A Disruptive Paradigm: The Systems Approach to Human Error


How we think about incident causation is beginning to change.  Though it seems to have taking decades to progress, safety professionals are beginning to understand and pay more attention to the impact workplace design and operating systems on worker behavior and safety performance.  Referred to as the “context of work”, we are recognizing how work occurs in context and how it directly influences accident causation.   Management decisions, work pressures, resource allocation, compensation schemes, peer pressure and incomplete training are all examples of “how work is done” can be influenced by the context itself.  Taking the eye off the behavior and understanding the context can offer a new view of how better workplace safety can be achieved.

Trying to change worker behavior has been the focus of accident prevention for a very long time.  Dating back to 1931 and the writings of H. W. Heinrich, we have been taught to focus on the behavior of the workers to improve safety.   We have tried multiple methods, including behavior based safety observations, incentive programs, worker training, posters and many more.  We have most recently been taught by organizational psychologists to create a safety culture.  Some organizations with mature safety systems and cultures have experienced success with these behavioral approaches and culture interventions, but most others have not realized sustainable positive results.

As W. Edwards Deming stated to management teams in the 1960s and 70s during their drive to improve quality, “There would be no problems in production or service if only our production workers would do their jobs in the way that we taught.  Pleasant Dreams!  The workers are handicapped by the system, and the system belongs to management.”

The parallel to modern safety management is obvious.  Focusing on worker behavior before making sure the work processes and supporting systems are safe will not produce the desired results.  People make mistakes.  They error all the time.  It is when human error occurs in an environment that is poorly designed for safety and has suspect support systems that bad consequences happen.  It’s time to think differently about safety and how accidents occur.  It’s time we disrupt organizational thinking about safety and shift the paradigm.


Disruptive Paradigms

A recent article in The Firebird Forum, published by William Corcoran, PhD., discussed the importance of “disruptive paradigms” in bringing meaningful change. There were a number of thoughts conveyed in this article, the least of which had to do with the definition of the words “disruption” and “paradigm.”  According to Corcoran, “Disruption can be adverse or beneficial.  The value judgment of a disruption often depends on whether one has been helped or hurt by it and usually comes later than the disruption itself.  When we use the word ‘paradigm’ we are referring to a way of thinking, a way of perceiving, and/or a way of performing.”

In 1962, Thomas Kuhn wrote The Structure of Scientific Revolution, and fathered, defined and popularized the concept of “paradigm shift”. Kuhn argued that scientific advancement is not evolutionary, but rather is a “series of peaceful interludes punctuated by intellectually violent revolutions”, and in those revolutions “one conceptual world view is replaced by another.  For example, the introduction of the personal computer and the internet have impacted both personal and business environments, acting as catalysts for a (disruptive) Paradigm Shift. We are shifting from a mechanistic, manufacturing, industrial society to an organic, service based, information centered society, and increases in technology will continue to impact globally. Change is inevitable. It’s the only true constant.”

Taking Kuhn further, Corcoran wrote that “A disruptive paradigm is a paradigm that is life-threatening to the old ways of looking at things.  Often when a critical mass of people in an organization or in a society adopt the disruptive paradigm the days of the old paradigms are numbered.  This is often a tipping point after which the old paradigm recedes and the disruptive paradigm gains momentum.  But more often the disruptive paradigm exists side-by-side with the previously conventional paradigm for years, and this co-existence is antagonistic.”

Systems thinking about human error is a disruptive paradigm.  It threatens the set of beliefs we and our organizations hold about worker behavior and safety.  It threatens to make our previous approaches obsolete.  It threatens the army of consultants, their training programs and software to model and predict, and our own way of seeing safety.  Even though there will be push-back and antagonism, the time has come for Safety 2.0 and Safety Differently.


Working In Context

Systems thinking isn’t new to the safety world.  In fact it has been around for a long time in aerospace and nuclear safety.  But to most safety professionals or practitioners, focusing on risk factors that arise from the workers and their behavior has been more in-vogue than assessing risks from work related systems.

According to Nancy Leveson, PhD. and professor in aeronautics and engineering systems at MIT, systems thinking is an approach to problem solving that suggests the behavior of a system’s components only can be understood by examining the context in which the behavior occurs Viewing operator behavior (and human error) in isolation from the surrounding systems prevents full understanding of why an accident occurred; and thus the opportunity to learn from it.

It is easy to see in hindsight what should have been done, but in the moment it is far more difficult for the employee to see what is about to happen.  Workers are engaged in their work, trying to be efficient and get the job done.  They probably have done the job successfully many times, and may have been praised for how quickly and effectively they performed the work.  But then one time things didn’t turn out as planned and an incident occurred.


Local Rationality:  “It made sense at the time!” 

It is our job to find out why, in the context of work, exhibiting this type of behavior made sense at the time to those involved.  If you prejudge or think you know, you will almost always be wrong.

Almost instinctively, the supervisor and others look to see what the person did wrong as they begin to investigate.  Often biased in their beliefs about the person’s role in the mishap, they embark down a road to find the root cause.  Assuming that accidents have a root cause these investigations focus on the mistakes or behaviors involved (operator error) or technical failures, and ignore the plethora of organizational related issues that likely influenced the behavior (the context).  Thus, the behavior of the worker is most often blamed for the mishap.

