Learning Curve: Work it back

by Tracy Clayson
Tracy Clayson is director of client development at
In Transit / CPC Logistics Canada. t.clayson@callcpccanada.com

When communicating with employees about job safety, managers often speak in generalities, outlining mistakes that can be made and injuries that might result if rules are not followed. Sometimes they’ll throw in accident statistics too, and they might devote some time to explaining the importance of regular maintenance and safety inspections.

It’s rare that a management team adds a dynamic, focused, real-life look at specific workplace accidents (and tragedies) to share lessons directly from them. It’s rarer still for them to talk about what went wrong, what happened to the victim(s) and his/her colleagues and to try measuring the true impact of such incidents.

Our company is sometimes tasked with providing expertise on safety, including risk assessments to address training shortfalls, fixing outdated training programs and even developing new employee orientation packages.

We do it differently from most. We prefer not to focus up front on best practices, what works and what doesn’t, or to provide detailed advice that our clients can madly scribble on a pad. We know that rules for rules’ sake don’t work.

Mostly, we start by listening. And we take a problem-based approach. We talk to the employees about specific accidents and events – and their real-life consequences – and let this drive the conversation.

Human beings are prone to making errors. We know this, but I believe we aren’t digging deeply enough when considering how to stop them.

I believe what’s missing is a look at causes. We should be “working it back” to find out why something happened. And in a work environment, we all know not working it back can prove very costly, in financial and human terms.

This concept has been documented before. The Undoing Project: A Friendship That Changed Our Minds, a book by Michael Lewis, writer of Moneyball, discussed the work of Amos Tversky and Daniel Kahneman, whose research about how people make decisions won the Nobel prize for economics.

Significantly, their experiments showed that people’s judgement was systematically incorrect. There are two primary reasons for this, claims Lewis. First, people’s judgement could be distorted by memory.

Second, he said “the more easily people can call some scenario to mind – the more available it is to them – the more probable they find it to be. Any fact or incident that was especially vivid, or recent, or common – anything that happened to preoccupy a person – was likely to be recalled with special ease, and so be disproportionately weighted in any judgement.”

Lewis also shared two examples from Tversky and Kahneman where this held true for them personally. In one case they drove past a serious car accident on the highway. This immediately made them drive more slowly. Their sense of the likelihood they would suffer the same fate as the other driver had quickly changed. In the second example, “after seeing a movie that dramatizes nuclear war, they worried more about nuclear war; indeed, they felt it was more likely to happen.”

So, conversely, I would suggest that in the absence of any memory of a recent accident at work, an employee will assume one won’t happen to him/her. But they do keep happening. For example, sometimes it’s thought processes such as, “Those pedestrians will see me” (because pedestrians always do) or “I don’t need to check the brakes as often as the regulations say (because I’ve never had a problem)” – that eventually lead to a tragedy.

Either way, we know human beings will continue to make bad judgements. We can have good rules and regulations, ensure management and staff are engaged and update policies and processes, but we might make a bigger impact by thinking more about causality too, and by working it back.

In addition, if we find an error was made and we look at it in a very focused way, we may find it’s because a staff member hadn’t eaten a healthy breakfast or didn’t get enough sleep, or that the lighting in the shipping area was bad.

By interviewing the people involved and working it back, we may determine what led directly or indirectly to the accident. And if so, management likely would fix these problems quickly, making a real impact with little effort.

It’s a more constructive alternative to believing only that more training, rules and maintenance are the panacea for what ails all workplaces. That’s simply not specific or focused enough. It might just scratch the surface of why an accident happened. Better to work it back.