Expert Commentary

Managing System-Driven Incidents—A Business and Performance Approach

Safety or the lack of safety is an outcome of human performance. Human performance creates the outputs of organizations in terms of products or services. Much of the output falls within an acceptable range, but some of it does not.

Construction Safety
August 2011

Those that do not meet the acceptability standard can be considered the organization's operational "defect rate." The "defects" can be broadly categorized as falling in the quality of the output (fitness for use) or the efficiency of the process (such as waste generation, underutilization, under-optimization, etc.), as well as damage, losses, or injuries the workforce suffers. All of these result in some form of loss, which adversely impacts the organization. Safety viewed as a human performance issue and the factors that influence that performance and its resulting outcomes constitutes a different perspective on safety and its management.

Traditional Safety Practices

Traditional safety management involves creating a program that, for the most part, follows the Occupational Safety and Health Administration Safety Standards. Such programs usually include a policy statement, a code of safe practices, rules and regulations, accident investigation, training, communication, meetings, inspections, and some form of reward/discipline process. The bulk of the program generally is a restatement of the safety standards as promulgated by the state in which the organization resides or the federal safety standards. The more sophisticated organizations may add additional requirements to this program based on past experience, specific needs, or external requirements. These may include drug testing, transitional duty work, vehicle driving requirements, behavior modification, charge back systems, and cost allocations.

The safety process is managed primarily by looking at past results, analyzing them, and using that information as a basis for future interventions. This is a common practice in the industry at large. This method works to some extent, but since the future is never exactly the same as the past, this method can never eliminate all operational risk, and therefore reaching zero injuries with this method is virtually impossible. The traditional interventions in which companies typically engage fall into three broad categories: engineering controls, training, and audits/inspections. Virtually all safety standard and interventions as promulgated by state or federal agencies fall into these three broad categories.

Underlying all this is the general belief that safe work is controlled by the worker. And it is the worker who ought to make sure that they perform their tasks in such a manner so that they do not get hurt. This thinking assumes that the worker is in total control. Nothing could be further from the truth. Workers certainly should try to work safely and follow proper and safe work practices. But they do not control much of anything except their own actions. It is management who controls just about everything on site or at the facility. Management plans the work, coordinates activities, assigns the task, selects the workers, decides where the worker works, who they work with, how fast they work, how long they work, what equipment they use, and the list goes on and on and on. So, if we are going to find a solution to our loss or injury problem, there is ample opportunity for this in the management area!

Organizational Elements

Basically, most people work because they have to work. They work to make money so they may support themselves. To accomplish this, most of them end up working for some organization. The general goal of business organizations is making a profit and generating value for stockholders and benefits and salaries for management as well as for their employees. The organization accomplishes this by producing a product or service that meets the needs of others, who are willing to buy it. Some organizations may not have profits as a goal, but they still provide something (a service) others need or want.

To produce the output, the organization has two key elements: systems and people. The operational system may include plant, equipment, material processes, procedures, and practices. And they have people to activate, energize, manage, and control the systems so as to produce the outputs. While the organization produces the outputs, it also produces or creates some undesirable outcomes. On the product side, there is the issue of quality. If it is below par, it may require rework or replacement. On the production side, the undesirable outcome may be waste or inefficiencies. And on the people side, it could be lack of motivation, involvement, cooperation, support, sharing, and possibly injuries. All of these undesirable outcomes ultimately generate waste, increase costs, and impact profitability.

The operation is a subset of a larger system, which is the organization. The organization also has two key elements, which are systems and people. The people in the operations are the producers (workers), and the people in the organization are the managers. The systems at the operational level produce the output. The systems at the organizational level are the policies, procedures, chain of command, resources, structure, metrics, etc., devised to effectively and efficiently run the operations to achieve the organization's goals and objectives.

In the process of producing the output, which is desired, there are side effects that are not value creating or desired. These defects are produced as part of the output of the operating system. So, the question is, what causes this model to generate the defects or undesirable outputs? At the operational level, tools like lean thinking and Six Sigma can be used to make the operational systems efficient; that is the easy part. "Fixing" the people element is more complex and challenging.

Performance Management

We've already discussed how human performance is managed in the safety arena and how it is usually less than optimal. In business, typically performance is managed by setting goals and defining expectations for employees. These goals may be set for production, quality, or some other objective and possibly for safety outcomes. Goals that are achieved may result in some form of feedback or reward given to the employee by management, but sometimes that may be delayed or none given at all. Failure, on the other hand, usually means the denial of promotions, recognitions, or money. For workers who do not achieve the expected goals, the organization may provide counseling, training, or some other form of consequence.

