Complexity & Agility: Why the Human Element Is Critical to Operational Safety

Industries heavily rely on a useful set of tools to reduce the likelihood of incidents and injuries in the workplace. These include rules, policies, procedures and various mechanical safeguards, such as personal protective equipment and machine guards. While unquestionably useful, these also are inherently insufficient. No matter how well designed or assimilated, these devices simply cannot prevent all incidents in complex workplaces. As such, there is a need for something different; something more naturally suited to mitigate risk in our highly complex work environments; something that is more agile than our usual tools.

Rules, policies, procedures and mechanical safeguards are not wholly impotent, of course. Rather, there is a fundamental misalignment between these kinds of tools and the nature of operations. These tools are relatively static. They are slow to adapt and constrained in their application.

To see why, consider the normal process by which such risk mitigation devices are designed and implemented: A hazard is recognized in operational activity, and the risk associated with that hazard is common or potentially severe enough that decision makers determine something should be done about it. For example, it is discovered that employees are using corded drills in a space that could contain flammable gases, and that these drills produce sparks that could ignite the flammable gases. Such a situation presents a hazard that many organizations judge “risky” enough to require a resolution.

After the hazard is recognized and a decision has been made to address the problem, decision makers develop a method for reducing or eliminating that risk.  In the case of drills being used in flammable environments, a company likely would create a policy specifying that no corded drills can be used in those areas.  Then the solution is assimilated into the organization and the policy is communicated to employees, added to the employee manual and built into accountability systems.

Each part of this process, from beginning to end – from hazard identification to assimilation of the solution – takes time. In other words, policies, procedures and the like are slow to adapt.  They also are constrained in application, as they are designed to work in predictable situations. The corded drill policy requires that employees not use drills in a designated space, because policymakers anticipate that that space might contain flammable gases. The policy does not reduce the likelihood that the spark from a drill will cause an explosion in other workspaces outside of the designated area.

In short, rules, policies, procedures and mechanical safeguards are poorly suited to quickly resolve unexpected risks. Herein lies the problem, as workplaces are rapidly changing and reliably unpredictable.

Dynamic  and Unpredictable

Most modern organizations are complex. They comprise an immense swirl of interacting elements – mechanical, procedural, environmental, technological and human elements – each of which is complex in and of itself. People, with their bewildering cognitive processes, also are subject to social influence, emotions, the cyclical waxing and waning of attention, energy, hunger and countless other factors. People are complex, and so are the machines they operate, the software with which they interact and the procedures they follow.

Not only are organizations complex in their structure, but that complexity is amplified by the dynamic nature of the different elements making up the organization. Machines break, new tools are put into operation, weather varies, material stockpiles fluctuate, personnel change and people’s moods swing. The highly complex nature of our organizations means that “the situation on the ground” is both dynamic and unpredictable from moment to moment.

Incidents emerge from this dynamic and unpredictable interplay of variables. Take, for example, an incident at an oilfield equipment yard. A normally safety-focused supervisor was suffering from a painful toothache that had kept him awake for three nights. On the day of the incident, he was tired and irritable.

When he looked out of his office window and saw that the tools that had been delivered the day before were still sitting outside of the warehouse, he became uncharacteristically angry. The first employee who passed by his office – a young new hire with few workplace relationships – was broadsided by the supervisor’s surly outburst to “Get those tools moved now!” The young employee found that his coworkers were busy with other tasks and the only forklift already was in use.

With no help, no forklift and what he perceived as career-threatening pressure from his supervisor, he began moving the tools alone. While carrying a large, moderately heavy tool across the yard, he stumbled over a small rut that had been made by the tires of a heavy truck earlier that morning. He fell to the ground and the tool came down on his chest, fracturing multiple ribs, pinning him to the ground until a nearby employee came to his aid.

If we avoid the temptation to attribute the entire incident to human error – which would have us blaming the young employee for doing something he should not have done – we can recognize how the incident emerged from a complex situation. It was the interaction of many factors that gave rise to the injury. These factors include the young employee’s experience-level and social status, the lack of help from coworkers, pressure from a supervisor, a toothache, a tire rut and more.

Addressing Root Causes

Of course, a new policy could be created, requiring that employees only use forklifts to transfer certain tools, but this policy likely would give policy-makers the illusion of improved safety. It would not address the root of the problem, which was the complex interplay of personal, social, physical and institutional elements. If such a policy already was in place in the original case, the young employee, under pressure from a toothache-plagued supervisor and with no help or forklift immediately available, almost certainly would have done the same thing. Never mind that the policy would allow company leadership to point a finger at the rule-breaker and would not have prevented the incident, which, after all, is the real purpose of our safety programs.

