We recently compiled and published a guide to “new views” of safety—things like human and organizational performance (HOP), safety differently, safety-II, resilience engineering, and human performance improvement (HPI). That guide includes 29 safety professionals from around the world explaining what these “new views” are, giving simple tips on how to apply it at your workplace, and even suggesting books, websites, and podcasts where you can learn more.
If you read the guide, which we encourage you to do, you’ll notice a few common themes. First, what we’re calling “new view” isn’t necessarily exclusive to safety but is more about creating business success. And second, a LOT of what we’re calling the new view has to do with relationships between safety managers and the employees who do the real work.
One of the ideas involved in the relationship between workers and safety managers/professionals is something called local rationality. Studying local rationality makes sense for safety managers for many reasons, but it’s especially important after an incident has occurred (sometimes in the new view of safety the term “event” is used instead of incident).
In this article, we’ll explain local rationality a little more and explain why studying local rationality is important when performing an investigation after an incident has occurred.
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You can probably find more detailed explanations of studying local rationality (for example, check out this wonderful Introduction to Safety-II by Eurocontrol for a great explanation), but a simple way to think of it is trying to learn why a person chose to do something. What were they thinking at the time? Why, at that time, knowing what they knew at that time, did the decision they made make sense to them?
In this discussion with Todd Conklin, he puts the act of studying local rationality this way: “…traditional safety looks down and in, and HOP looks up and out. So if you really had to give an elevator speech, HOP asks what failed, and classic, traditional industrial safety asks who failed?”
Compare the idea of studying local rationality to learn what an employee was really thinking and why they made the decisions they made and performed the actions they performed with other approaches where you may not wonder much about what the employee was thinking at all. Perhaps you can see how this can be a more empathetic approach and how it might lead you to more operational and organizational learning.
Local Rationality and Incident Investigations
One of the key principles of the new view of safety is that the workers are the solution, not the problem (see our discussion with Ron Gantt on “safety differently” for more on that). And that’s because the workers at the so-called sharp end, where work gets done and risk and hazards are real, are the real experts on how work gets done and on safety issues. So as a result, in new safety it’s considered very important to “study normal work,” and you can see how understanding local rationality and what employees are thinking when they make decisions would be an important part of that.
But studying local rationality is especially important after an incident at work has occurred. And that’s because your ultimate goal shouldn’t be to say it was the result of worker error, you shouldn’t be aiming to blame the worker, and you should want to learn something about why the event really occurred. And your best chance of doing so is by learning what the worker was thinking in the moments leading up to the incident, why their decisions made sense to them, and why they did what they did.
This is what Todd Conklin meant (above) when he said we want to look “up and out.” We want to put ourselves in the shoes of the worker and view the workplace context/environment/system from their perspective. And when Conklin says we don’t want to look “back and down,” he means we don’t want to judge the worker’s decisions and actions from an outside perspective that’s not informed by what the worker was thinking and doing at a later time when we have much more information about what would happen (because by the time of the incident investigation, the incident has occurred and everything NOW seems obvious, logical, predictable, and even inevitable….see our recorded webinar on incident investigations and cognitive bias for more on this).
It may occur to you that you’re unlikely to really get an understanding of what the worker was thinking if the worker doesn’t trust you. And you’re right—you won’t. Which means you’re going to have to begin putting in the work, creating those relationships, and developing trust with workers well before any incident. And you’ll do this by studying normal work, like we said, by asking workers questions and by being genuinely interested, by recognizing and respecting their expertise, and by helping to develop an environment of what Amy Edmonson calls psychological safety at the workplace.
Local Rationality and Systems Thinking
The end result of studying normal work and local rationality is you will learn more about the systems at your workplace. Because if your incident investigations end by saying “there was human error,” and your resulting safety improvement efforts revolve around trying to stamp out human error, know now that your efforts will be doomed to failure.
Humans are humans. They create great successes at work under varying conditions every day and they also do many things we might call “human error” every day. Most of the time, those errors have no significance. Sometimes, they’re involved in an incident. But no matter how much you try, you won’t make a human worker anything other than human, and they’ll continue creating those successes and making “mistakes” that sometimes become wrapped up in what we call an incident.
By studying local rationality, you can find what it is in your workplace system (sometimes called the context or environment) that made the worker think what they thought. You can then make changes to your system (not to the worker) to improve the capacity of the system to continue to operate successfully and safety even if “human error” does occur. And that’s where you’ll really improve the safety performance of your organization.
For more, see our introduction to systems thinking, this discussion about systems and safety with Pam Walaski, and this discussion on systems, complexity, and safety with Adam Johns.
Our Conclusion on New Safety and Local Rationality
We hope you found this article helpful. If you begin creating respectful, trusting relationships with employees through work, by asking questions, respecting their expertise, and developing psychological safety, you can begin creating a safer, more productive workplace. And studying local rationality is a key part of all that.
Before you leave, feel free to check out some of the additional resources linked below:
And, because we always like to link you to many sources when we can, here are some more articles on local rationality:
