Now, Listen Carefully...

Now listen carefully: your system is perfectly designed to get the results you received… because your system is perfectly designed to produce the behaviors you shaped.

You built it, folks. You and your engineers, and your managers, and your industry egg-heads, and your consultants, and people you’ll never know who built parts of your system long ago. All of you constructed the systems, processes and environment that put the worker in a position to take the risk. Don’t go blame the worker. Instead, work with that worker to understand why, in the systems you built, they felt the risk was necessary; or why perhaps, they weren’t aware of the risk at all.

Feeling a lot of responsibility now? This maxim can be liberating. You can’t ‘fix’ the worker (there is nothing to fix). However, you can fix the system, sometimes by yourself, sometimes with a lot of help. The system is under your control.

This approach opens us up to a wide range of possibilities, a wide range of things we call “solutions.” Have you heard of these? Solutions are functional. Solutions are practical. Solutions are what we seek. They displace the need to blame and label people – dysfunctional practices that lead to fear and avoidance. Instead we seek to engage in the functional practice of seeking solutions.

What is this “system”?

Everything that can influence behavior is part of this system, and that’s a lot! Let’s start with all of the things managers do (or don’t do) to help their employees stay safe. This would include making safety budget investments and training, mentoring, policies, procedures, safety processes like Job Safety Audits (JSA), inspections, reporting schemes for close calls and minor injuries, meetings (upon meetings upon meetings), signage, discipline and justice, incentives, awareness programs, and the list goes on. The system also includes the tools available to use, the equipment to be worked with, and the facilities to be worked in—and all the engineering designs and plans that go into them. Preventive maintenance, warehousing the proper replacements, availability and suitability of personal protective equipment all count as system factors. The work process itself is important, as are production expectations/quotas and the bonuses tied to them. Supervision and leadership behaviors are huge system factors as they are they are often the precursor to the rest of this stuff.

There are many more system factors out there; I could write another whole book on them. Unfortunately, without a sober analysis of the causes of behavior, you may never learn what the precursors are in your system. If you insist on blaming the worker you won’t find deeper causes and those system factors will be still out there, lurking, ready to steer the next worker, like the banks of a river, toward the next risk.

Who sets up this system? We all do. Leaders build it when their behavior (leaders behave too) sets in motion the creation and adaptation of systems. Supervisors and engineers and planners build smaller pieces and maintain these systems. Other contributors include the different support functions such as HR and its policies, finance and those bean counters, maintenance, facilities management, procurement, and contracting, to name a few—all those folks in offices whose decisions and actions have direct or indirect impact on the context within which your workers work.

I’m not done. Governmental regulatory actions contribute to the system as do your competitors’ actions, the local economy, and your industry trade groups out there disseminating best practices. Your suppliers, expert solution provider consultants, knowledge givers (yours truly), and insurance companies are all potential influencers. Your stakeholders (demanding stockholders and customers) and owners and financiers and board certainly can have an impact on the systems that shape behavior. All beyond your pay grade perhaps.

Complex right? See why it is sooooooo easy to blame just one person instead? Blaming one person for errors is low-hanging fruit. The path of least resistance. Much easier than pulling back the layers of a complex system that actually caused the problem. We need a crystal ball that helps us learn what system factors are at play so we can surgically make the correct changes to make a difference. Fortunately, we have that crystal ball.

Your system is perfectly designed to get the behaviors that it shapes. This means your system is perfectly designed for the worker to take a risk. Thus, your system is perfectly designed to produce the injuries you’ve suffered.