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By: J.A. Rodriguez Jr., CSP, SGE

8:50 am, Monday morning – Your phone rings. You pick up. A lead supervisor reports: “One of our employees is injured. Apparently, he was not wearing his safety glasses during a crate assembly operation and something struck him in the left eye. We have called emergency management services and the ambulance is on the way.”

The affected work area is quarantined. Your investigation team starts their work. The obvious questions surface:

  • Why was he not wearing his safety glasses?
  • Why was he allowed to proceed without the correct personal protective equipment?
  • Why was the personal protective equipment not available?
  • Why did someone not stop him from himself?
  • Why, why, why?

In this traditional approach to incident investigations, asking “why” questions multiple times until the root cause is identified is the goal. Once the root cause is identified, a mitigation plan is designed and moved into action to fix or correct the root cause. In theory, this event will never happen again. Case closed and on with the rest of the operation.

Unfortunately, the “five-why” approach to incident investigations is very limited in assuring sustainable and predictable outcomes. It will happen again. The five-why approach often leads to what some safety practitioners call the “blame, shame, and train strategy.” This is where, inevitably, someone along the line is held up for the world to see as the reason for a failure. Something went wrong and someone has to pay the price.

Failure to report injuries usually follows as fear spreads across the organization. Opportunities for prevention are stifled as they are deeply buried and often not brought to the attention of leadership. Eventually, the statistics start to catch up with the number of unexpected events and suddenly, a very, very serious injury occurs. The next appropriate question is, why does this happen?

What Is Process Thinking And How Can It Help?

Process thinking (PT) is an alternative way to look at any undesired outcome including potentially deleterious events like a hard object striking a worker’s soft eye. Let’s take quick look at PT, what it is, and how we can utilize it to become better leaders.

PT is a mindset, a way to view your world from a systematic viewpoint in its totality. PT asks “how” and “what” questions. In the injured employee case, PT would ask: “How did the he come to the conclusion that work can performed without the protection of safety glasses?”

PT is a way to evaluate rather complex outcomes one piece at a time, one process at a time, one person at a time and then combining the results in a way that paints the entire picture of how the process produced the eventual outcome. Only then will you be able to derive sustainable solutions tailored towards generating the expected results.

To start using PT, adopt the mindset that every process works precisely as it was designed; that outcomes, expected or not, desired or not, are the results of their process. The process is therefore not faulty for producing the unintended results, the design of it is…your design. After all, who is accountable for the performance of all processes within an organization? Most would say, leadership.

In the eye injury example, PT proclaims that it occurred because leadership has a process in place that generated a particular undesired outcome (a serious eye injury). There is the root cause. There is no need to search for another one. This approach to thinking is very distant from asking why the injured employee was not wearing his safety glasses.

PT is very revealing. It exposes a story. One that, if modified correctly, will result in a different, likely desirable, and predictable outcome.

What is Leadership’s Biggest Error?

Human behavior is the result of a risk assessment. We all behave the way we do because we have evaluated the pros and cons of the alternatives and decided on an action forward based on risk. Consequences of actions drive each of our behaviors.

If we perceive the risk as being low, then we are likely to take that action. Conversely, if we perceive the risk to be high, we will likely not take the action.

If I perceive my life is in grave danger by choosing not to lock-out a hazardous energy, then the probability is high, that if I value my life and my family, I will make the right decision and will hold myself accountable for taking the right actions to assure my safety. If on the other hand, I perceive my well-being is assured by not locking-out the hazardous energy (after all… nothing has ever happened in the past), the probability is high that I will make the wrong choice. The wrong choice in the sense that the outcome may not be what I predicted it would or could be.

In both instances, a risk assessment, my risk assessment, determined my behavior based on a personal view of the potential consequences of the anticipated outcome.

Very often, helping the individual or organization early during this personal risk assessment is the difference between who gets to go home after work and who never returns to their loved ones.

The biggest error I see within organizations is that leadership designs processes that rely on the “correct” human behavior for the success of the intended outcome. For instance, if the employee remembers to follow policy, then the end result will be as planned. Another example is when, given a multitude of options, leadership expectations are that the employees will select the one they want them to choose, always, every time, simply because that is what is implied or expected.

While reliance on employee behavior is an important factor in successful process outcomes, it cannot stand on its own merits to support safe completion of the work. Conscientious employees report to work operating within a rather narrow and stable behavioral bandwidth. Regardless of their emotional state, anger, fear, joyfulness, etc., they seem to operate within the upper and lower limit of acceptable risk.

Other employees, report to work with similar feelings, but their perception of the upper and lower limit of acceptable risk is somewhat different. They often operate within boundaries outside those recognized or approved by their employer. Their behavioral bandwidth is much wider. The wider this behavioral bandwidth the more unpredictable these employees are within their organizations. As we all know, the world around us revolves around predictability. Gambling solely on highly predictable behavior for consistent safety compliance is a recipe for the generation of surprising outcomes.

What is the solution? Leadership must design processes that account for but limit their reliance on human behavior for success.

PT looks at the big picture first offering insights into how things happen. Thinking in terms of process facilitates the identification of sustainable solutions. We often arrive at a root cause that blames employees or others for injuries, when in fact, we are missing an opportunity to identify a process step or two that needed to be modified, deleted or included.

If we believe that every process works exactly as it was designed, then the design is defective if it produces an injury or other undesirable event. While employee behavior is a very important process element, it is definitely not the only one. Leadership’s biggest error in safety management system design is in believing that solving employee behavior is the golden ticket to exceptional performance.

A Second Look At Process Thinking

If the eventuality of human behavior is guided by an influenced risk analysis, then the starting point to changing it is by modifying the process that encouraged it in the first place.

Behavior-based safety focuses on people and on getting people to make the right choices based on their understanding of the consequences. This is an important element of any safety management system. The difference here is that I am saying there is more, much more.

By modifying the broken process you minimize choices and decision points thereby allowing for more consistency of performance and preventative action sustainability.

A leader’s success in establishing accountability for safety begins with embracing ownership for all processes supporting his/her organization. This is leadership in action.

If leaders can reach the realization that they are part of the process producing the outcomes, good or bad, then they are on the way to making the biggest positive impacts in safety management system improvement. Consider taking a second look at incorporating PT into your team’s leadership tool box. Focus on systems thinking next.

Discover the power of focusing on “how” and “what” when your processes unpredictably perform exactly as they were designed.

Dare to think differently…