November 2017, Vol. 244, No. 11
Features
Error Reduction as It Relates to Human Performance
Increasingly, gas and pipeline operations are implementing an array of safety systems and protocols, including risk, stakeholder and safety management systems, along with robust human capital management programs.
However, in many cases, safety performance is still plateauing and safety metrics, including perception surveys, injury frequency and severity rates are indicating a lack of forward progress.
To better understand this lack of forward progress, it is important to understand the three distinct phases of the gas and pipeline industry safety journey, each having different strategies and unique characteristics. In simplistic terms, the three major phases include:
1)Eliminating intrinsically unsafe conditions: Focusing on physical conditions, tools and equipment, and looking for opportunities to engineer unsafe conditions out of existence.
2)Developing safe work procedures and safety management systems: The specific procedures and systems industries used to reduce the potential for harm when dealing with hazards that can’t be completely eliminated, such as working with sources of energy.
3)Error reduction and human performance: Creating an environment in which the likelihood of errors is reduced and lowering the potential for harm when inevitable human errors occur.
The challenge for most organizations lies in the overlapping nature of these three phases, each requiring very different types of management effort for success to occur. In companies that truly excel in safety, the principles involved in all three phases are well understood and, as such, the organization is able to apply the most appropriate response for the conditions present.
To explain why management’s approach must change between the three phases, it is useful to look at the commitment needed to achieve success in each phase. In Phases 1 and 2, the typical approach to continuous improvement is through analyzing risk, developing action plans and obtaining commitment to completing the required actions.
Management can insist on an audit of pinch points and have guards manufactured (Phase 1). Similarly, management can insist on safe work procedures being written or a monthly safety audit being done, then hold people accountable to the completion of the activities (Phase 2).
Phases 1 and 2 respond well to a commitment to informed activity. However, in Phase 3, management cannot stand in front of the workforce and seek commitment that employees will not make an error in the coming year. This strongly suggests that management must think differently through the various phases of the safety journey.
To date, organizations have typically achieved success in Phases 1 and 2 of the safety journey. However, Phase 3 is where safety performance typically stalls. The third phase of the safety improvement journey, error reduction and human performance, involves reducing the frequency and impact of normal lapses in mental focus and memory. True success in this phase involves strategies designed to positively influence the workplace and employees to reduce the potential for human error.
Common examples include using a pre-flight checklist on an aircraft to reduce the potential for well-trained pilots to make errors arising from the complexity of their tasks, or embedding specific safe work habits, such as applying lock-out, tag-out procedures and keeping personal workspaces free from clutter.
Cognitive Disconnect
Reducing the number of errors made by otherwise well-intentioned employees and the harm that results requires an understanding of the way the mind works. The principles arise from cognitive psychology and the relationship between our conscious, subconscious and unconscious minds.
The conscious mind processes active thoughts and what we need to remember to do. The subconscious mind allows us take action, such as walking to a destination without consciously thinking about each step. The unconscious mind handles activities like breathing while walking. With respect to cognitive psychology, the major implications affecting industrial safety performance are:
- There is an upper limit on the number of thoughts we can maintain in our conscious minds at a single point in time. At work, exceeding that upper limit puts us at risk of an error created by complexity in the workplace.
- All of us experience the inevitable feeling of our minds wandering. In the workplace, no one will maintain perfect mental focus over extended periods of time. This affects how complacency in the workplace is viewed and addressed.
To understand why minds work the way they do, it is helpful to realize that conscious processing in the brain requires more energy than subconscious or unconscious processing. The more conscious processing we do, the more calories our brains require. As a result, our brains are hardwired to move functions that don’t need conscious processing to the subconscious or unconscious levels.
Studies indicate that the average person can maintain four to seven discrete thoughts at a single point in time, but even that requires a concentrated effort. When a person is forced to consider a new thought, one of the previous thoughts is “squeezed out” of the conscious mind.
In addition, if there is no reason to be concentrating on something, our brains are conditioned to stop thinking about it and instead move to a less calorie-consuming state of mind.
However, in the gas and pipeline sector, it is very rare to see considerations made to address and mitigate complacency traps. Instead, common responses to incidents involving “complacency” include: blaming the individual, warning the rest of the crew about complacency, reminding people to keep their mind on tasks or assuming it’s a training problem and retraining. Unfortunately, many of these strategies are flawed.
Blaming an individual who becomes complacent or warning them to never be complacent is unrealistic. Complacency will happen – it’s in our DNA! Furthermore, retraining does not address the complacency trap as it was not a skills gap that needed to be addressed in the first place.