Most of our standard safety tools are designed to mitigate anticipated hazards and are slow to adapt, while the actual workplace presents unanticipated hazards and rapidly is changing. In other words, our standard risk-mitigation tools are inherently insufficient to prevent all incidents in complex work environments.

This should not sound like a critique or dismissal of rules, procedures and mechanical safeguards. Rather, it is an acknowledgement that we should not surrender to the illusion that such tools will, once refined and assimilated, be sufficient. In other words, something more is needed; something more agile than our standard tools.

To suit our complex workplaces, this additional component needs to meet three criteria. It should be (1) ubiquitous, (2) reactive and (3) creative. Fortunately, we already have such a resource available. People meet all of these criteria.

Ubiquitous: Present Throughout  the Organization

The complexity of organizations makes it practically impossible to anticipate when and where a hazardous situation will emerge. It could be on the loading dock between deliveries or in a hallway during lunch hour. Because it is unclear when and where hazards could appear, we need a safeguard that is ubiquitous – that is, present throughout the organization.

Fortunately, most organizations are saturated with people. People are everywhere, from the warehouse to the executive floor. They are integrated into systems ranging from inventory management to accounts payable. Hazards can show up in the most remote corner of the company, far from the scope of policy-makers. Fortunately, there probably is at least one employee inhabiting that same remote corner.

Reactive:  Able  to Quickly Respond

When a hazard emerges, the response needs to be timely. As the young employee steps toward the rutted ground with a heavy tool in his arms, there is no time for a new policy to be researched, developed and assimilated. We need a quick solution.

Humans have, as part of their makeup, a remarkable set of sensory and perceptual capacities. We can see, hear, smell, feel and taste. Even more fascinating are our less-obvious capacities: We have a sense of balance, “internal clocks” and specialized chemical sensors built into our physiology.  These capacities may not be perfect, ¹but they are remarkably effective. Moreover, people have an astounding ability to rapidly and even pre-consciously “make sense” of their surroundings. They can recognize that a tire rut in the ground is more than simply a tire rut in the ground; it is something that could trip an approaching employee whose field of vision is blocked by the tool he’s carrying.

With this robust collection of sensory and perceptual capacities, humans uniquely are equipped to react to hazards as they emerge.

Creative:  Able  to Resolve New Problems 

Due to the complexity of our workplaces, the hazards that emerge often are unpredictable. Leaders would need to be nearly omniscient to identify all of the ways that the organization’s vast and dynamic elements will interact over time to produce hazards. When a novel hazard appears, a novel solution is needed, something that will work given the particular and unanticipated situation at hand. Creativity is required.

Perhaps the most distinctive of human capacities, our ability to create something entirely new – whether it be a machine, a painting or a solution to an unfamiliar problem – makes us remarkably adept to resolve hazardous situations that are, themselves, entirely new.

Given that people meet these three criteria – we are ubiquitous, reactive and creative – we are uniquely suited to prevent incidents in complex environments.  We are capable of quickly intervening in unanticipated hazards as they emerge.

Most safety professionals already know that direct human intervention in unsafe operations is essential to operational safety, but until recently, very few have taken seriously the task of building this component into their safety systems. Stop work authority is not enough, nor is a statement in the employee handbook declaring that employees are expected to intervene when they see something unsafe. It takes more to build this vital component of operational safety into an organization. Employees need to be informed, motivated, enabled and supported:

Employees need to be informed

• of their responsibility to intervene when they see something unsafe.
• They need to be motivated to assume this responsibility, which is a responsibility that many people would rather not have.
• ²They need to be enabled to intervene in a way that is effective and does not elicit defensiveness from others.
• Employees need to be supported by leaders and peers as they make the effort to intervene more frequently and effectively.

When we come to recognize the inescapably complex nature of our organizations, we realize that basic safety management tools – including rules, policies, procedures and mechanical safeguards – inherently are insufficient because of their static nature. Despite the familiar impulse to attribute incidents to human failings (e.g., employees broke rules, didn’t follow procedures or sidestepped safeguards), we must not too hastily overlook the profound value that people bring to our safety management efforts.

For all of our shortcomings, we are uniquely suited to prevent incidents in a complex world filled with unexpected hazards. We just need a little help filling this critical role.