Hey everybody. Today I am going to share some thoughts on determining system induced behavior and some common discussions I find myself in when teaching human performance.

Like so much of leadership, this one is an emotional journey. On one hand, we have this great new awareness for managing safety performance that we didn’t have when I started this career. Human performance has opened my eyes, helped me look at the world in a different way, helped me become more forgiving and inspired me to believe that we can finally make major change in the amount of death we experience every year.

At the same time, I continually watch people display resistance and negative emotion when teaching this subject. Most of it revolves around the shift from blaming the worker towards the new view of systems thinking. I continually watch people struggle with this so I wanted to share some thoughts in case you are having a similar experience.

Before we get in to determining if a behavior is system induced or the fault of the worker, I want to tackle the negative emotion that comes up often in these conversations.

The one I hear the most is a person says, “I get all the systems thinking but at what point do people need to hold themselves personally accountable?”.

That was exactly how it was said to me recently. I was teaching an intro to human performance session and a student asked me that question. When he asked it, you could feel the emotion behind his words. You could hear the frustration in his tone and volume projection. He was frustrated.

There are a couple things that come to mind that influence this frustration. One is how we communicate human performance and the other is that we are asking people to challenge long held belief systems. I truly believe that we need to take extra time to address both of these issues. Especially when looking for buy-in.

The first issue is we need to recognize that we are asking people to change the way they have been thinking for years, maybe even decades. I think a lot of us are guilty of communicating the need for soon, certain, negative consequences for at-risk behavior. I know I am guilty of communicating that in the past. 

“Discipline for safety violations needs to be clear and consistent no matter who you are.” I have made that statement many times in my past but that was before gaining awareness of the science of human performance. Now I know. Now I have a responsibility to tweak my communication.

At the same time, I need to be cognizant of the fact that those I communicate with have been hearing that old view for a long time. I need to take extra time to explain how some of the things we have taught in the past regarding safety management have been disproven or expanded upon. 

I also need to accept that you can’t just go deliver a new class on HP and expect it to automatically erase long held belief systems that have been preached for decades. People will need time to come around. They will need time to reflect on this new view, to process this new understanding and to see the concepts at play in their own work-life experience. It won’t happen overnight. We will have to continue preaching the new view, but we need a little patience because we can’t erase 30 years of old safety management theory overnight.

The second one is how we communicate.

People tune us out. People rarely take in everything you are saying and context is everything. As messengers, we are also limited in communicating the depth of our thoughts and knowledge with spoken word. I’ve mentioned before that the average person can think 600 words per minute but only speak about 100 words per minute. So, even when we have great intent, we typically only communicate 20% of the depth of what we know. 

Things get lost in translation. We mean well but we are severely limited in verbal communication. Wouldn’t it be awesome if we could communicate with telepathy and just upload everything we know to the other person’s brain? Well, we can’t. But we can improve our communications, gain awareness to what other people are hearing and then redirect.

The issue with communicating human error is that people who hear this message often think we are saying that nobody is responsible for their behavior anymore. It’s always the system that motivated the behavior and it’s never the worker’s fault…….and that is not true. But people often think that is what we are saying. 

I understand why people think that way. We seem to communicate human error through a pendulum method that was hard left in the past and now we have swung the pendulum so hard to the right that what our people here is, “No one needs to be held accountable anymore”. That is not human performance thinking. Personal accountability is important.

But here’s why people misunderstand and hear that, even when we don’t intend it to be perceived that way. We have swung the pendulum so far to the right that we find ourselves saying:

“It’s the system, it’s the system, it’s the system.”

“It’s not the worker, it’s the system.”

“It’s not the workers fault, we just placed them in a situation designed to fail.”

I get why we do that. We do that because we want people to shift their thinking away from blaming the employee and focus more on the systems that influence at risk behavior. But we never mean that no at-risk behavior is the fault of the worker. We mean that most at-risk behavior is influenced by our systems.

Unfortunately, although we have great intent, our communications are often misunderstood.

When considering the research of Edward Demming and Sydney Decker, somewhere between 85-90% of the time, at-risk behavior is influenced by the workplace system. 10-15% of the time, it is the fault of the worker. 

So, sometimes, it is the fault of the worker. It’s just that most of the time, or a large percentage of the time, the system is where we need to focus. But definitely not all the time.

For a lot of you, I know you are already there. You get that concept. But I think all of us can fall into that situation where we find ourselves communicating, “It’s not the worker, it’s the system”. But it is not absolute! There is no absolute when we communicate about human behavior. There are always variables.

