ESSENTIALS OF SAFETY BLOG 7/14
We cannot see everything. It is not one of the skills a human can have, so do not expect it from yourself or your team. Instead, teach them how to see, how to think about what could go right and what could go wrong and to have the right level of chronic unease.
This is the seventh of a dozen or so blogs covering the Essentials of Safety that I talked about in the first blog of this series. We have covered an introduction – which we called Essentials of Safety, Understands their ‘Why’, Chooses and displays their attitude, Adopts a growth mindset – including a learning mindset, Has a high level of understanding and curiosity about how work is actually done and Understands their own and others’ expectations.
The other blogs in the series are:
- Listens generously.
- Plans work using risk intelligence.
- Controls risk.
- Applies a non-directive coaching style to interactions.
- Has a resilient performance approach to systems development.
- Adopts an authentic leadership approach when leading others.
- Bonus – The oscillations of safety in modern, complex workplaces.
Understands the Limitations and Use of Situational Awareness
It turns out that what we call situational awareness is very poor when compared to what is actually going on in any given situation.
A human cannot see the world in its entirety at any point in time. It is very much like looking through a pair of binoculars at a football match. We can see one little spot in quite a bit of detail but we cannot see what is going on at both ends of the field at the same time. Our view may move around the field but we cannot easily expand our field of view. In this way, we can only effectively perceive a small part of the world at any one time. We need to recognise that we are not capable of keeping an eye on everything in the workspace, nor, in fact, do we need to. The fact that we do not need to see everything at once is especially true as expertise develops in an individual. Think about driving. When we first get behind the steering wheel, we are overwhelmed by the number of things we need to keep an eye on and a side conversation about politics or religion is out of the question. Within a few years, however, we can drive and have an in-depth philosophical conversation at the same time with ease and skill. Two different people will also perceive the same work in the same work location at the same time in two different ways. This often comes up in post-workplace incident investigation interviews. We all see the same world differently.
It is not only in the visual field that we are not very good at perceiving the world. We are bombarded with signals in the workplace all of the time – there is always a lot going on. Not all of the signals, whether weak or strong, visible, tactile, or audible, are important and not all changes are of interest to us. We do, however, need to have systems and signals that tell us when things have changed so that we can process the meaning of the change and decide whether it is of interest to us or not. There are many ways this can happen and a lot of it is engineered like the haptics in an Apple Watch. Some of it is not, like the engine noise telling us when to change gear in our cars. Some of these triggers are very important, and we need to be very careful not to engineer out feedback at the expense of triggers for alerting us to a situation – situational awareness – for this reason. An example is in the modern motor car. We do not get the same sense of speed today that we used to get in cars in the 1970s. (I absolutely knew I was going fast at 120km/h in my 1968 Mini. I do not get that sense now in my Range Rover in 2021.) There is also so much more going on with the vehicle dashboard now than then. In my Mini Minor, I had a speedometer, temperature, and oil pressure gauge and that was it. In the Range Rover, I am now overwhelmed with computer controls, buttons all over the steering wheel, a radio that tells me what song is playing, a moving map that tells me where to go, and a tonne more seemingly arbitrary and disconnected stuff that I usually don’t use or understand. Although I must confess that I don’t think I ever looked at the oil pressure gauge in my Mini.
Pulling strongly from The Invisible Gorilla by Chabris and Simons can help people understand the limits of their situational awareness. If you have not seen the invisible gorilla clip, check it out on YouTube. We generally see far less of the world around us than we think we do. We suffer from not only visual blind- ness to our surroundings but also inattentional deafness. We tend not to see the things we do not expect to see, and we do not hear the things we do not expect to hear. Although we do actually hear them and see them, we just do not process the data into information. This is why telling people to be situationally aware is pointless – it is just like telling people to be safe or to pay attention at work. You need to be very specific about what aspects of the workplace you want people to focus on as people can only focus on a few specific things at a time.
Even given these limitations, situational awareness is practised everyday by everybody – whether they consciously think about it or not. The difference you can create in your business is that you can help your people understand the limits they have as human beings in this space. And that we all have a few tricks up our sleeves to assist us in understanding our workplace surroundings. As an example, we can learn what to look out for, rather than try to look out for everything.
‘What is going on here?’ is a fantastic question to ask about situational awareness during a field leadership conversation or when we sit down as a team to do a TBRA (Task-Based-Risk-Assessment) prior to starting a job. It is an open question and it can illicit responses that can pick up concepts such as sensemaking, mindfulness, situational awareness, drift, chronic unease, outcome bias, inattention blindness, focus, curiosity, observation skills, and seeing both strong and weak signals, just to mention a few that come to mind. Many of these ideas relate to the concept of ‘mental models’.
A mental model is basically a theoretical blueprint of what is happening, what will happen next, and what could happen in the future. A shared mental model is simply a mental model that is shared – a mental model that is pretty much the same across a group of people. A mental model is in other words a representation of the aspects of the situation of interest that the individual or team is aware of – Situational Awareness.
It is a good idea to spend a lot of time on mental models with your people. It is a subject that can be discussed during task planning, during field leadership conversations, and during after-task post-mortems. These post-mortems are when, after a job is done, you talk about whether or not the task progressed in alignment with the mental model the team had of it before the task started, and what we can learn from it.
