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Same thinking = same problem = same results
A need for new thinking?
Charles Shoesmith
PsychaLogica Ltd
1
Who we are
• PsychaLogica
• Charles Shoesmith
Consultancy specialising in behavioural approaches to performance improvement
Chartered Psychologist / Chartered Scientist with extensive experience in human factors and behavioural approaches to safety improvement
www.psychalogica.com
2
Unsafe acts associated with many accidents
Behavioural
Safety
“observe, challenge, record”
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Fatalities
Serious incidents
Minor incidents
Near misses
Unsafe acts
Technology, infrastructure
etc Systems,
processes, controls
Behaviour
Bird / Heinrich / Bradley
The behavioural logic
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Behavioural Safety A
ccid
en
t ra
te
• Has BS made a significant
difference?
• Does the benefit outweigh
the cost?
5
Piper Alpha
Texas City
Deepwater Horizon
Same old problem?
6
The Behavioural Trap?
Observe what is easy to observe
Satisfied that we are reducing risk.
Behaviour? We have it covered!!!
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Attribution Theory
The problem is attributed to be a worker behaviour problem
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BBS Limitations
• By nature reactive
• Over simplistic
• Seductive
• Data creates over-confidence
• It’s a “process”
• Reinforces “bad behaviour” syndrome
• Need to maintain momentum
• Ignores thinking
• Takes focus off leadership / supervision
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The behavioural journey
How far have we got?
0
10
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The behavioural journey
How far have we got?
0
10
A long way to go!
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A Historical View
Now Then Future
Behavioural Safety ???
Is it time to move on?
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Moving our thinking on
From Chris Argyris
Current thinking
Deeper thinking, challenging the
assumptions upon which our theories
are based
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Moving our thinking on
From Chris Argyris
Current thinking
Deeper thinking, challenging the
assumptions upon which our theories
are based
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Fatalities
Serious incidents
Minor incidents
Near misses
Unsafe acts
Technology, infrastructure
etc Systems,
processes, controls
Behaviour
Bird / Heinrich / Bradley
Passed their sell
by date?
16
Situation / context
Fatalities
Serious incidents
Minor incidents
Near misses
Unsafe acts
Bird / Heinrich
Has served to
reinforce focus on
unsafe acts
But … a serious
omission?
17
Bradley Curve
Technology, infrastructure etc
Systems, processes, controls
Behaviour
Need for an integrated approach!
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“All accidents are preventable”
Random errors
Systemic errors
R B Whittingham
Challenge the rhetoric?
“Safety is our number 1 priority”
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“We think there is something like the cause of a
mishap … and if we look in the rubble hard enough, we
will find it there. The reality is there is no such thing as
the cause, or primary cause or root cause. Cause is
something we construct, not find.” Sidney Dekker
The Root Cause fallacy?
20
Changing workplace?
Safety improvement
Increasing complexity
Increased and more complex risk exposure
“Behavioural Safety”
doesn’t fit the changing
pattern of work?
21
Behavioural
Safety
Human
Factors
We have to do more than
just change the label
22
Human
Factors?
How we behave
and why
• Errors • Violations • PSFs
How we explain how we behave
• The theories we hold • Human bias
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Human Factors
Levels of Analysis
“Down and in”
Reductionist
“Up and out”
Systemic
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Safety Survey 1
Which are you?
1 I have sado-masochistic tendencies – love pain, enjoy getting
hurt, get a kick out of inflicting it on others
2 I think a bit of pain and minor injury is tolerable, a bit of blood
is acceptable, but I think it is really important to do all I can to
avoid serious incidents
3 I don’t want to get hurt or injured in any way if I can help it – or
to be responsible for someone else getting hurt
25
Safety Survey 2
Which are you?
1 I am a safety liability – make lots of mistakes, take all sorts
of risks, think rules are to be broken, I’m not interested in
how others behave
2 I am fairly normal, make occasional mistakes, can be
tempted to take some short cuts, may not always challenge
unsafe behaviour
3 I am perfect – never make mistakes, never tempted to take
short cuts, always follows the rules, always challenge
unsafe behaviour
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Safety Survey Result
2 I am fairly normal, make occasional mistakes, can be
tempted to take some short cuts, may not always challenge
unsafe behaviour
3 I don’t want to get hurt or injured in any way if I can help it – or
to be responsible for someone else getting hurt
Explain?
27
Remedies
Our conclusions
Our thinking
Our model
Beliefs
Assumptions
A need for new
thinking?
28
Assumption 1
The workforce are not as focused on safety as us managers
Assumption 2
The workforce are as focused on safety as us managers –
their apparent lack of engagement is a product of how we
manage safety
The second assumption leads to a
different approach!
29
“… you will need to shift your
paradigm if you want to make real
progress on safety …” Woods et al
30
More Important Considerations?
• Active safety leadership
• Real supervision
• Safety by design
• Valid learning
• Dynamic risk assessment / situational
awareness
• True engagement
BUT – if it’s working for you, it’s a useful tool.
However recognise it’s limitations
31
• Need to think more systemically about why
things happen
• Need to think beyond the obvious
• Need to surface the propensity for bias in how
we think and explain events
• Need to recognise the problem of hindsight bias
• Need to surface and challenge our current
beliefs and assumptions – change the prevailing
“behavioural model”
32
Behavioural
Safety?
Too simple a solution
for an increasingly
complex problem!
33
• Simple
• Behavioural
• The obvious
• Critical
• Reactive
• Count incidents
• Personal beliefs
• Safety perfection
Old thinking
• Complex
• Systemic
• Less obvious
• Empathetic
• Proactive
• Measure risk
• Science
• Safety vulnerability
New thinking
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