Accidents, injuries, errors, or losses are undesired outcomes resulting from people's actions or behavior while engaged in performing their work. Though such undesirable outcomes are relatively rare, and many of them have a minor to moderate negative impact, some do, in fact, have serious consequences.
Situational variables have an effect on the degree of seriousness of these unexpected events, which causes management to try to find means and methods of stopping their occurrences or minimizing their negative impact on the organization.
Another reason for the focus on workers emanates from the psychological need to try to understand or explain the reason for information, conditions, situations, or events. The important distinction is that different people may see the same event or condition or hear some information and make a completely different attribution to it.
This attribution refers to the cognitive process people use to identify the reason for either their own actions or that of other people. This tendency of people to interpret their behavior different than that of others is known as attribution bias. Researchers found that people have a tendency to make distinctions among behaviors that are caused by personal disposition as opposed to environmental or situational conditions. Attribution is made in four areas: our success or failure and other people's success and failure.
When it comes to making personal attributions, people are more likely to explain their own successes in terms of dispositional factors (i.e., caused by their innate ability) while ignoring the surrounding environmental or situational factors. They tend to explain their failures as caused by environmental or situational factors (i.e., as being beyond their control). Conversely, people are more likely to explain other people's failures in terms of dispositional factors (i.e., caused by that person's innate abilities or disabilities) while ignoring the surrounding environmental or situational factors. Likewise, they tend to explain other people's successes as caused by environmental or situational factors (i.e., luck or happenstance).
Attribution and Safety
During a job walk (inspection), the safety practitioner may observe a worker performing their task in a way that may result in an accident. The inspector's attribution bias will cause them to think the worker does not know how to do the work safely and so tell them they are at risk and must change the way they are performing their work. They may also suggest the worker should attend a safety training session to improve their knowledge.
But the worker may be doing the work in that particular way because the physical conditions are such that it is the only or easiest way that the work can be done. Or, the worker is rushing because the supervisor asked him to work faster to meet a production goal. The cause of the unsafe behavior is not a shortcoming on the worker's part but is caused by situational factors. This would require a different attribution resulting in a completely different reaction on the safety practitioner's part.
Due to attribution bias, when conducting an accident investigation, the investigator more than likely will attribute the cause of the accident to the worker. Such responsibility attribution tends to become a significant barrier to understanding that the underlying cause of the negative event was not some deficiency on the worker's part but possibly caused by some other salient (external) factors.
Researchers have found that there is a tendency to attribute greater responsibility to an accident's perpetrator for a severe accident rather than for a mild one. Researchers have also found that when the investigator feels an affinity or some "similarity" to the person involved in the accident, they attribute less responsibility to the perpetrator when the accident severity increased. The opposite was found to be true when the perceiver and the perpetrator were somewhat "dissimilar."
Underlying all this is the general belief that safe work is controlled by the worker, who ought to ensure that they perform their tasks in such a manner that they do not make an error or 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 that controls just about everything on-site or at the facility. They create the work climate and devise and control the operational systems. It is management that plans the work, coordinates activities, assigns the tasks, selects the workers, sets the production goal, and decides where the worker works, who they work with, how fast they work, how long they work, and what equipment they use. The list goes on and on and on.
Immaterial of how or why the worker is deemed or assigned the responsibility for causing the accident, the end result is that the interventions devised to reduce or eliminate their occurrence in the future is going to fail to achieve their intended or expected outcome due to the attribution bias. 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 as well as the operational systems and controls!
Human error can occur due to factors associated with the individual worker (cognitive, perceptive, attentional, etc.) or due to environmental or situational factors. Errors can occur if something is done that was not intended or did not conform with stated procedures or expectations. Humans can fail to achieve goals in two ways: performing work resulting from a defective plan or means that results in a mistake, or the plan is correct, but the performance is deficient. This can be a lapse or a slip on the part of the worker.
"Human error" and "human performance" mechanisms are one and the same. Unacceptable human performance is labeled human error after the fact and is actually an integral part of human behavior. Human error and its associated risks are commonly identified in accident investigations and influence the selection of interventions aimed at trying to control or minimize their negative impact.
