rely on your working memory to implement. Typically a risk assessment is completed and the hazards is noted on the JHA/JSA and if it cant be removed, reduced or engineered out (which is many) beware of the hazard is listed in the controls. We load this control up into our working memory and there we hope it will stay for when we need it. Thats where the problem lies.

I was involved in a crane incident where its counterweights contacted a fixed structure. The crane could only be positioned where a slew anticlockwise meant collision. So a risk assessment was completed and everyone agreed the structure couldn’t be removed so the control was to slew clockwise and operate in the 2 o’clock to 4 o’clock arc.

During the cranes set up a wind speed measurement device needed to be fitted to the boom. This meant the boom had to be slewed to the 8 o’clock position and lowered to near ground so it could be fitted. Well the operator had a lot on his mind that morning and what had been discussed, agree, reinforced and put into the operators working memory went straight out again once he started using his working memory for other thing, like crane setup. He basically forgot what had just been discussed. Ever have that happen to you?

Well working memory is limited. Most people can only remember 5-7 things at a time, so once you attempt to use working memory for more than that something has to be dropped off. In this incidents case it was the control of “not slewing anticlockwise”. He hit the structure!

So whenever you see controls that rely on remembering a newly written down admin control, be wary. Our memory is prone to forgetting and that can get someone hurt.

How rushing and frustration leads to inattention

When we rush or get frustrated, our ability to process the number of things in the cognitive part of our brain diminishes. Our brain reduces its focus to what it thinks is important. Unfortunately that may not be the hazard that unexpectedly pops up in front of you.

Let me give you an example. Today I investigated an incident involving an experienced driver that struck a small white pole about 600mm high. The driver noticed the pole when he parked the car about 2 minutes before hand but when he went to move off he didn’t see it or remember that it was there, hence contacting it.

We had been discussing the incident for a couple of minutes I asked “What were you thinking at the time you starting moving the vehicle?”

He said “Well, I had just been called back to the workshop where I’d already been, awaiting for this guy to turn up”. He continued but his voice raised “Now, he calls me to tell me he’s there and ready for me and tells to me come now!”. He quickly calmed down and reflected on his thoughts and said “I suppose I was frustrated that I had to go back there and I’ve got a lot to do. This bloke has already wasted half an hour of my time!”.

So I asked “do you think you were rushing?” He said “Shit yeah and pissed off too!”. I could see his emotional state.

When we are in this state, our body pumps out adrenaline. This causes your focus to narrow to the task that is occupying your emotional centres in the brain. In this case, having to repeat a process that has already wasted valuable time for an individual. Time he perceives he doesn’t have lots of.

This is a common lead up to safety incidents. When an event occurs that takes us out of the logic and rational part of our brain, into the emotional part and with a narrow focus. This is a dangerous phase. If something unexpected pops up that requires cognitive resources to sort out……then you better hope that there isn’t a lot of hazardous energy involved.

So what can you do? Well basically there are two options available. One is to recognise that you are rushing and/or frustrated and try to calm yourself. Typically this requires cognitive resources to do, which we have just said are limited.

The second option is build a routine into your brain that triggers when you are in the emotive state. A ‘look for hazards” or “eyes on path” type of automatic routine (habit). This routine will run automatically without you having to think about. Therefore cognitive resources are not required. I call these keystone habits.

So be wary of people that are rushing and/or frustrated. They are likely to not be paying attention to you!!!!

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.