Expert Commentary

Applying Systems Thinking to Safe Operations

Let's start with the premise that one of the primary focuses of an organization's safety function is to avoid having accidents and keep its employees from getting injured at work. The primary focus in accomplishing this is and has been to somehow change the worker's behavior. This is primarily addressed by training, additional training, and refresher training. In some cases, the injury rate might change or certain particular injuries may diminish for a time period, but, despite all the training provided, workers continue getting injured year after year. It would seem that, after a number of tries in this particular intervention practice, organizations would conclude that the training effort is less than effective in "fixing" the problem and that a better approach to addressing it probably lies elsewhere!


Construction Safety
February 2015

Another common practice includes inspections of the work site to ensure that the workers are working safely and/or following company safety rules. This does make some impact, but it is not highly effective because the safety practitioner—and not site supervision—is usually engaged in the safety inspection effort. The safety practitioner is on site a small fraction of the time, is not responsible for driving performance, and therefore has little overall impact on the outcome. This particular intervention would garner "better" results if the organization made supervision responsible for overseeing safety performance. Though this is a better approach, it too is not highly effective because policing takes the supervisor's focus away from managing overall performance, and, more importantly, it is not an effective way to manage safety performance.

Production Procedures

In some cases, the organization writes procedures for how the worker should do the work despite the hazards faced. The expectation is that, if the worker follows the procedures, he or she will avoid getting hurt while doing the work. This, also, is an ineffective approach because of a number of inherent weaknesses. The primary problem is that management is not willing or able to identify the risks associated with the task design, demand, or work processes involved and tries to come up with some "workaround," which they expect the worker to follow. This method depends on the worker continually following the procedures and dealing with the hazards, which is a somewhat unrealistic approach. Management should try to eliminate the risk or try to change the resulting outcome so that the injury does not happen or the negative impact is greatly diminished. Or, better yet, they should redo the task design, demand, or process and, as a result, impact the risk and error-proof the work.

Because of the high level of variability in the construction work process, error-proofing has limitations. Construction ultimately is a production process, but it usually produces unique products in unique locations, which makes it different from manufacturing, which produces multiple somewhat identical products in one location. But notwithstanding, it does have value and will reduce the risk faced by the construction workforce and also make operations somewhat more efficient while diminishing the potential for accidents and injuries.

System Thinking

System thinking is a more encompassing, holistic approach to problem solving. This approach demands a robust understanding of the relationships and behaviors inherent in the elements that characterize the whole work system. In traditional safety management, the interventions devised to reduce accidents are focused primarily on the worker. This approach ignores the fact that workers have to function within the operational systems in order to do their work, and this complex work system influences the choices they make as well as the way they go about performing their tasks.

We have to take a look at an elemental graphic of organizations (see Figure 1). At the operational level, the organization has an output. This is generally a product or service. In construction, it is the completed structure. The organization then has internal systems with which to create the output. This in construction is plant, equipment, processes, technology, etc. And they have people to operate and oversee the systems so as to create the output. These are the field staff and crafts persons.

Figure 1: Elemental State of Operations

Elemental State of Operations

The operational element is the organization's unit that produces the output. The organization also has systems that support the operational unit (see Figure 2). The organizational systems include various specialized departments such as accounting, estimating, scheduling, cost control, procurement, human resources, legal, risk management, safety, etc. They also have policies that establish expectations that guide as well as govern organizational behavior. And they have (people) management who plan, organize, direct, lead, staff, and control as well as devise and oversee the organizational systems so as to oversee, enable, energize, and support the operational unit.

Figure 2: Influence of Organization on Operations

Influence of Organization on Operations

As the operational unit goes through its production process, it creates side effects or discrepancies, which can be characterized as outcomes of the work process. The outcomes can be portrayed in three major classifications (see Figure 3). The output has an inherent value, quality, or utility. In other words, it either meets the customer's needs or it does not. The process that produces the output is either efficient or it is not. This is an extensive area that includes such things as process integration, procedure administration, supply chain management, practice oversight, suitable communication, etc. And the workers who engage in the task perform it either safely or unsafely.