Human performance is subject to variability that may increase operational uncertainty and, in combination, result in performance errors. Management can minimize many of these errors by devising plans that eliminate many of the physical hazards, improve the flow of information and resources, and anticipate and rapidly address barriers associated with the tasks that employees are assigned to perform. They can design tasks that minimize employee slips and lapses and better match task demand to the employee's capabilities, which addresses some of the mistakes.
Management focusing on this phenomenon provides a means for controlling construction uncertainty and human performance variability by applying resilience engineering methods to the management of safety. The central idea of resilience is to address and adjust performance before, during, or after any disruptive events. Since human error is inevitable, management should try to "error-proof" operations as much as possible.
A system is a network of interdependent components of policies, protocols, processes, practices, and procedures (subsystems) that are developed over time. They work interdependently to aid the workings of the organization to enable the achievement of goals and objectives and, as a group, make up some of the operational and production subsystems. Change in one subsystem or the creation of a new one may create misalignment, thereby affecting others by creating potential impediments, slowing down progress, increasing complexity, hindering smooth flow, creating confusion, and potentially impacting the system as a whole. The system produces the workflow that generates the value proposition.
Anything that influences the business results must be part of an integrated management system. This approach looks at the business as a whole and establishes its purpose, vision, mission, and structure. The structure provides the basic framework for the core processes to enable effective and efficient outputs. The organization's operation fundamentally has two core elements: systems and people (workers, supervisors, and managers).
The organizational systems should be designed in such a way to ensure that the "right" person is placed in the "right" position (or assigned to the "right" task) and enable them to do the "right" things by providing them with the proper resources along with timely information to ensure it is done at the "right" time as well as providing the "right" oversight (empower and encourage them, provide them with relevant feedback, and recognize them for their efforts and results) so as to ensure that they can and will succeed.
This requires that the organizational operations function properly, effectively, and efficiently; management and supervision plan, organize, staff, direct, and control the work, with an eye on eliminating or diminishing the adverse effect of any and all operational risks that can cause the undesired negative side effect of production work.
Supervisory Practices Oversight Risk
How the supervisor plans, organizes, directs, and controls the day-to-day operations has a considerable impact on the workforce's activities, perception, motivation, and satisfaction regarding their work. More importantly, they are supposed to train, coach, support, and enable employees. Research has shown that "high-quality" supervisors directly impact the workforce's engagement, performance, and productivity. It has been said that workers do not leave bad firms; they leave bad bosses.
It is important to note that the supervisor greatly affects the work climate. A positive work climate encourages and sustains employee engagement, motivation, and a positive perception of the organization. An open, empathic, and supportive management style fosters involvement, a sense of ownership, and the contribution of the employee's discretionary effort toward achieving the organization's goals and indirectly has a positive impact on safety.
Some of the basic supervisory operational activities that have a significant impact on fundamental task-related risks include the following.
Matching worker capability to the task's demand. Prior to making a worker's task assignment, supervision should ensure that they have the proper experience, capability, or knowledge to properly and safely perform it.
A worker whose capability is not known. It is irresponsible to assign a new worker to a task without observing them to ensure that they, in fact, are capable of performing it properly and safely.
Support and oversight. This should be commensurate with the individual worker's abilities (capability, experience, knowledge, etc.) compared to the task demand. Supervisors should provide guidance, training, and coaching to ameliorate any and all deficiencies on the worker's part.
Setting challenging yet doable production goals. Production or performance goals should be set in line with the employee's overall capabilities.
Ensure that production does not trump protection. The workforce must understand that safe performance is the only acceptable way of doing things.
These fundamental factors play a significant role in ensuring risk management and safety are properly addressed and are an integral part of the performance.
An organizational operation includes two key factors: people and systems. The people-centered theory of safety management ascribes the cause of accidents to some form of deficiency on the part of the workforce. Workers can make mistakes or engage in unsafe behavior for any number of reasons. This thinking has to be broadened to include a system-centered theory of safety management that links risks embedded in elements of the operational system as significantly contributing to accident causation.
But there is another significant factor, which is the broadening of the people element mentioned above. The people element includes workers, supervisors, and managers, as well as executives. In reality, the systems are devised by management, and only management can modify them. Managers also hire, oversee, and manage the efforts of the workforce, thereby influencing their actions and performance. As a result, accidents are caused by multiple factors stemming from complex interactions involving people's decisions and actions, as well as risks embedded in elements of the operational system and management's involvement and oversight.
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