Half a dozen things to think about before and during Investigations.
This is designed to be used as a guide for use in investigations and also for leaders in the field. Use it as you explore what is going on that has driven a gap between Work-As-Done and Work-As-Intended.
(All of the concepts below are derived from extensive reviews of the great works of Sidney Dekker, Erik Hollnagel, Todd Conklin, Dylan Evans and Daniel Kahneman.)
To start with, we should always be “defining Safety as the presence of positive capabilities, capacities and competencies that make things go right and not as the absence of things that go wrong”. In my opinion this fundamentally changes the way we view work, the way we view incidents, how we search for blame or reason after something goes wrong, and how we interact with people in the work place on a day-to-day basis.
1. What is the level of Risk Intelligence in the individual and the team?*
Risk Intelligence is the ability to estimate probabilities accurately, whether the probabilities of various events occurring in our lives, such as a car accident, a workplace event, or the likelihood that some piece of information we’ve just come across is actually true. We often have to make educated guesses about such things, but fifty years of research in the psychology of judgment and decision making show that most people are not very good at doing so. Many people, for example, tend to overestimate their chances of winning the lottery, while they underestimate the probability that they will get divorced.
At the heart of risk intelligence lies the ability to gauge the limits of your own knowledge— to be cautious when you don’t know much, and to be confident when, by contrast, you know a lot.
Being able to understand the risk associated with an activity is vital to controlling the risk and getting the task completed in a safe and effective manner. It is just as important in understanding the likelihood of an event turning out as planned as it is to understand the risk of event not going to plan.
In essence, risk intelligence is all about having the right amount of certainty.
Some topics to think about in relation to asking what can go wrong:
- On what basis did the creators of the THA base their assessment of likelihood of an outcome?
- Through conversation, what do the individuals in the team understand by the risks they have described in their THA / Take 5 / “Stop and Think”?
- In conversation with the team, ask “What could go wrong here?”, and was that included in their THA / Take 5 / “Stop and Think”?
- Do you think anyone has ever got hurt doing this task?
o Does this impact their view of the risk likelihood?
- What do you think happened?
- Could that happen to you?
- Does any of the above change how they view the likelihood of the event, or a potential event?
Some stuff to think about in relation to actions after events related to asking what can go wrong:
- Blunt End** – Include the concept (and assessment) of risk intelligence in the Training Needs Analysis process
- Sharp end** – Undertake a series of Field Task Observations / Field Leadership activities that focus on the level of risk intelligence involved in the creation of THA / Take 5 /”Stop and Think”
*Much of this is taken, including the concept and definition, from “Risk Intelligence – How to live with uncertainty” by Dylan Evans – Atlantic Books London, 2012
** ‘Blunt end’ refers to system level actions, ones that work on a broad business-wide level. ‘Sharp end’ actions refer to fixing the problem exactly as it is. E.g. ”Change the working at height procedure to include….”, or “Install a barricade between…..”
2. Resilience*. Resilience is often described as the ability to bounce back, to accommodate ‘unexpected’ change and to absorb uncertainties without falling apart.
Events, according to Resilience Engineering do not represent a breakdown or malfunctioning of normal system functions, but rather represent the breakdowns in the adaptations necessary to cope with the real world complexity:
- Knowing what to do, i.e., how to respond to disruptions and disturbances by making adjustments to normal work.
- Knowing what to look for, i.e, how to monitor that which is or could become a threat in the near term. (in the discussions, not the written theory component, we could include the concept of anomalies here, and also line-of-fire, and seeing the unexpected.)
- Knowing what to expect, i.e., how to anticipate developments and threats further into the future, such as potential disruptions, pressures, and their consequences.
- Knowing what has happened, i.e., how to learn from experience, in particular to learn the right lessons from the right experience
*Much of this is taken from “Resilience Engineering: New directions for measuring and maintaining safety in complex system Final Report December 2008” by Sidney Dekker, Erik Hollnagel, David Woods and Richard Cook.
Some topics to think about in relation to Resilience:
- Does the THA (or JHA, JSEA or JSA et cetera – Whatever you use) or Procedure encourage people to think about which bits of a task people need to really pay attention to?
- Does it encourage them to plan what they ‘could’ do if something goes wrong?
- Does it help them think about what steps they need to do when it does go wrong?
- Is the THA or Procedure useful?
