As you start learning about worker error and Human Performance, you are introduced to the concept that up to 90% of “human error” is encouraged by faulty work processes. In other words, the worker, to some extent, was “set up” to make a mistake. Not on purpose, but something was not quite right, or as expected, and the worker either missed it or wrongly diagnosed it, leading them to make a mistake. Most of the time, something in the system failed the worker.
The idea is to get leaders out of the “whack-a-mole” mindset. If you hammer the worker and don’t address the organizational breakdowns, then it’s only a matter of time before the next worker falls into the same error trap. We’re pretty good at blaming and punishing the worker. Let’s think about fixing the system first.
This effort to get people thinking about human error a little differently easily gets overstated and gives the impression the organization is solely at fault and the worker is always a helpless victim. In seeking a little more balance in how we approach human error, we swing the pendulum too far in the “organization” direction. This leads too many leaders to ask, “Does this mean we never discipline ANYONE?” No, but it does mean we think a little more about when discipline is appropriate and when it’s not.
To help us understand how to react, we first need to understand the behavior choices of the worker. However, every situation is unique, and we often don’t know what motivated a worker’s decision. This makes it difficult to draw hard lines and confidently categorize every behavior choice, but we can create some general guidance to help us respond to worker error.
At Knowledge Vine, we teach leaders to consider three types of worker behaviors: Error, At-Risk, and Reckless.
Error: An error is something the worker wouldn’t consciously choose to do. It’s often the result of a breakdown in defense barriers (the things the organization puts in place to protect the worker), and the person simply triggered the event. A good example of this is the shooting down of the Ukraine airplane (read about it in more detail here). The missile operator was put on high alert, had no way to tell the difference between an attack and a commercial airline, couldn’t contact higher-ups for help, had 10 seconds to decide to launch or not, and had no way to abort an inadvertent launch. They made an error—shooting down the airplane was not something they would choose to do.
All the dominos were set up; this individual just happened to be the person to make the mistake that tipped the first one. In the event of an error, the appropriate response is to fix the system and console the worker.
At-Risk: At-risk behaviors occur when the worker drifts into risky choices. The worker knew there was a hazard but thought the risk was small and they could manage it. They underestimate the risk and overestimate their ability to manage it. Often, they don’t recognize their behavior as being risky. Risk-taking is a gradual process. They take a small shortcut, it works out, and they push the line a little more the next time. Without even thinking about it, they have drifted into risky behaviors. Sometimes their risky behavior can feel justified. If it’s a common unsafe practice (everyone does it and leadership constantly walks past it), then the worker won’t see themselves as being “at-risk.”
When confronted with at-risk behavior, the appropriate response is to coach the worker. Help them to understand the risk they are taking. Help them better consider the consequences of their actions, not the likelihood it will go wrong. Set clear expectations for how the work is to be accomplished and to recognize when they are drifting from this standard.
Reckless: Here’s where you start to move away from errors and into violations. The worker knew the rule and was aware of the risk they were taking. They made the choice to engage in unjustifiably risky behavior. This is breaking cardinal rules or going rogue. They make the kind of dangerous choices that you can reasonably assume other workers in the same situation simply would not make. They put themselves or others at extreme, inexcusable risk. Again, this is a violation, not an error.
Here is the situation where you need to crush this reckless behavior and employ discipline. You simply cannot tolerate reckless behavior; you must take steps to remove it from your organization. Truly reckless behavior is rare, but when discovered, it needs to be dealt with swiftly and definitively.
When responding to an event, we often go straight to “crush” and hammer the worker regardless of how it happened, but it’s never that black and white. Consider the behavior that led to the event. Was the behavior an error, at-risk, or reckless? This should guide your response and help you decide if you should console the worker, coach the worker, or crush the behavior through discipline.
Toolbox Talks offers quick insights and thoughts to use for your toolbox (tailboard) talks. Dave Sowers is a founding member of Knowledge Vine, a veteran-owned human performance training and consulting organization that strives to reduce the frequency and severity of human errors in the workplace. He has almost 30 years of experience in power generation and the utility industry. He is a veteran of U.S. Navy Nuclear Power Program and holds a bachelor’s degree in resources management and a master’s degree in both management and emergency management and homeland security.
