THE CHALLENGE OF THE SYSTEMS/BEHAVIOUR

INTERFACE IN SAFETY
Prof Petri Schutte
CEO
PROHUMAN Inc
pcschutte @absamail.co.za

Conditions, systems and people

In any particular work situation, performance depends on the interaction of

three factors conditions, systems and people. Design and maintenance of the
physical environment, along with available tools, equipment and general
housekeeping, determine organisational conditions. Conditions provide the
means by which a person can be successful. Systems such as work permit
procedures, job safety analyses, training, rules and procedures set the
expectations. Finally, people, their beliefs, values and motivation provide the
application – how people perform relative to a set of expectations.

A properly functioning interface

Consider this example in which these factors are working in harmony. It

involves de-energising equipment, a critical safety action in almost every work
setting, according to Groover (2001).

Conditions

Proper lockout / tagout devices are located near the equipment to be de-
energised so employees can easily attach locks or tags. Equipment is clearly
labelled so workers can quickly determine whether they are locking out the
proper equipment. In this environment, safety performance is easy to
accomplish. The company might even install light curtains that automatically
shut off equipment when a worker is in close proximity.

Systems
In this setting, systems are aligned with a value for safety and, therefore,
support the de-energising process. For example, a written procedure outlines
the steps of lock-out / tag-out. Employees receive classroom (conceptual)
training on the procedure, followed by field training during which they practice
the procedure on equipment in their respective areas. Where expectations
are made explicit, skills are provided and systems are coupled with favourable
conditions, good safety performance is likely to occur more often.

Performance

With conditions set and systems established, it is easy to assume the job is
done. However, a progressive organisation – one that truly understands and
supports the continuous-improvement process – takes yet another step. It
does not rely on chance, simplistic reinforcement strategies or fear-based
approaches to achieve continuous safe performance or continuous
improvement in performance. Instead, it establishes mechanisms that
engage employees in understanding the value of performing safely and
develop within each employee the desire to perform safely. Motivational
approaches are selected based on their appropriateness to the culture and
organisational direction.

Such an organisation also ensures that employees value the mechanisms. In

a fully functioning system, performance of this critical procedure is measured
and performance feedback is provided. Performance data are shared
throughout the organisation and when performance variation is identified, the
root cause is identified and addressed. This is the final piece of the puzzle – it
allows a company to measure the effectiveness and efficiency of conditions
and systems in place and facilitates its efforts to manage the interface
between people, conditions and systems.

A crucial trait of such an organisation is that it knows it is dynamic, not static.

Factors are always changing, sometimes rapidly. These changes include new
employees, new job assignments for existing employees, new equipment
installation, equipment modifications, and shifting priorities based on
production, quality and cost concerns.
Often, any one of these “shifts” can contribute unintended “support” for taking
risks. After all, employees seek to please their employer and are driven by an
internal motivation to do a good job. An effective organisation strives to
leverage this underlying motivation in a positive way. It establishes
mechanisms to systematically measure performance of critical safety
processes and to provide feedback on performance. This ongoing
measurement allows the company to detect negative influences before they
have any adverse impact on safety performance.

Misalignment and the interface

When conflict or misalignment exists among conditions, systems and people,

it emerges at the interface among them. As a result, personnel are at-risk for
injury, and equipment or conditions are at-risk for damage. When risk is
present but behaviour/systems management mechanisms are not deployed or
are not in place. “accidents” are waiting to happen.

Excellent safety processes and programs measure the interface and identify
what barriers exist to eliminating friction points at this interface. Consider this
simple example of an interface. Reach out and grab the air in front of you.
You are likely at little risk of injury and could continue this action without
worrying about injury. Now, imagine that same action, but instead of grabbing
air you are reaching for a part jammed in a piece of equipment. The action
can now be put into a context of exposure. Such risk taking must be explored
to determine why an employee took this action rather than shut down the
machine to clear the jam.

This brings the discussion back to the central question. Why do employees
who obviously do not wish to get hurt none-the-less take risks that could lead
to injury (and possibly discipline)?

The first step is to expose problems at the conditions-systems-people

interface. This sets the stage for discovering what is influencing employee
decision making. Typically, this reveals deeper issues, such as a breakdown
in training or a conflict between production values and safety. It provides site
personnel with the whole story, and reveals mechanisms for creating change.
Such interactive, interface-based knowledge and engagement is crucial for
continuous improvement.
Pivotal to success are efforts to develop employees who do not merely blindly
follow rules and procedures, but who are engaged, motivated and equipped to
see and continuously evaluate risk. Workers seldom reject this responsibility
because it represents a situation where management is asking them to think
critically. At this point, an organisation must make sure employees
understand the limits of their authority and managers recognise that when
people make decisions, they will not always be correct. The concern here is
that if only poor decisions are recognised, the organisation will revert to a
situation in which employees are unwilling to make decisions.
Achieving continuous improvement in safety is a challenge. By taking a
holistic integrated approach, and involving employees meaningful and
continuously at all levels at the interface, sustainable success will be
accomplished.