- How do they keep an eye on things that may become a threat in the near future?
- What else could happen that has not been thought about yet?
- What can happen unexpectedly and how do you prepare for it?
- What do you do if something unexpected happens? For example, an interruption, a new urgent task, an unexpected change of conditions, a resource missing, something that goes wrong, et cetera?
- How stable are the working conditions?
- Is the work usually routine or does it require a lot of improvisation?
- Does it encourage them to think what ‘could’ go wrong?
o We should always encourage people to ask “What could go wrong here?” and encourage them to think about it all the time.
Some stuff to think about in relation to actions after events related to Resilience:
Blunt End
o Include the concept of resilience in the Training Needs Analysis process
o Include the concept of resilience in the THA process
o Include the concept of resilience in the Procedure creation process
Sharp end
o Carry out workshops to practice resilience with scenarios relevant to the team of interest
Task / Procedural / Situational Complexity.
Humans are capable of doing more than one thing at a time, but only if they are easy and understandable. We cannot handle too much complexity. Sometimes, we try to put everything into a procedure and what can result is a procedure, or set of procedures, that cannot be clearly understood or followed. What is going on around us also affects how we function. The more complexity involved, the higher the level of risk. Understanding the level of complexity and managing it is vital to the safe completion of tasks.
Some topics to think about in relation to procedural complexity:
- How many procedures or standards or work instructions need to be followed to get the task completed?
- Is the task complex or complicated?
- Is the procedure complex or complicated?
- Are other activities in the area impacting the task?
- What impact can the task have on others in the area?
- Are the procedures et cetera able to be followed?
- How do the team members feel about the procedure? Is it useful?
- Is the procedure able to be followed, exactly?
- How easy or hard is the task?
Some stuff to think about in relation to actions after events related to task / procedural complexity:
Blunt End
o Include the concept of resilience in the THA process
o Include the concept of resilience in the Procedure creation process
Sharp end
o Review (and maybe change) the procedure of interest
Work-as-Done versus Work-as-Intended and long-term Drift
Work As Done (WAD) is the way work is actually done in the field, on the day. It is nearly always different from Work As Intended (WAI), which is the way the procedure or work instruction says to do the job.
Remember that workers consistently create safety in what they do while they do their work. It is from their capabilities, competencies and capacities that safe work is produced. They adapt to suit the conditions on the day. The way the work is done in-the-field on a day-to-day basis does not always match the procedure. In fact, it rarely matches the procedure. Yet, it usually (usually greater than 99.99% of the time) results in ‘safe work’. Failure is extremely rare.
Over both the short term and the longer term, we change the way we do tasks and often that has a higher level of risk and it is only by luck that things have not gone wrong in the past.
Drift explores whether the way we do the task today has changed slowly over a period of time. If it has, has the procedure also changed over time, and has the change, the drift, resulted in a higher or a lower level of risk?
Some topics to think about in relation to Work-as-Done versus Work-as-Intended and Drift:
Looking back over the years or months, has the way we have done this task changed?
- Is the way the task was done the same way for all crews and shifts?
- Is the way this task is ‘normally’ done the same as in the procedure, standard or work instruction?
- Is there a safer way, or a ‘more safe’ way of doing this?
- How comfortable are the team doing the task this way?
- How easy or hard is the task?
- Has the crew done it this way before?
- Did it all go well and as planned?
- Have they ever tried to do it another way?
- How often do you change the way you work? (rarely, often?)
- What else could they do?
- Is there anything stopping them from doing the job the way they want to do it?
Some stuff to think about in relation to actions after events related to Work-as-Done versus Work-as-Intended and Drift:
Blunt End
o Implement a Field Task Observation (Field Leadership) process which includes comparisons of Work-As-Intended (the procedure) versus Work-As-Done in the field.
o Provide coaching to those required to undertake the Field Task Observations
o Build the leaders of those required to undertake the Field Task Observations into great coaches
Sharp end
o Carry out a regular set of Field Task Observations on the activities and procedures of interest to the event.
5. How people make decisions in the workplace
When people are aware of what is going on around them and make sound assessments of how something is, they are more likely to make good decisions about what to do and how to do it.
People decide what action to take and then take it based on how they view the situation.
Their view of the world is the truth, at least to them at the time.