Figure 3: Output and Possible Resulting Outcomes

Output and Possible Resulting Outcomes

Focusing on the Workers

All these outcomes are a result of human endeavor. In other words, these outcomes are a side effect of the overall production process. If the systems are designed well and are aligned to function seamlessly, the value and quality of the resulting output should meet the owner's expectations. If the processes are designed to produce the output efficiently and the planning as well as execution is aligned, the output should be produced efficiently with minimal wasted resources. If the task is designed properly, the production expectations are reasonable, and the workers assigned to perform the work are knowledgeable and capable, they should be able to perform their work safely and not get injured in the process. This speaks to the overall effectiveness of the work system the organization has created and is utilizing.

The worker does have some impact on the potential undesirable outcomes. So, it is important that management have a process that ensures that the "right" worker is selected for the task. The supervisor makes sure that the proper resources are available and the worker has the proper knowledge, capability, and information to perform that task. The supervisor must also make sure that the worker's capabilities match the task demand and that the worker will be able to complete the task within the allotted time. Another important aspect of performance is the worker's motivation to perform the task in such a manner that it successfully meets the positive aspects of the three attributes of the output. Here again, the supervisor has some influence in creating a work climate that is intrinsically motivational.

Granted, the worker may not follow good work practices or pay attention to the task and may use poor judgment or make a mistake and get injured as a result. However, it is a proven fact that humans make mistakes, and since those mistakes have a negative impact on the organization, it would seem rather obvious that management should make a concerted effort to make the work as risk and error free as possible so as to minimize or eliminate the possibility of an injury occurring. But, in traditional safety practices, this thinking is not followed, and what is done is trying to change the worker's behavior by training, using personal protective equipment and various engineering controls, posting signage, threatening disciplinary action, offering incentives, or devising procedures rather than trying to address the underlying risks associated with the work.

Since people have to work within the context of systems, and people are prone to make mistakes, the obvious approach to this problem is to try to address it from a different perspective. Rather than a reactive approach, which is the traditional way safety addresses this issue, the organization should take a proactive approach by anticipating barriers to performance, system discrepancies, and process problems and work toward eliminating them before they cause injuries. Appreciating that plans may go awry, organizations should have some general contingency plans ready for field personnel to use or build upon, if and when needed, to assist them in problem solving more efficiently and thereby reducing potential risks that may be incorporated into the operational process due to having to deal with problems while still maintaining the schedule, which increases pressure and stress. This is a more effective approach to dealing with potential problems.

Focusing on the Systems

In general, the more rational approach would seem to lie in focusing on fixing the system and spending less time and effort in trying to change the people's behavior. This then gives it an operational focus rather than a worker focus. This undertaking looks at the inner workings of the processes and how they create discrepancies, which in turn creates risk. It also looks at how this impacts the worker's functioning within the work system context for solution to the injury problem rather than writing safety programs that try to deal with workers who have accidents or are caught working unsafely. (A quote from Albert Einstein: "We cannot solve our problems with the same thinking we used when we created them.")

The operational as well as the organizational systems have subsystems. The subsystems interact and affect each other. These system interactions create discrepancies, which are divinations from design or intent. People work with these systems, and, as a result, they may impact the workings of these systems, which in turn may create additional discrepancies. Some of the discrepancies may compensate for other discrepancies, thereby reducing their negative impact, while others may have an accumulating effect and increase the negative impact. The combined discrepancies create risk within the work environment.

The workers at the "sharp" end (where the actual work is performed) have to function within the work environment and effectively deal with the residual risks. Some of these risks are tolerable (fall within an acceptable envelope), some are manageable (the worker can deal with or compensate for them), and the rest may cause process failure (if the worker is not able to effectively manage the risks involved, there are negative consequences). These process failures impact production, quality, safety, customer relations, profits, or any other target or standard organization used to measure performance.

