Work as imagined and work as done

"the unknown brings with it danger, disquiet, worry - one's first instinct is to get rid of these awkward conditions" Nietzsche, 1888

This week I attended a workshop on human and organization performance (HOP). For those of you that may not have heard of HOP it is a set of principles and a philosophy to understand how work is done. The first principle is that people make mistakes. I make mistakes all the time. Typos, failing to put my turn signal on while turning and putting too much salt in my mushroom soup. But in the world of complex high hazard work mistakes can result in serious injury or fatalities. For the past 100 or so years, in an effort to prevent serious incidents managers, engineers, and safety professionals put their heads together to imagine the work and how it should be done in a manner to prevent injury.

This worked for a while until we made work and life more complicated. We added technology, we created regulation upon regulation, procedures, added technical controls, more inspections, more audits and better personal protective equipment. However, now when an incident happens during the work as imagined it is infinitely more difficult to determine what failed. Out of all this we have come to determine that blame fixes nothing. Which is the second principle. When investigating to learn about what failed we will not improve simply by blaming the worker. Because behavior is driven by the context of the work, environment, people and experience.

Which is the third principle. Context drives behavior. Why did I put too much salt in my soup. Cause it was missing a little something. What did I learn? The salt in the shaker flows more freely in this restaurant than at my house. Which is the fourth principle. Learning is vital. What we have learned is that training is not learning and unless the corrective actions generate personal and organizational learning the incident will happen again. This is actually helpful as you can simply pull out the investigation report, change the date, location and names and resubmit. Out of all of this how we respond to how the work was done as opposed to as imagined is critical to create a just work culture. Which is the last principle. Response matters.

What is the story here. When incidents happen at work our leaders must respond in a measured and professional way. We must look at the context with which the workers operate under and recognize that it shaped their behavior. Workers when operating in a complex and hazardous environment continually adjust their behavior and most of the time those little adjustments achieve safe work. When work as imagined and work as done fail to align we must learn or we will repeat the same mistakes as before.

Additional thoughts:

• successful work and unsuccessful work basically happens in the same way

• humans are a source of knowledge to understand adaption and flexibility

• we cannot change the human condition we can change the conditions under which we work

• “Human error” is a construct, a symptom of something deeper

• efforts to eliminate error are likely to be counterproductive and may make things worse

• if we really want to understand “work as done”, we need to speak to the people that do the work.

• seek to understand the messy details behind successful work