I know I made these mistakes in my early years. In the early 1990’s “Behavior Based Safety” was all the rage, and it had me “hook, line, and sinker.” Sometimes, I wish I was still in contact with some operators/maintenance tech who got the raw end of our (mostly mine) investigations and causal analysis so I could apologize for my mistakes. It was not until I attended my first TapRoot course in the mid-90s that I began to realize how wrong I had been about “root causes” and how BBS was being abused at the worker’s expense. I am still a big believer in BBS when it is implemented at the right time in the journey to a culture of safety and managed/measured properly. This means that when a culture is “immature” in its journey to a culture of safety, BBS will almost always be abused and usually does more harm than good (IMPO).
Dr. Conklin explains wonderfully (as he seems to do often) how easy it is for us to find fault in the worker’s behavior after an undesired event. There are certainly occasions where the worker simply chose not to do as he/she knew to do; however, over the last twenty years of my career, I have found far more often that the worker was influenced by many factors within the organization, and these shaped their decision-making. (e.g. Reason’s Active Failures vs Latent Organizational Failures). Here is Dr. Conklin in his own words:
“Organizations are biased to believe that the worker is the problem. For some reason, a good worker became operationally incompetent. That bias is incredibly dangerous for three reasons:
(1) It is wrong in almost all the time.
(2) It causes a wrong type of thinking about the problem.
(3) It does not solve the problem.
When we are convinced that the problem is the worker’s behavior, the learning tends to go out and seek places where the worker’s behavior should have been different. Those places are very easy to find. When you find these places, they are attractive to the investigation team. All that good thinking about doing a great learning is misdirected toward a temporary and non sustainable understanding of what should be done to fix this particular worker in this specific situation. This investigative bias toward correcting the person actually tells a different story of the event. Usually, it is an incomplete story. It provides a false sense of resolutions as whatever caused the problem.”
Source: PRE-ACCIDENT INVESTIGATIONS BETTER QUESTIONS, TODD CONKLIN, PhD., 2016