Generally, these interventions or consequences are primarily directed at the worker. In other words, the intent or goal is to "change" the worker, while ignoring the fact that, in the operational model as described above, there are two sources of failure risk: people and processes. Since producers work within the system (interface with the system), the system influences them and may cause them to take action, make choices, or arrive at decisions that may results in errors or discrepancies and so lead to underachievement or failure to meet expectations, to say nothing of the influence on the worker by the organizational systems as well as management's actions, prognostications, and behavior—and/or the worker's perception of these!

Human deficiencies, errors, or performance discrepancies are simply a difference between an actual state and a desired state. Failure to meet expectations is generally attributed to human failings (operator error) on the worker's part. This may be attributed to inattentiveness, poor judgment, a lack of focus, incompetence, negligence, stupidity, or worse—an intentional act. Such a management outlook prevents digging deeper into the inner workings of the organization for possible reasons causing such failure. This is one of the major reasons why traditional safety performance improvement interventions tend to have short-term effects.

It is important to note that all human deficiencies, errors, or performance discrepancies do not result in catastrophic negative outcomes. In many cases, the outcomes may be tolerable, have an inconsequential impact, or even turn out to produce positive results. To understand failure, we must also understand our reaction and response to failure. Workers do not operate in a vacuum, where they can decide and act all-powerfully. To err (underperform) or not to err is not a choice. Instead, people's work is subject to, and constrained by, multiple factors that exist within themselves, their perception, their motivation, the operational and the organizational systems, as well the human dynamics.

If the worker is somehow "defective," that is, performing below expectation, then it is possible that the hiring practices may have failed in the selection process. Or the orientation of the worker may be at fault. It may be that expectations were not clearly communicated. There may be a mismatch between the worker's capabilities and the task demanded. These shortcomings point to deficiencies in the organizational and management systems and not necessarily to the worker. If the worker met hiring criteria and somehow changed (for the worst) after being hired, then the reason for the change (more than likely system driven) must be identified and dealt with to alter the worker's performance, which is not what is typically done.

The Human Error Factor

The impact of human error on organizations is far reaching in terms of productivity, customer service, quality, teamwork, decision-making, execution, injury, and loss. There is little in terms of statistics for most of these categories except for accidents. In many of the most serious accidents in the past 50 years, almost all initial findings attributed the failures primarily to human error. Examples include:

  • Little Rock, Arkansas, construction accident (1965)
  • West Virginia cooling tower collapse (1978)
  • Union Carbide Bhopal, India, disaster (1984)
  • Piper Alpha oil platform explosion (1988)
  • Phillips refinery explosion in Texas (1989)
  • Exxon Valdez oil spill in Alaska (1989)
  • Hamlet chicken processing plant fire in North Carolina (1991)
  • Texas City BP refinery explosion (2005)
  • Crane accidents in New York City (2008)
  • BP Deepwater Horizon explosion (2010)

Referring back to the organizational model within which the operational model exists, we identified systems and people (management) as sources of risk. Management devises all the systems, and as humans are fallible, creates systems with latent defects. Besides the system, management's action, behaviors, and communicated expectations and prognostications influence workers. The producers (workers) at the operational level have to function within the systems as well as respond to management expectations. Any latent defect, combined with operator perception actions or errors, may lead to all kinds of failures.

The Systems-Human Interface

Management's intention is to devise efficient and effective systems, hire capable workers, and manage the process so as to meet the organization's goals and objectives. So why do we end up with less than desirable results? If you think about it, in every realm of our lives, there are rules of engagement. These rules apply at work, in our social life, and in our family life. And, if we further think about it, these rules come in two varieties: written and unwritten forms. The written rules are how we are supposed to act, and the unwritten ones reflect the way we actually do act. Think of this as it relates to safety. The written rules represent the safety programs, the policies, procedures, training, etc., which are there to help keep workers safe. The unwritten ones are the way workers actually act and/or are expected to act, in spite of the written rules. So, why and how do unwritten rules come about?

Safety management can be a much discussed and sometimes a misunderstood topic. Over the years, many different theories and interventions have been tried, and many of them have had less than stellar results. Some folks have tried behavior-based safety; others have gone the systems approach path; some would have you believe that safety should be management driven, while others propose an employee-driven approach. There are also the metrics issues in safety and how best to measure performance and success. All of these approaches have been around for 15, 20, and even more years—so, why haven't we hit on the "mother lode" of safety intervention as yet?

To run an effective organization, management sets out rules for how things are to be accomplished, for without rules, there is chaos. These rules make up the policies, procedures, and practices for accomplishing the organization's mission and vision. Management also establishes a strategy to make the organizational vision become reality. To accomplish the strategy, management sets objectives, metrics, and targets. Management also interacts with the employees on a daily basis through their statements, actions, and behaviors. These actions and behaviors may not necessarily be aligned with the written rules. These signals (management's actions and behaviors), along with the written rules, interact with each other as well as other factors, such as the employees' values, beliefs, expectations, agendas, etc., to create "the organizational climate." The employees "read" this and determine the best way to accomplish management's as well as their own goals and objectives. These become the unwritten rules.

