When things go wrong, it is a natural reaction to be upset and outraged at the individual responsible. Because of hindsight bias, we look at the event with knowledge of the outcome and this makes it easy to blame the individual’s actions and decisions leading up to the incident. Once we blame, the immediate solution that comes to mind is to remove the individual. But to thrive, we must not fall prey to our hindsight bias. We need to learn because the same or a similar event may end up happening again, and maybe next time the consequences will be worse. Although not all accidents and injuries are predictable, if the organization does not learn and improve when things go wrong, the organization’s culture begins to stagnate.
If we ask questions that help us to see beyond the individual’s decisions and actions just prior to the incident, we will be more likely to learn about our business from many perspectives. The individual-environment interaction that takes place as people perform work is supported by the science of Ergonomics and Human Factors (the study of work). One way of describing work to help with learning about how work is done is the Sociotechnical systems model. ‘Socio’ refers to the social environment and includes individuals and team dynamics, and ‘technical’ refers to the technology, tools or equipment being used and also includes consideration of the organization of work[1].
Modelling work as a sociotechnical system means looking up and out to all areas of the business and this may be most helpful for discovering sustainable solutions after an unwanted event such as a workplace injury.
Suzanne Jackson, Human Factor West
The key elements of that model should include the cognitive/affective, social, organizational and physical aspects of the work. Although the tendency is to focus on the physical aspects of a work injury, all the aspects of work interact and impact how workers behave.
Rather than looking at the individual involved (just one component of a dynamic work system), we can ask questions that gives us back a narrative that includes all the human factors in the particular work system. Watch out for hindsight bias and our reactions to unwanted events such as workplace injuries. We have many biases that prevent us from asking good questions – if we are not aware of them, they can fuel the blame logic and leave people feeling unsupported.
[1] Carayon, P, Peter Hancock, Nancy Leveson, Ian Noy, Laerte Sznelwar and Geert van Hootegem. Advancing a sociotechnical systems approach to workplace safety – developing the conceptual framework (2015). Ergonomics, Vol. 58, No. 4, 548–564.
