Why Good Operators Make Poor Decisions That Lead to Incidents

We recently came across an article by Marcin Nazaruk in the September/October edition of Drilling Contractor titled “A brief history: the evolution of human factors, human performance”.  The article is a concise synopsis on the origins of Human Factors / Human Performance thinking and does an excellent job explaining the connection between people, their performance, and the system in which they work.  At Vetergy, we pride ourselves in being able to explain why good operators make poor decisions that lead to incidents and accidents.  If, as a leader, you find yourself frustrated with seemingly poor decision making and repeated errors while exhausting all efforts to get employees to be more reliable, the following three concepts may provide you with a new perspective to consider in your endeavors to improve performance.   

1. People are just one part of a broader system. To make sense of the decisions and actions employees take in the workplace, leaders must understand all components that exist in the work environment and have an impact on decisions there.  These components, when combined with the human element, are what we refer to as the “system”.  The most basic components of any high reliability system can be grouped into three main categories: mechanical reliability, process reliability, and human reliability. By looking at the system this way, we are less prone to focus just on the human error and more likely to identify gaps in other areas that influence decisions and contribute to mistakes. 
2. People make decisions (and errors) within the framework of the system.  From our experience investigating incidents and analyzing human factors, people typically want to do a good job.  Often, we find errors occur when employees are trying to “make it happen” by compensating for known gaps in the system.  Of course, no system is perfect, and gaps will exist. By understanding how the system is connected, leaders can more effectively manage gap related-decisions to produce predictable results.  To illustrate this point (and quoted in the article) is Geary Rummler’s observation “if you put a good performer against a bad system, the system will win every time.” 
3. As leaders, you must understand the system if you want to make improvements.  Systems are complicated and the mechanical, process, and human components of systems are connected in complex ways.  The structure and design of a system may vary both over time and from one organization to another.  

The figure below illustrates the complex nature of a generic operating system.  An error, gap, or disturbance introduced at one end of the system may take weeks, months, or even years to manifest as an accident or incident on the other end. The better leaders are at understanding their system and how it is connected, the better equipped they will be to make informed decisions to improve system health, prioritize resources, promote innovation and communication, learn from mistakes, and improve overall performance.