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The Art of Screwing Up

Phil La Duke of Rockford Greene International explains why errors may be with us always, but the injuries associated with them need not be. His insights into the world of error reveal how underlying behaviors cause people to make mistakes and why we must rethink the proper way to engineer a safe workplace.

Posted: October 8, 2012


Errors may be with us always, but the injuries associated with them need not be. These insights into the world of error reveal how underlying behaviors cause people to make mistakes and why we must rethink the proper way to engineer a safe workplace.

On one hand, industry spends a fortune trying to prevent mistakes: We put up posters, conduct safety talks and provide awareness training in an attempt to get workers to do their jobs more safely. Despite all of these efforts the workplace still endures that inevitable injury that makes us scratch our heads and wonder how things could get so screwed up.

On the other hand, many people are pretty cavalier when it comes to making mistakes: “It’s an imperfect world . . . to err is human . . . that’s why we put erasers on pencils, etc.” When it comes to screwing up, choose your idiom. Many times it seems that some incorrect actions aren’t just tolerated, they are actually encouraged. After all, aren’t mistakes the vehicles through which the most lasting and important learning occurs?

The handshake between these two sides creates a workplace environment that readily acknowledges how perfection is impossible as it looks with murderous intent to blame those who make mistakes. This sort of dichotomy is never desired, but its results aren’t always bad.

Consider, for example, personal injury lawsuits. This oft-maligned practice has actually weeded out some incompetent doctors, improved the urgency associated with patient safety and increased the awareness of personal responsibility. Though many politicians deride them as the single-handed cause of sky-rocketing healthcare costs, the reality is that many medical advances, improvements in machine safety and heightened awareness of preventable safety concerns were all encouraged by these cases.

But back to that dichotomy: To overcome this implicit sort of division through proper engineering of a safe workplace, the underlying behaviors that cause people to make mistakes must be recognized, understood and addressed.

This begins by identifying behaviors that fall under the blanket term “mistakes.” They run the gamut from simple errors to misjudgments, risk taking and catastrophic breakdowns. Note that deliberate actions shaped by depraved indifference (like carelessness or recklessness) are excluded because the worker in those cases makes an informed choice that disregards highly probable undesired outcomes. Fraud or sabotage, for instance, is not a mistake.

Errors are unintentional actions that produce an unwanted result. Because errors are unintentional we cannot really blame the person who makes them. Punishing someone for something they never intended to do is unjust. However, we can hold those who make errors accountable.

If your neighbor accidentally breaks your window you may not call the police, but you do expect him to cover the repair costs. People don’t generally expect to mete out justice for someone who causes an accident if they categorize the act as an honest mistake because honest mistakes tend to be the errors others make that we could see ourselves making. Factors like impairment from drugs or alcohol change the act from an honest mistake to something more serious that deserves punishment. The event transforms from a simple mistake to recklessness.

In his book Why We Make Mistakes: How We Look Without Seeing, Forget Things In Seconds, and Are All Pretty Sure We Are All Well Above Average, Pulitzer prize winning author Joseph T. Hallinan explores the nature of mistake making. His book is an incredible collection of facts relative to mistake-making that has profound implications for worker safety. All safety engineers should read and internalize these amazing studies to gain insights into the world of error making.

  • Rick Pollack wrote:

    Once again, Phil, you’re moving our thinking beyond behavior-based safety and into the realm of systems design and “toward mitigating the severity of the injuries that might occur if someone makes a mistake.”

    Fred Manuele writes about designing out the “error provocative” or the complicated, multi-tasking, poor ergonomically-designed elements of work that provoke error. I think it was Todd Conklin who said that safety is the absence of (severe) consequences. One is to design tasks that help humans work more efficiently with less error. The other is to provide a safe landing.

    Either way – and preferably both – I appreciate your writing on the subject. Thanks.

    • Phil La Duke wrote:


      Thanks for reading and thanks for your comments. I think there is a strong temptation for safety professionals to get too deeply engrossed in a particular methodology. And while behavior certainly plays a role, I don’t think we have anything close to consensus as to how we should act to manage behavior, or indeed if such thing is even possible.

      Fred Manuele’s writings are important works that have brought him a lot of undeserved, in my opinion, criticism. The fact remains that many people still derive their livelihoods by selling solutions, irrespective of their effectiveness.

      As for Conklin’s definition, I prefer to think of safety as the probability that one will avoid injury.

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