Behaviour at Work and You
It’s not always what we do, but how we do it, which causes accidents
Health and safety advice is relevant to all types of workplace - manufacturing plants, schools, banks and building sites.
These all have one thing in common - people are involved.
Even in organisations where systems are highly automated, people will play some role. People use the machinery, set in train the machinations of the system, keep it going and monitor systems of work and check and re-check methods used.
We have learnt much about how machines function and malfunction from the investigation of accidents; we have also learnt about human failure in terms of behaviour and about the mis-fit, at times, between the human and the machine which results in near misses or accidents.
When we look into accidents, we must look at what has happened to identify causes.
We look at
- what occurred just prior to the accident,
- the series of events which occurred before the accident.
- what happened this time different in some respect to what always happens?
- why the difference this time?
- are there regular risks being taken?
- is the system inherently flawed?
- are accidents and near misses happening as a result of an ineffective ‘system’?
We try to ‘classify’ error. We can do this by looking at:
- Omissions- leaving something necessary out
- Commission- doing something wrong or doing something right, in the wrong context
- Extraneous activity - doing something extra within a task, which is harmful
So, it's not all about disobeying the rules, nor is it all all about a freak piece of 'bad luck'. It’s not about a faulty piece of equipment, although all of these can and do occur and can explain some accidents.
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How to improve our system of work – analyse what we do
1. Task Analysis
There are, obviously, different types of task required of different people at work, each relying to some extent on the other.
In a control room, one person needs to raise the temperature on a piece of equipment by 3 degrees. He/she could do this perfectly, or with an error. What is the task required?
The task requires choosing and pressing a button. An error may be that he/she
- presses the wrong button - a slip type error,
- or that he makes a mistake - the right button was pressed but he/she wrongly assumed what that button would result in
- or a violation, where the employee intended to press that button (not the correct one) as it's a quicker but more inaccurate way of taking the temperature down.
Every task involves some degree of choice and in making that choice, error can occur. Error is dependent on some individual and some organisational and situation factors.
2 Choice analysis - Human error
When considering human behaviour and performance, we acknowledge that people are not perfect and we all make mistakes.
- At certain times of the day (towards the end of a shift, for instance) we may be more likely to make a mistake as we are tired, or are focused on getting home.
- If we have stresses coming from outside the workplace or from within it, we are more likely too to make mistakes – our minds are not ‘on’ the job in hand.
- If we are rushed, or have many other distractions, we may not have enough concentration capacity to properly attend to a task.
In order to address and prevent mistakes - as mistakes can sometimes lead to accidents - the type of error being made needs to be addressed.
This usually involves coming at the issue from two perspectives:
- The individual and his or her characteristics, age, gender, type of learning style, risk taking tendencies etc, and
- The perspective of the wider, organisational culture, management systems and prevailing climate, training given and reward systems in place
Within both of these sub-systems is the matter of the physical plant, machinery, upkeep of machinery and plant and housekeeping.
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There are a number of different classification packages, which have been developed in order to assist in this area of activity. Briefly, they are:
- PHECA - Potential Human Error Cause Analysis and
- SHERPA - Systematic Human Error Reduction and Prediction Approach
Both have manual and computer versions. For instance, PHECA uses a system of prompts for task type and human errors:
- Task - operation, maintenance, check, monitor, communication
- Errors - Not done, part of it done, less than it done, more than it done, other thing (similar) done, as well as, repeated, sooner than, later than, miss-ordered
SHERPA links both task types and error types together to get a combined set of prompts but keeps error causes separately stored
It is important to distinguish between error types and underlying causes.
- An 'error type' should be tied back to defined performance goals and thus a human task - i.e. blade only partly covered by guard.
- Causes will be linked to the relevant underlying stage of the human action chain within a human information-processing model and classified into either a skill, a rule or a knowledge based error.