This reminds me of line from a Star Wars movie, “Only the Sith deal in absolutes”. So, are we going to communicate like a Jedi or Darth Vader? We might want to take a note from Obi-Wan-Kenobi.

As I’ve noticed how my communications are interpreted in this human performance journey I have started communicating more about the “fault of the worker” truth. I find myself becoming more extreme with that communication like, “evil does exist”. In my last class I even mentioned atrocities like rape and molestation to reinforce the idea that there are bad people in this world. There are evil workers that purposely want to do the wrong thing, for all kinds of reasons that do not make sense, to sane people with a halfway decent morale compass.

Since so many people seem to hear that human performance means nobody is responsible for their behavior anymore, I truly believe we need to continually communicate that there are bad people in this world, it’s just that the greatest amount of at-risk behavior is influenced by the system, but definitely not all of it. 

Once is not enough. If it’s a class or a meeting, nobody is listening to you 100% of the time. We need to say it over and over again, “Sometimes it is the fault of the worker. Most of the time it is the system.” But we also need to help people gain more insight into determining the difference. So, let’s go down that road for a bit.

Once we have explained the overall concept of systems thinking, people need tools that they can put to use right now. They need methods for determining system induced error today. They need methods that will work out in the field to help them make these determinations. There are already strong forces in their minds that make them want to blame the worker, like the limbic brain. The more we can help them see the difference between systems and personal problems, the more they will shift toward this operating philosophy.

My favorite is concerning firing someone: “If you fired this person today, would you never see that at-risk behavior again for the remainder of the project?”

Some call this the substitution theory. If you substituted another worker in the same situation, would the problem be resolved for good?

As an example, if you saw someone standing on the rails of a scissor-lift and fired them, would you never see that at-risk behavior again for the remainder of the project? You can insert whatever at-risk behavior that fits your job into that statement. Standing on the rails of a scissor lift, standing on a step-ladder, using a step-ladder as an extension ladder, not tied off, not using cave in protection….whatever fits your line of work.

We are trying to point them towards thinking about if this is a one-off, singular event, or a common at-risk behavior that is observed often in our culture. The more singular the observation, the more it might point toward culpable behavior. The more common the behavior, the more likely it is system induced.

This ties in to another concept: social proof. Social proof is a motivator of behavior. Whenever people are unsure of the correct behavior, they tend to look at what everyone else is doing and follow suit. This helps us determine the difference between system induced behavior and personal culpability. If a lot of workers display similar at-risk behavior, it’s a cultural problem not a personal problem.

Another method that might help is attempting to gauge how personally accountable a worker is. This requires knowing people. So, we have to know them and engage with them often to make a determination like this.

One thing I use a lot when determining if someone holds themselves personally accountable is in how the communicate. Do you notice the person talk more about what others should do, or when presented with challenging circumstances, do they talk more about what they can do? The more they talk about what other’s should do, the less personally accountable they are. 

They may complain about how challenging their job is making everyone happy from a schedule standpoint and a safety standpoint but still, they are dealing with the circumstances given to them. That tells us they do have a higher level of personal accountability.

Of course, this puts the ownness on us to get to know them first. I can’t make that determination about someone I have never met before. I can only attempt to make that determination about someone I regularly engage with. I have to start by engaging with my workers to even begin the process.

As an example, let’s say I’m talking with a foreman and they didn’t have the right equipment for the task. What did they do about it? Did they take the time to consult with purchasing, or the safety department, or their manager, or all the above? If not, why not? Were they asked, “Can you get by with what you have?” Or were they told, “Buy whatever you want”, and just didn’t choose to do so?

So much can be learned with why. “Why do your actions make sense to you?” We can learn so much by their response. Do they respond with an “I don’t care about safety” response? Or do they respond with something pointing toward production pressures and goal conflicts they are having to choose between? When we ask why the behavior makes sense, at the same time withholding any judgements of their character, their response gives us the ammunition to make a better determination.

I wish this one were easy but it’s not. It’s actually quite normal to ask someone a question while having a goal of proving your existing theories about the person. That’s normal. It is a force we must work against in our brain. If you take a little time, you might see that force at play in yourself. It doesn’t mean you are bad, it’s just part of the function of our limbic brain. But we do have the power to shift toward our prefrontal and intentionally go into the conversation with “I’m not going to judge this person, I’m just going to listen to them, I really am going to consider their point of view and see if there is another truth there that I am unaware of.” Then, and only then, can we make a more enlightened determination.

A couple other concepts I use are substance abuse and theft. Sometimes I am extreme with this communication, but I do it to try make sure I am not swinging my systems thinking too hard to the right. 