So, to effectively address these organizational risks to garner improvement, one has to have a robust understanding of the systems, the people, and their operating interrelationships. Performance improvement can be addressed at any level in any area (see Figure 4). Effort expended at the sharp end (task/work) will take less effort and will provide limited improvement, which, in all likelihood, will also not be sustainable either. Greater effort will be required as we go deeper into the workings of the organization, and, of course, the gains will be greater and will be sustainable to a much greater degree.

Figure 4: Functioning of Organizational Elements

Functioning of Organizational Elements

Project Delivery

Traditionally, safety practitioners' interventions fall in the execution chain, primarily focusing at the sharp end (task), which involves addressing hazards in the work environment as well as looking at the worker's behavior and trying to somehow modify it. As we know, the results of these efforts are less than stellar. Bureau of Labor Statistics figures indicate hundreds of fatalities and many thousands of injuries on construction work sites every year. So, to "fix" this serious drain on resources, we need to look upstream at the project delivery processes to identify systems approaches to improving performance outcomes in this area.

As to the worker: in construction, not much evaluative thought is given to task assignments. We need to make sure that the worker assigned to the task is physically capable and has the requisite experience required to effectively perform the work. The field staff must make sure the worker has the appropriate information necessary to accomplish the task. Supervision must appreciate that the workers need to know and understand the importance of doing what they need to do in a way that meets the organization's requirements and job's expectations.

The safety practitioner can impact the task risk by evaluating the task design. This invariably is left up to the worker, who may or may not be competent enough to address this in such a way that he or she meets production expectations and performs the work safely. This can be ascertained to some degree before assignment, or, if that is not practical or is missed, supervisors should observe the activities to make a determination if there is a need for any intervention. This is simple and does not take much time but may have a substantial impact on improving results. This should be an expectation of supervisors and an operational practice.

Another area of risk that the safety practitioner may impact is analyzing the task demand with project staff. This may lead to a number of actions. One is influencing the selection process that matches the "right" worker to the task. Another is changing the production goal or the number of workers assigned to perform the work. It may cause the rethinking of the way the task is planned to be performed. It may highlight equipment needs, means, and methods utilized, etc., making the task safer and the work process more efficient while improving production.

Proper Planning

Planning is probably the easiest area in which to address the operating risks so as to garner some improvement in safety outcomes. Planning is an integral part of construction, and the schedule is a key driver of the project delivery process. Usually, planning in construction primarily focuses on productivity. This process can be slightly modified to include a discussion of potential hazards faced by the workforce. A robust discussion should not only identify and deal with worker injury potentials but have a significant impact on streamlining the production process.

Planning can also ensure that the proper equipment is available, sufficient material is at hand, accessibility is addressed, the area is "made-ready," and many of the potential barriers are identified and dealt with beforehand, reducing the potential for "firefighting management," which plagues many projects on a regular basis. Another thing that could prove useful is doing a "what if" analysis, identifying potential problem areas, and devising a number of contingency plans that will be ready and available for the crews if and when a problem arises. This will provide them with some ready approach to problem solving rather than having them try to resolve problems from scratch and taking their attention away from their primary goal.

Other things that can be addressed are timing, organization, layout, logistics, the task activity plan, objectives, and any other relevant factors. Some of these suggestions are probably being done on some sites, but, as long as the process is not formalized and rigorously implemented with sufficient oversight and control, it will happen haphazardly. A haphazard process cannot be measured, managed, or improved. Nor can it be implemented uniformly throughout the organization.

Assigning the "right" supervision to the project is another important element in managing human performance. Supervision should have the proper technical, administrative, and people skills to manage the workforce effectively. They have to be able to plan, organize, lead, staff, and control. They also must be able to direct the crews, coordinate the effort, solve problems, make good decisions, have good judgment, anticipate obstacles, remove barriers, effectively delegate, and motivate the workforce.

The other two elements (chains) in Figure 4 are the work climate and systems sphere, which are generally not formally or systematically addressed in construction in relation to operational efficiency and/or effectiveness. Both these areas can play a significant role in improving overall performance of the project and organization. There are also the foundational elements of culture and leadership to consider. These will be covered in a future article.


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