Examples of the causes of error are the following:
- A wrong mental model - a person pictures the way something is best done and does it that way as it appears immediately the 'right' way, although it is not. The cause of this can be lack of training, lack of re-enforcement of training, out of date procedures, bad modelling
- Risk tolerance - error occurring because a person believes that it's worth it to have a few errors each week as it is made up for by the quicker way of working. This is allowed occur due to poor supervision locally, insufficient training on safety, insufficient reinforcement, both positive and negative and lack of monitoring
- Demand overload - error occurring because a person makes mistakes. The cause is obvious - too many demands, not enough supports and can be referred to as stress-related error
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How to Change Human Behaviour
Two distinct approaches to changing behaviour in order to better manage workplace safety have competed for attention over the past decade.
1. The first of these approaches, behaviour-based safety, focuses on the identification and modification of critical safety behaviours. This is a focused approach using the above method/sequence to classify behaviours which led or might lead to errors, regardless of whether accidents ultimately resulted. This approach emphasises how our behaviour is linked to workplace injuries and accidents. The focus is on producing systematic changes in objectively defined behaviours. It uses Operant Conditioning (the use of consequences to modify the occurrence and form of behaviour) and Reinforcement Theory (shaping behaviour by controlling the consequences of the behaviour)as its guiding psychological principles.
2. The second approach, culture based approach, emphasises the more fundamental importance of the organisation’s safety culture and climate - how management practices and policies shape and influence safety behaviour and operations for effectiveness. With respect to safety, the logic of the culture change approach is that the organisation’s basic values in relation to safety hugely influence the level of effort and specific plans used within the organisation to manage safety. Thus, these activities serve to shape the perceptions held by employees regarding the importance of safety. Their expectations regarding the importance of safe work practices, hazard control, incident reporting are thus set down. In contrast to behaviour change, culture change approaches to safety are more ‘top down’.
Which is best?
The HSA recommends an amalgamation of both approaches. You could express this as starting from the top and working down, while simultaneously, starting at operational level and working across and upward.
Both approaches should be implemented at the same time so that change is not segregated into a ‘pocket’, but rather, change is a shift to a new way of doing and thinking about doing.
Behaviour Modification Programmes (BMod) are generally accepted not to be effective into the mid or longer term unless there is broad, organisation-wide scope to the change.
Implementation of a Behaviour - Based Safety program
The typical implementation of a behaviour-based safety program usually involves 4 well-defined steps.
- First, a set of critical safety behaviours are identified. The focus is on identifying specific behaviours or work practices that result in or have direct potential for producing injuries or other losses. The targeted behaviours are most often behaviours performed by shop-floor or front-line personnel.
- Next, performance goals for the behaviours are determined, and the pertinent behaviours are observed or sampled over some time period.
- Some type of feedback or contingent reinforcement is then applied to increase the probability of desired behaviours and to decrease the probability of undesired behaviours.
- Results are tracked and feedback on performance provided to the relevant audiences within the organisation. Performance trends are recorded and/or plotted, and these data are frequently posted in conspicuous locations in the facility.
The typical implementation of the culture-based approach (which we recommend occur at the same time as the above) usually involves direct feed in to management.
This process quite often involves the use of questionnaires or interviews to assess aspects of the existing culture as it relates to safety. These assessments may involve all employees or they may be limited to managers and supervisors.
This can be referred to as a Risk Assessment , a Safety audit, a health and safety questionnaire or a stress audit for psychosocial /cultural issues. Our tool, Work Positive, provides a measure of respondents perception of how seven aspects of work are managed – demands, controls, supports, relationships upward and laterally, role and change.
There is considerable variation in the types and extent of information collected in these culture assessments. Discussions and formal and informal meetings should also provide feedback to assessors regarding the ‘way things are really done’ at that place of work.
Safety policies and practices can be assessed but only insofar as they fit with the organisation’s core values and assumptions regarding safety.
Collecting information about the availability of safety equipment and safety training, or about the status of hazard control activities, can set a baseline for drawing inferences about the safety culture, but it is not the same thing as assessing the culture directly. Following the assessment phase, most culture change programmes aim at an analysis and planning process to focus the organisation’s safety-related values and vision. This includes identifying action priorities and implementation strategies for improving safety performance within the organisation.
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