A brief task analysis view of safety

How to position safety in-company

In today’s highly competitive business climate, having operating personnel

perform job safety analyses may not be a high priority, and that simply is
reality. In addition, performing job analysis solely for safety purposes can be
perceived as separating safety from the core business.

Job safety analysis usually examines the work only from the perspective of
safety and health. It has resulted in safer work. But is has also resulted in
duplication of effort and paperwork, and confusion with safety procedures,
quality procedures and efficiency procedures. Because procedures which
deal only with safety are not always perceived to be related to the primary
purpose for doing the work, they tend to get ignored in the face of other
pressures.
Safety’s marketing opportunities can be greatly enhanced if the task analysis
system is perceived to have a direct impact on operational needs and is
consistent with management goals. Management speaks the language of
productivity, cost efficiency and quality. Extending task analysis systems will
give safety practitioners greater opportunity to “get on the manager’s page.”

Safety practitioners are often frustrated by management decisions that seem

to indicate lack of support. On a given day, managers must consider multiple
proposals that require spending money. Safety proposals must compete
against all other proposals.

This in no way suggests that the thoroughness of the safety and ergonomics
aspects of a combined task analysis be diminished in purpose or scope.
Conducting such task analyses often better serves safety management
purposes.

A systematic, practical approach to preparing and using task procedures

and/or practices” would be the following stages:

• Inventory occupations;

• Inventory all tasks within each occupation;

• Identify the critical tasks;

• Analyse the critical tasks: a) break tasks down into steps or activities;
b) pin-point loss exposures; c) make an improvement check;
d) develop controls;

• Write procedures of practices;

• Put to work; and

• Update and maintain records.

Some tasks are inherently more hazardous than others, and should be given
priority for analysis if they present a potential to create an incident that may
produce serious injury, illness, property damage or environmental damage.

To determine what tasks to analyse it is suggested that the following factors

should be considered:

• actual incident history, including legally recordable and lost workday

cases, and workers’ compensation history;

• incidents that, under slightly different circumstances, could have

resulted in serious injury or damage;

• input from workers on tasks they perceive to be hazardous;

• hazardous, non-routine tasks (e.g., maintenance and trouble-shooting);

• other known high-hazard tasks; and

• new tasks with which workers may not be familiar.

Throughout this process, judgement and experience will prevail. Input from
and involvement of those performing the tasks – the workers – is crucial as
well. Actual incident history will indicate which tasks should be given priority,
yet one must also consider “near-miss” incidents that could have produced
serious harm or damage as well as tasks about which workers express
concern. To identify those, a modification of the critical incident technique
must be applied; this requires worker input.

In applying the qualitative technique, an interviewer questions a number of

persons who have performed particular jobs within certain environments and
asks them to recall and describe unsafe errors that they have made or
observed, or unsafe conditions that have come to their attention.

Once tasks are identified for analysis and priorities set, task analyses follow.
To extend this process to encompass ergonomics, productivity, cost efficiency
or quality, the safety practitioner must understand the conceptual significance
of what is to be undertaken. The conventional job safety analysis system
must be rewritten; the safety practitioner must convincingly conduct several
analysis using the extended system; and a training program to indoctrinate
others into the revised system must be initiated.

This must be achieved on a “designer” basis to ensure that the system

realistically addresses needs and opportunities and can overcome barriers in
individual operations. In designing such a system, the following
extrapolations (taken principally from the resources reviewed) must be
considered. When determining which to include in all extended task analysis
system, aspects of productivity, cost efficiency, quality and safety should be
considered.

The following questions must find answer:

• What is this task to accomplish?

• Is this task necessary?

• Does a more-efficient way to perform this task exist?

• Is equipment appropriate to the task?

• Would efficiency be improved if other equipment was provided?

• Is equipment maintained properly?

• Do environmental conditions negatively affect task performance (e.g.,

illumination, noise levels, air contaminants)?

• Would revisions in workplace layout and configuration improve task

performance effectiveness?

• Does a written, easily understood procedure exist that is appropriate

for all aspects of the task?

• Is staffing adequate?

• Is the task structured to encourage deviation from established

procedures?
• Do methods prescribed to perform the task encourage risky behaviour?

• Could employee errors be attributed to workplace or work methods

design?

• Is the design of the workplace or work methods overly stressful?

• Does the task require excessive physical exertion, awkward body

postures, extreme reaching, bending, twisting, ….?

• Does the design of the workplace or work methods provoke error?

• Can work methods be redesigned to make errors less likely?

• Do task requirements induce fatigue?

• Are task requirements difficult?

• Is easy access provided for maintenance tasks?

• Is storage and use of smaller quantities of hazardous substances

practical? and

• Can hazardous substances be replaced with less-hazardous

alternatives?