That said, there are actions management can and should take so that complacency does not create a safety hazard. Viable and effective strategies that can mitigate the complacency trap include:
- Engineering out the complacency trap, for example, ensuring a stairwell has consistent stair heights.
- Developing alarms that “alert” people to a higher point of focus.
- Creating methods of checking items that are easy to overlook, such as using staged checklists.
- Building defensive safe work habits, such as doing a field-level risk assessment before every job, even if it is not documented.
On the opposite end of the spectrum, complexity in the workplace arises from several sources, including performing inherently complex tasks, information overload which creates mental complexity, and cluttered workplaces or environments which can create situational complexity.
Regardless of source, complexity leads to errors and hazardous situations in different ways. It can be simple omissions leading to potentially devastating incidents, information overload preventing critical steps of a process from being retained, or working in a cluttered space so people fail to see developing hazards.
Like complacency, there are specific actions management can and should take to mitigate the various sources of complexity. Viable and effective strategies that can mitigate the complexity trap include:
- Breaking complex tasks into components with prompts to remind operators about easy-to-miss steps by implementing phased checklists.
- Aligning information transfer with the needs of the audience and not the preferences of the provider.
- Designing the workplace to reduce situational complexity by implementing programs such as 5S workplace organization methodologies.
- Building defensive work habits; i.e., how carpenters arrange their tools or how operators test respiratory and rescue equipment before use in confined space entry.
Building Safe Habits
An effective strategy to reduce the loss of focus from complacency or omissions due to mental complexity is by building safe work habits. However, in industry, we often see leaders at all levels either reluctant to try to build safe work habits or at a loss on how to coach employees to establish this goal.
Companies often rely on cardinal rules and writing procedures that cover every eventuality. Ironically, some of these additional rules and procedures add to the complexity challenge, this increasing the chance that employees make mistakes.
Conversely, many of the best companies and industries identify the specific habits they expect to see exhibited all the time and strive to build and anchor those habits so that they become second nature. These are coached and re-enforced at every level of leadership to the degree that the ingrained habit is not only exhibited at the workplace, but in almost all aspects of an employee’s life.
This concept of intentionally building safe work habits requires more front-end effort than the typical approach taken by most companies. Too many companies assume that telling a person to do something or providing information in a computer-based training module creates the knowledge leading to desired habits, but it rarely does. Most of us have had to develop safe habits over time through reinforcement, coaching and feedback. It’s not as straightforward as putting on a training seminar.
However, once a new habit is established, it becomes the new normal practice that requires little effort to sustain. If you consider the time and dedication needed to anchor good behaviors, coaching to establish safe work habits is less effort than training, retraining, threatening, and discipline.
Companies that excel in safety performance understand it is incumbent on them to go beyond telling an employee what to do in training. Behaviors must be repeated at a high-enough frequency over a period of time to become a habit.
This reality means that the coaching process always extends beyond most companies initial training programs. As a result, supervisors must play a role in the safe work habit-forming process. On a positive note, there are only four prerequisite coaching requirements essential for supervisors to anchor safety behaviors and create the right habits.
Front-line supervision must spend time in the field, positioning themselves to observe, having courage to speak up and communicating in a manner useful to those being coached.
It is crucial to coach foremen and supervisors to achieve a level where they understand their safety role and have the skill sets and confidence to constantly move the needle forward. Managers and senior leaders, on the other hand, would benefit from a clear understanding of the pros, cons, and limitations of default tactics – specifically safety messaging and formal discipline.
As much as senior management may take the lead on safety strategy, front-line supervision has the largest impact on safety culture, standards and performance. Front-line employees are exposed to the greatest risk, and, as such, their immediate supervisors have the greatest potential to influence employees, habits, conditions, and practices.
By setting clear expectations, holding people accountable, observing what is actually going on and acting on observations, changing employee behavior is a realistic and tangible goal. Front-line supervisors have a specific role in error reduction through leveraging their observations and knowledge of good versus bad habits, and having the courage required to establish and change work habits, including challenging leadership on safety strategies that are not resonating at the front-line.
Authors: Duncan Kerr is an operations executive and managing partner with the Engine Room Consulting Group. He has over 28 years’ experience, with half of his career spent in industry leadership roles spanning operations, engineering, asset management, supply chain, general management and capital projects.
Milan Trpin is a managing partner at the Engine Room Consulting Group. He has worked within multiple industries supporting leader’s abilities to execute and sustain behavioral changes and operational performance improvements. His experience encompasses strategy development, safety, leadership acceleration, process excellence and front-line execution.
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