Professional Documents
Culture Documents
• Human error
• At-risk behavior
• Recklessness
A supervisor whose motive is control often assumes that the primary reason for a safety incident is
that an employee made a mistake or made a poor choice. With this mindset, it is not a surprise when
the supervisor attempts to correct the behavior through some kind of admonishment.
In contrast, a supervisor who believes in a just culture realizes that more than 90 percent of the time
people are set up to fail (by error traps) or are influenced to take a risk (by a perception, habit,
obstacle or barrier). This supervisor realizes that truly reckless behavior rarely happens.
His focus in a safety conversation is to actively listen for influences and error traps. The employee’s
behavior is identified as reckless only when there is a choice to consciously disregard a substantial
A 5-Step Guide for a Safety Conversation
and unjustifiable risk. Reckless behaviors exist in the industrial world, but they happen only
occasionally.
Take Action
A supervisor who expects to maintain control takes actions that are directed toward compliance.
These are typically some form of re-training, warning, counseling, or discipline.
In a culture of compliance, supervisors assume that people should perform work using standard
procedures and abide by the safety rules. If they do not, then they need to be held accountable.
It is a mistake to simply warn, counsel or discipline someone for not using a procedure or following
a safety rule without understanding the reason for this decision. There could be hidden organization
or process issues that influenced the employee. Sydney Dekker in “The Field Guide to Understanding
Human Error” identified numerous reasons for what he termed procedural drift (a mismatch between
standard procedures or rules and actual practice that increases over time):
• Rules or procedures may be over-designed and do not match up with the way work is really
done.
• There may be conflicting priorities that make it confusing about which procedure is most
important.
• Procedures may be vague, poorly written or outdated.
In a culture of commitment, a safety conversation concludes on a very different note. Because the
conversation proceeds in a spirit of learning and co-discovery, the actions are built on collaboration.
When a mistake is identified, the supervisor seeks to understand and mitigate any error traps. In
some cases, this could include a collaboration on mistake-proofing solutions. These are simple
process design changes that make it easy to do the right thing and difficult to do the wrong thing.
If an employee drifts into an at-risk behavior, the types of influences on risk determine the best
course of action. Coaching often is effective for perceptions or habits. Like addressing error traps,
a collaborative effort is a common approach to removing obstacles or barriers. Counseling or
discipline is warranted for truly reckless behavior.
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