The unwritten rules help employees understand and cope as well as successfully function within complex organizations. The unwritten rules tend to have side effects. Some of the side effects result in positive outcomes. They are unintended and unexplained, but at least they do not create barriers to achievement or change. Other unwritten rules tend to be undesirable from management's perspective and hamper accomplishment of improvement or change initiatives. In safety, the undesirable side effects are the incidents, injuries, and losses we see at our facilities and job sites. Understanding the unwritten rules is more than just a way of removing barriers to performance; it is a way to replicate success. The greater the divergence between the written and unwritten rules, the larger to organization's problem!

Let's look at some of the written and unwritten rules interactions and resulting unwanted outcomes. Let us assume that a construction firm wants to develop future project sponsors (managers). They may implement the following rules to create a more rounded future management group.

  1. Everyone must rotate though all the departments (estimating, purchasing, cost control, scheduling, and field operations) to better understand their workings and relationships to other departments. This will normally take about 24 months.
  2. New talent will help improve the processes and practices of the department, thereby improving the organization's performance.
  3. Fast learners can be promoted out of the department earlier if the manager determines that the individual has a good understanding of the department's functions.
  4. Typically, departments are evaluated on their performance and contribution to the bottom line.

Rules of intent:

  1. Breadth of experience (learning)
  2. Teamwork and innovation
  3. Efficiency and process improvement
  4. Accountability and superior performance

Obviously, this is a win-win for the employee as well as the organization. But, how may the employee see these rules? As planned, it will take 8 years or longer to become a project manager. So, to accelerate the process, the individual must get the boss to promote him or her out of the department as soon as possible. The individual may also determine that innovative employees may be kept in the department longer as the department head may want to achieve ongoing improvements to department functions and results. Below is an example of possible unwritten rules the employees may devise to achieve their goals.

  1. Not contributing—Do not standout as an innovator and therefore be retained longer.
  2. Since departments are measured on performance—Watch the quarterly reports so as not to be flagged as a nonperformer.
  3. Avoid failure—Don't take any chances; limit participation in teams that may fail.
  4. Keep the boss happy—Do whatever it takes to stay on the boss's good side to ensure promotion.

Doing so may produce the following outcomes:

  1. Short term-ism
  2. Poor team work
  3. Lack of cooperation
  4. Little or no innovation

This certainly was not management's intent, but it may result from not looking at the proposed initiative holistically and understanding how individuals may perceive and react to these rules. In construction, the schedule (time) and budget (money) are key performance drivers and may create unwritten rules that encourage risk taking. A worker may take risks to keep his or her job if it is perceived that the supervisor values production or achieving the day's production goal over safety work, even if it involves taking shortcuts or not spending time planning as there is too much to do in the allotted time. The list goes on.

Performance Improvement

We have looked at a number of opportunities to make performance improvements in the safety function. The first was in the worker selection process. We then looked at ensuring the worker has the capability, knowledge, and motivation to perform the work effectively and safely. These are the easier interventions. They more difficult performance improvement opportunities lie in the understanding of the basic drivers of risk within organizations that emanate from system design and operation.

One approach to eliminating or reducing the impact of some of the system-driven risks may be to look at some of the core drivers of organizational actions and behaviors such as the values, mission, vision, and strategies. The first step is to list the business issues, performance shortcomings, or barriers to improvement initiatives that cause the greatest concern. The next step is to identify the unwritten rules that influence the employees' behavior, resulting in the undesired side effects.

Three core underlying elements create the unwritten rules. The first is what motivates the employees. Let's call these the motivators. What do the employees want, value, and perceive as a reward or punishment? What is important to them? Their behavior will be driven by what they want to accomplish, achieve, or get. The next core element is who in the organization can give the employee what they want. This generally is the immediate supervisors, though it may be someone further up the chain of command. This represents the power structure of the organization as perceived by those within it. The third and final element is the trigger. The trigger links the previous two elements. Triggers are the conditions that must be satisfied so that the employees get what they want.

The process starts with a behavioral concern or problem, and by understanding the three core elements that create the unwritten rules, which in turn motivate and drive the employees' behavior, we are able to get at something concrete that we can do something about. This analysis traces the unwanted side effects to the corresponding written rule, thereby allowing for a structural correction of the discrepancy and elimination of the undesirable outcomes.


In safety, there are tremendous opportunities to apply the unwritten rules concept to get at under-optimized safety performance. In safety, strategy is deployed based on analysis of accidents and losses and the implementation of "fixes," such as writing or rewriting programs, training or retraining, inspections, and audits. None of these interventions analyze why the employee engages in the unsafe activity and tries to address the core drivers of that behavior.

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