Encouraging teams to discuss their mental models as they go about their tasks, especially when something intrudes or changes during the task, can also help a lot. Get the team to get into the habit of stopping and talking about what has changed and how it may impact the way they think the job is being done – recognising that change can grab us unawares and that we need to reassess our mental model when that happens. This idea is closely related to resilience, the ability to create foresight to anticipate the impact of changes.
Having an appropriate level of worry about the possibility of failure is a worthy message to train people on as you explore the issues associated with situational awareness. So is trying to be reluctant to draw conclusions and to be sensitive to experiences and expertise, particularly so for the frontline operators. In short, having chronic unease is a lens through which you can operate – being mindful of what could happen – in a positive or negative sense.
Always be on the lookout for weak signals that may point to problems in the near future. Encourage people to stop and resolve differences within the team regarding their mental models rather than just ploughing on regardless of things changing and being different from the original plan.
At pre-shift or at pre-task meetings you can talk about the work and the way it is seen (the team’s mental model). Then explicitly talk about what needs to go right, what could go wrong, and what plans the team may need to have in place to manage those things.
Get people to recognise that each time a routine is undertaken, it is done in a slightly different way and it pays to stop and think about what might be different, what might happen that could be different than before. Then plan for that eventuality.
To help create a mindful approach to mental models you can use field leadership conversations to stop and simply look around in a workplace with the worker and discuss what you all ‘see’ – this encourages the individual or the team to look and see beyond the mundane. The aim is to develop the skill of seeing differently, not just seeing more. This activity also aids skill development in sensemaking. Sensemaking is especially useful when we face an upset in our work, an encroachment into the normal way of doing a task. It helps in these situations to see things differently and hence resolve the problem more effectively and easily.
When you are in the field, you can easily create a conversation aimed at exploring situational awareness based on this broad set of questions:
- What assumptions are we making about how the work is, as compared to how we thought it was when we wrote the procedure?
- Does everyone know their responsibilities and activities for this job?
- What do they think will go right? Wrong?
- What do they think about the procedures?
- Do they have plans for what to do if it all turns south?
- Are they seeing any drift? Any changes in the way they are doing the task compared to how they have done it in the past?
- What happens normally that may influence the ability to follow the procedures?
- What do they have to keep an eye on in the environment of the task? What level of situational awareness is needed, and on what, specifically?
To help people build the appropriate level of situational awareness along with their individual and group mental models, it is worth touching on the topic of foresight with your people. Foresight is a very difficult thing for people to become good at. Spend time working with and talking with your people, helping them understand that the workplace is not 100% ordered and that order breaks down sometimes. This state needs to be accepted as the way things are and that sometimes the things we do and have always done do not work out the same way each time. This means that we need to maintain a sense of chronic unease – even for those things for which we feel we have ultimate control and familiarity. Recognising this also drives us to be ready for an upset and be ready to adapt to the given situation as needed – to bounce back in the face of adversity.
Foresight is all about the ‘what if?’ It’s the chronic unease and resilience engineering piece.
Resilience engineering as it relates to the individual and situational aware- ness is all about being able to respond to events, even before they manifest, as well as monitoring on-going developments and anticipating future opportunities and threats. Importantly, it’s the skill of learning from successes and failures. Resilient performance is all about what people actually do. Viewing it this way, it can be taught. Observing weak signals, having the right sense of chronic unease, a lack of trust in the efficacy of risk controls, and bouncing back from the face of adversity before anything hits the fan is an important ingredient in the recipe for creating safe work.
We need to look for resilient performance on a daily basis. We need to attempt to understand it, learn from it, celebrate it, and share it. A measure of resilient performance is the recognition in the work team that they have a good understanding of the now – their mental model of the work – and that they also have some foresight on what could happen next. They know what needs to go right, what could go wrong, what to look out for to indicate that things are possibly going wrong. They have a plan.
All of these techniques help people and teams to generate the right level of situational awareness in the workplace as they control the risks.
An Example
I was in a large mobile equipment workshop with the superintendent of the area. We had just entered the workshop and I asked the superintendent to stop and look around. I asked him what he saw and what was of interest to him. He responded by saying the obvious things like the fact that the individual truck bays were demarcated with chains and tags, that the workshop was clean and tidy, that all the mobile equipment tag out lock out boards were in place and being used. I asked if there was anything else of interest that he could see. I asked him what he thought about a maintainer working on a Caterpillar 793 truck directly in front of us. He noted that the maintainer was standing on top of the tire. He was about 3.6 metres above the ground. I pushed further about the harness, lanyard, and fall height. Until I pointed them out, he hadn’t seen any issues. But then he saw the fact that the lanyard the maintainer was using was a fall arrest lanyard and was attached to an eyebolt on the top of the wheel guard at the level of the maintainer’s feet. The maintainer would have firmly hit the ground before the harness was of any use. This was very obvious to me as an issue when I walked into the workshop but it was not seen by the maintenance superintendent until it was pointed out to him. It was only then that he clearly saw the issue. This is a classic example of situational awareness at work. We all have filters and we all see things differently.
Key Takeaway: We cannot see everything. It is not one of the skills a human can have, so do not expect it from yourself or your team. Instead, teach them how to see, how to think about what could go right and what could go wrong and to have the right level of chronic unease.