How we assess a situation is greatly influenced by “Plan continuation’, ‘What-You-See-Is-All-There-Is (WYSIATI)’, ‘Answering a different question’ and ‘Intense task focus’.
5a. Plan Continuation
Conditions often change or deteriorate gradually and ambiguously, not suddenly and obviously. In such a gradual change, there are almost always strong initial cues that suggest that the situation is under control and can be continued without increased risk. This sets a team on the path to plan continuation. Weaker and later cues that suggest that another course of action could be safer then have a hard time dislodging the plan as it is being continued.
5b. (What-You-See-Is-All-There-Is (WYSIATI)
We assume, quite subconsciously, that what we see is all that we need to see and the story we make up about a situation is correct.
Because we tend to create a story about how the world is around us and ignore other things. This drives us to jump to conclusions which are then harder to change.
Simply being aware that this is going on helps people ask, “What is really going here that I am ignoring?” ”Is there something that I am missing, or not seeing here?”
5c. Answering a different question
We tend to follow the path of least effort and answer questions without much scrutiny of whether it is truly appropriate.
We see a situation and interpret what we hear, what we see and what is being asked of us in the workplace.
How we hear it is not always the same as how the boss thinks he asked us to do something.
We always put our own twist on instructions given to us. We make it make sense to us, and that is sometimes quite different from what the supervisor thinks he has asked us to do. This can result in people getting hurt.
5d. Intense task focus
Sometimes we are so intent on the job, so focused and ‘into’ the task, that we do not see anything else going on around us. (Watch the Monkey Business Illusion video: https://www.youtube.com/watch?v=IGQmdoK_ZfY)
Some topics to think about in relation to how people make decisions:
Did the task require so much attention that other things were not seen?
- What is the perspective of what is happening of the people involved? What do/did they see and make of it? How do you see it?
- Is the perspective/view of the situation the same for all team members?
- Does the THA/Procedure reflect the team view? (Their reality)
- Is there another way to look at this situation?
- Was it ever imagined that the outcome we have could be possible?
- How realistic are the hazards and events in the THA?
- What decisions were made during the event (or when creating the THA) that made sense at the time, but seem not quite so clear now?
- What was the quality of the task assignment?
- How was the task assigned?
- Did the way those involved receive the task assignment match the intent of the supervisor who assigned the task?
- How intense is the task?
- What impact does the work have on others?
- Were there opportunities during the task to view what was going on around the place? But were not taken.
Some stuff to think about in relation to actions after events related to the way people make decisions:
Blunt End
o Implement a Field Task Observation (Field Leadership) process which includes comparisons of Work-As-Intended (the procedure) versus Work-As-Done in the field.
o Provide coaching to those required to undertake the Field Task Observations
o Build the leaders of those required to undertake the Field Task Observations into great coaches
o Include an assessment of the quality and effectiveness of task assignment into the Field Task Observation (Field Leadership) process
o Emphasize looking around at what is changing into the “Stop and Think” / Take 5 training processes
- Including multiple scenario practices
Sharp end
o Carry out a regular set of Field Task Observations on the activities and procedures of interest to the event.
o Carry out a regular set of Field Task Observations (focusing on the effectiveness of task assignment) on the activities and procedures of interest to the event
o Undertake a series of Field Task Observations / Field Leadership activities that focus on THA / Take 5 /”Stop and Think” usage as it relates to Intense Task Focus
6. Effective core competency training and induction
Inductions and core competency training can play a major role in how safe work is created and how it goes wrong in an incident. It is wise to consider the potential implications of training and core competency inductions relating to the event under investigation.
In this space, things to look into could include:
Was any inductions or training classroom based or more in-the-field, on-the-job based? Was it well connected to the work of the people involved? Did it cover topics such as: the essential basics of decision making, risk intelligence, task assignment, problem solving, communication, handling conflicting requirements et cetera?
Some stuff to think about in relation to actions after events related to core competencies:
Blunt End
o Carry out an audit to ensure the training system, including the training needs analysis process includes:
- Decision making, risk intelligence, risk management, THA, Take 5 / “Stop and Think”, task assignment, task acceptance, problem solving, resilience, communication, handling conflicting requirements, coaching (superintendents and above), investigation skills (e.g 5-Whys), et cetera
Sharp end
o Through Field Task Observations, check understanding of topics covered in core competency training (see above)