“Is the person drunk? Then fire them or get them some help.”

“Have they ever been caught stealing tools or product on the job? Then it’s a moral compass issue.”

If the person is drunk or high on drugs while displaying at-risk behavior then it’s a personal problem. If they are stealing from you, then it definitely is a worker problem.

Another thing that we should address is training. I often hear people say, “but they were trained”. The fact that someone was trained doesn’t mean it’s a personal problem. There might be things we can improve in the quality of our training. Having a card does not mean the system is perfect and everyone will do what they were trained to do. Never is someone personally responsible just because they were trained.

Training is flawed. People forget most of what they learned in training when they are not developed to use those tools in the real world. Training can often be viewed as a singular experience, especially classroom training. It’s quite normal for us to train people in classroom settings that occur over a few hours, a day, or a week at best. 

One week of training without continual development in the field does not change behavior. Was the organization satisfied now that they had documentation that the person was trained? How were they evaluated putting the concepts into play in the field? Are workers trained but not displaying the desired behaviors in the field? Why? Is it normal to see trained people not following the rules? That points to a system problem, not a personal problem. Training alone is never an excuse to blame the worker.

Here's another one I love: “Was the consequence as intended?”

We have to start with the belief that a worker doesn’t want to get hurt. If the at-risk behavior results in an accident, then most likely, the individual didn’t want to get hurt. 

There are people that intend to commit suicide. There are people that intend to get hurt because they are professional workers comp claimants. But most people don’t want to get hurt. Most people know that the schedule of benefits payment won’t be something they can retire on. If the worker was injured, we have to start from the belief that they didn’t want to get hurt. And if they did get hurt, they have already been punished for their actions, whether it’s their fault or due to the system.

To help with that, we should ask ourselves, “Could the task have been done in accordance with the rules?” 

Did they have the right equipment available? If so, what hurtles did they have to jump through to get it? Did they just need to go to the Conex box to get what they need, or did they have to go through a complex process of obtaining a permit at the same time dealing with goal conflicts of production pressures from other voices? We might want to review our permitting process and see if there is something motivating a person to skip obtaining the proper equipment.

There is a lot of crossover with systems thinking. In the previous example we should also consider the forces of social proof and ask ourselves how other workers respond in this same scenario. Do other workers always obtain the proper equipment or is it normal to skip that step? This can help us determine if it is a situational violation or a cultural norm. If it is situational, coaching might be a better response than discipline.

Another concept to think about is organizational gain. Did the worker believe that violating a rule or displaying at-risk behavior would benefit the company? Did they think it would save the company money to do the task the way they did? Did they think it would make the client, or their direct supervisor, happy to meet a certain deadline? 

Remember, construction by nature is a goal conflict in itself. Everyone is juggling the production, quality and safety balls all at the same time. If the at-risk behavior did benefit the company, coaching the worker on how we will back them up when safety conflicts with production goals is imperative. They need to know we have their back when these conflicts arise.

The last one I want to share is the mental lapse. Even the best people make mistakes. Everybody forgets and nobody does the right thing all the time, every single day. 

When a worker violates a rule or does something risky, we need to think how out of the norm this is for them. Do they normally do it the right way? How often do they forget? Where is the needle on the scale? If they forget often, why do they forget? Is the system complex and could benefit from checklists or peer checks to combat the normal tendency to forget things?

As mentioned before, this is another one where we have to know our people well enough to make that determination. If they just made a mistake, they are blameless. Even checklists can fail at preventing human error. 

If we know people have a great potential to forget a step then we might want to consider modifying our system to include some sort of peer check, like a second set of eyes to make sure people are less likely to forget or skip something. Personal fall arrest, confined space, lock out/tag out and calculating rigging capacity are all complex tasks that could benefit from a peer check to minimize mental lapses.

So, with all of this, people struggle with the new view of human performance. We have to remind them that adopting this new philosophy does not mean that nobody is personally accountable anymore. Culpable behavior does still occur. It’s just less often than system induced error in our complex, goal conflicting, work cultures.

We need to let people know that it is true that we are asking them to challenge long held belief systems; belief systems that we may have contributed to them believing in the first place.

We also have to educate people on the concepts of bias and how our limbic brain is always wanting to judge behavior….because it’s easier. But blaming workers doesn’t produce long lasting results. A great amount of self-awareness is required for implementing human performance into our safety culture.

But above all, we need to give people good tools that they can put to use out in the field. We need to give them good tools that help them determine if it’s the system, or if it’s a personal problem.

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