Organizational Weaknesses – A Trigger™ Training

This training is an excerpt of our Trigger™ Training. Please scroll to review how this training can be helpful for you and your company.

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The defense in depth model known as the swiss cheese model developed by Doctor James Reason.

The purpose of this swiss cheese model is to show layers of defenses an organization uses between its people and an event.

Defenses fall into four categories:

  • Administrative defenses, like: Policies, procedures, checklists, charts, training, work planning, and signs and labels to name a few.
  • Physical defenses, like machine guards, berms, barriers, guardrails, mechanical interlocks, and handrails.
  • Oversight defenses, like safety personnel, supervision, quality control, observation and feedback, and management walkdowns.
  • Behavioral defenses, like various safety & human performance tools such as use of personnel protective equipment (PPE), self-check, procedure use and place keeping, stop when uncertain, eyes on path, and electrical de-energized checks.

In the model, these defenses are represented by slices of swiss cheese. The defenses are developed by people and, we know, people make errors. The holes in the cheese represent these errors and result, at times, as Latent or Known Organizational Weaknesses that our people have to work around. The holes also represent active errors by the workers themselves. The bigger the hole, the greater the hazard. These weaknesses in the defenses can appear as visible Triggers to our workers and others.

Peer Pressure: Social norms call for us to behave in certain ways. This can drive peer pressure.

If we have a culture where we are allowed to chastise each other for not getting work done or not following along like others do by taking shortcuts and bending the rules, then Peer Pressure can be a problem and cause workers to remain silent, not speak up or ask questions, and not Stop when they are unsure.

Schedule or Time Pressure: Schedule or Time Pressure is like Peer Pressure. Social norms call for us to behave in certain ways.

If we have a culture where it is allowed to chastise each other for not meeting the schedule or “bagging” the next shift with uncompleted work, then Schedule Pressure can be a problem and cause workers to remain silent, not speak up or ask questions and not stop when they are uncertain.

Additionally, schedule pressure can drive workers into taking shortcuts based on their perceived risk.

If the culture only rewards for completion of work “on time”, and not on “Quality of Work” (e.g., how it was completed, by procedure, by safety protocols, etc.), then Schedule Pressure can be a significant problem and cause potential issues such as rework, repeat maintenance or other redo of work which should have been completed the first time as well as workers who remain silent, not speak up or ask questions and not stop when they are uncertain.

Sign Blindness: Another issue that tends to drive our behavioral choices is something known as “sign blindness”. Have you ever walked up to a door leading into a building or room that had four, five, or six or more signs, did you actually read them all or just blow through the door? Sign blindness creates blind spots that grow more and more over time when:

  • Sign placement conditions are unchanged
  • People are successful when not adhering to warning signs
  • There is an overuse in the amount of warnings or other informational signs

Habituation: Another factor that influences our behavior comes from habituation. A form of habituation is something we call the “Get Used to It” concept. This concept states that a human may learn to ignore a stimulus because of repeated exposure to it which means that a person tends to ignore a stimulus, such as a sign, a hazard, and or paged announcements when he or she has been exposed to it numerous times.

Pollyanna Principle: Pollyanna was the little girl who only saw the good in people and things. She did not focus on or acknowledge the bad. We, as humans, tend to focus only on the positive. Sometimes, to our own detriment.

At work, we run into this when we hear: “We do it this way all the time and never had a problem.”

It may be going right, even though we take shortcuts. We should not expect future success based solely on past results. Focusing only on the positive may prevent us from expecting the negative and not stop when unsure.

Rationalization is simply when we convince ourselves that it will be okay to proceed and we do not accurately account for the risk given the workplace hazards we face to accomplish work.

At HRT we have found that when workers rationalize, they fall victim to the #1 killer of their natural Questioning Attitude. In other words, we tend to rationalize our way into proceeding with the task or activity without getting the help we need with questions we have. This process of rationalizing our thoughts tends to drive an inaccurate risk perception.

Risk perception is the subjective judgement that people make about the characteristics and severity of a risk. Rationalization usually fits in here with “Risk Perception”. We rationalize our way to proceed.

With our Organizational Weaknesses – A Trigger™ Training course, we will provide you with the enhanced abilities in the following areas:

  • What You Will Learn | Defense-In-Depth (The Swiss Cheese Model)
  • Why People Proceed in the Face of Uncertainty | Human Nature’s Resistance to Stopping Work
  • Rationalization & Risk Perception | Summary
  • What You Can Do Tomorrow

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