Focusing of the failure of the worker and their attendant behavior is easy to understand when you think about who gathers the initial information during investigations.  Then consider how difficult it is for them to point out flawed management decision-making, safety culture problems, regulatory deficiencies, inadequate resources, and the pressure of time related issues, to name a few.  In the October, 2014 issue of the ASSE Professional Safety Journal, Fred Manuele wrote about incident investigations and how our methods are flawed.  He pointed out that much of our thinking about what and how to investigate, and who should conduct investigations is linked to the writings of H. W. Heinrich.

Heinrich believed that supervisors should be the ones to investigate, since they were closest to the work, and that it was their job to “identify the first proximate and easily prevented cause in the selection of remedies for the prevention of incidents.”  Of course this led poorly trained supervisors and anyone else conducting an investigation to look at what the person did or did not do, and, as Heinrich suggested, “to consider psychology when results are not produced by simpler analysis.”  After all, in Heinrich’s assessment 88% of all incidents were due to the unsafe acts of people.   Thus, the remedies or corrective actions that followed were focused on what the person did and their lack of knowledge, situational awareness, motivation, or worse their disregard for the rules or need for protective equipment.

As continues to be the situation today, supervisors are poorly trained in the investigative process, and lack the time and motivation to dig deeper into any of the system related issues.  As a result, most organizations find root causes that are really only symptoms without fixing the process that led to those symptoms.  As Dr. Leveson sees it, “if we don’t begin to look at the big picture and understand the context in which the behavior occurred we will continue to have process flaws that will fail again.”

So here is the disruptive paradigm shift:  Human error is not the root cause of most incidents.  All human behavior (and error) is affected by the context in which it occurs, and the context is the sum of all processes or organizational systems that influenced the situation.

The “Systems Paradigm”

We’ve all heard speeches at conference or read books that reference the work of James Reason.  A researcher and writer about the cultural and organizational influences that affect humans and their actions, Dr. Reason concluded “human error is only a symptom, not a cause — A symptom of issues deeper inside the organization resulting from its systems (how the product is built, parts are sourced, contract deadlines are established, compensation is determined, performance is judged, etc.).”

From recent articles about the VPPPA conference last fall, we are learning about a new safety initiative at General Electric called Human and Organizational Performance (HOP).  Based on the work of James Reason, and the desire to move beyond the results achieved from other initiatives, such as Six Sigma and Lean, GE has embraced HOP in an effort to wring out systems issues within the organization.

GE is shifting its paradigm and embracing the new Systems Paradigm.  They have turned away from focusing on the employees’ behaviors to accepting the fact that humans will make errors or mistakes.  Though it is far easier to focus on people and their behaviors, HOP shifts the discussion to process design, methods, tooling, procedures, schedules, and such.  They know this shift will take time, and will likely face strong resistance (like Dr. Corcoran suggests), but in the end will lead to a much stronger culture of performance.

James Leemann, PhD., wrote about HOP in one of his ISHN articles.  To him, systems thinking is long over-due.  Fixing the system and not trying to fix the people is the basic principle of the HOP philosophy.  He wrote, “Think about if you were a safety professional working in a manufacturing plant with 2,000 employees producing more than 400 products from 100 different processes, and the safety performance is less than stellar.  Would you rather fix the systems (i.e., 100 processes) or fix the behaviors of 2,000 employees?  Of course, keep in mind that the systems tend to stay the same day in and day out; whereas the behaviors of the employees change constantly.”



Systems thinking is a disruptive paradigm.  Clearly it forces safety professionals and management to think differently about accident causation, but it also opens the door to many other possibilities.  Initiatives like HOP hold great promise in making this shift away from behavioral causation.  Leemann says it well, “consider the willingness and enthusiasm HOP-trained employees will have locating risks and impediments in their work area with the objective of reducing, eliminating, or employing defenses to prevent injury or loss, versus being watched and critiqued by someone else in the name of behavior based safety.”  Obviously Dr. Leemann is “a disruptor” and not a fan of BBS.  Regardless of your position on BBS, I hope you see the value in looking beyond what the worker did or didn’t do, the choice they made, or other identifiable failure and see the value in looking at the context they faced at the time.

It is an exciting time within the safety profession.  We are hearing presentation after presentation, and reading numerous articles that are talking about human error and the systems approach to safety.  This is part of our evolutionary journey as we move through the focus on behavior, to the importance of the influence of cultural, and now to initiatives directed at the organization and its systems.  Whether we call this new paradigm “Safety 2.0” or “Safety Different” doesn’t matter.  What does matter is that we all embrace this change of thinking and do our best to spread the word.

As organizations mature I see us embracing all methods, systems and behavioral.  In upcoming blog posts I will write more about the HOP methods, and what other companies are doing to shift to systems thinking.  I’d love to hear your thoughts on this topic and any ideas you might have that could help others.  Thank you for reading and please share this post with others.


Richard Pollock, CSP, ASP