One of the things that is fascinating about my job is that I sometimes get the opportunity to spend time understanding how other people do their work. I know, it sounds a little boring. But the thing that’s so exciting to me is how work that seems boring or simple is, at least in my experience, always more complex and messy when you dive below the surface.
The other day at one of our construction sites we did a learning team* with some workers responsible for hanging and installing piping at our facility. Often these pipes are located high up near the ceiling, which means these workers are regularly in mobile equipment such as scissor lifts, raising the piping, rods, hangers, and other tools and equipment up pretty high in the air.
Regular activities we take for granted are often more perilous than we give them credit for.
Here’s the thing – this matters. This time we take to learn from the seemingly normal work around us. This isn’t just my little intellectual curiosity (well it’s not only that). In the stuff that seems boring and simple, there’s a massive amount of danger. Diane Vaughan called it the ‘banal accident theory’ – the idea that accidents are hidden in the mundane stuff.
Where work is difficult, challenging, or frustrating, that’s where you have risk. It makes a ton of sense if you think about it. That’s where you will have shortcuts (because who wants to work harder than they think they have to?) and you will have mistakes.
Of course, this begs the question, if there’s that much risk, why haven’t we noticed it before? Because people. People are so good at dealing with imperfect, difficult, complex things that they make it look easy. Dave Woods calls this the Law of Fluency.
So this is the reason we are doing these learning teams and other proactive learning events at our sites. To search for those areas that seem simple from the outside but are actually quite difficult. And, where we could maybe introduce new opportunities to support people.
Ok, back to our crew installing pipes. When you start to think about what could be difficult about installing pipe in the ceiling you can likely think of dozens (maybe more?) challenging things. Little decisions, dilemmas, assessments, etc., that have to be made that are ambiguous, uncertain, and require expertise.
We don’t have time in this post to go over all of these dilemmas, but one was really striking to me. It had to do with setting up exclusion zones underneath their lifts. You see, while carrying up their tools and equipment these workers sometimes drop them. We have controls designed to help avoid this, but there are so many ways something can drop that eliminating the potential is likely impossible. We have a backup plan – keep people out from under the lift with an exclusion zone when there is potential to drop something that could seriously injure or kill someone.
But this creates a decision point for the workers – how big should the exclusion zone be?
As a safety professional, I can answer that question. Your exclusion zone should be large enough to encompass the size and fall radius of anything you bring up, plus a reasonable safety factor to account for uncertainty. Pretty straightforward, right? (It’s not, but that’s for another post.)
What was really striking to me was when we asked the workers how they determined the size they didn’t mention any of that. In fact, they didn’t mention hazards or risks at all!
The first thing they mentioned, was how the exclusion zone will impact the other workers around them. Even taking time to negotiate which areas, and when, to block off so everyone can keep working. They actually spent a good amount of time describing in detail what they do.
Notice something interesting here – a question that, from my perspective, should have been a risk-based, or an engineering-based question, was a social-coordination question for the workers.
Note, this isn’t to say that the workers are right and I’m wrong (or vice versa). In fact, that’s not the point right now. The point is the way the workers are making their decisions doesn’t mean they don’t care about safety. It speaks to a conflict and/or pressure, previously unaccounted for, within the system that they are adapting to. It points to an unsupported aspect of our system.
Coordination.
All work (and most of the human experience) involves coordination. You can’t do your job without others doing some other job in some synchronized way with you. Think about it. You can easily see this is true. Likely, you can also think about instances where this breaks down.
Why is it, so few aspects of our system are intentionally designed to support coordination? Because humans are reasonably good at coordination on their own, so it makes it seem like it just happens without our intervention. That’s what happened during our learning team session. The negotiation the workers were doing on their own allowed them to work with and around each other at our sites. This was happening without us even knowing it was happening. If we thought about it, we might have guessed it was happening, but we certainly weren’t spending any resources to make it happen or support it. We were enjoying the hidden coordination dividend that so many companies (including yours) enjoy as a side effect of employing adaptive humans.
We have to recognize, that just because it happens without much intervention doesn’t mean it’s not difficult, that breakdowns aren’t very costly (or dangerous), and that we can’t implement things to support people in making coordination smoother.
Step one - we have to recognize coordination is, or what some have called ‘joint activity’, a critical aspect of safe, successful, and resilient performance.
Instead of merely being a factor dictated by personalities, coordination can be seen as a system attribute. We can evaluate the coordination needs within our system and develop systems, processes, and tools supporting the development of common ground and management of the costs of coordination.
Personally, I echo the work of Mike Rayo who argues that coordination and joint activity are the next big frontier in the new view/HOP and human factors world. As we dive deeper into the world of supporting people in doing complex work, we will quickly find we need to support people doing complex work, together.
*This is a semi-structured focus group with workers and other subject matter experts with the goal of understanding the complexity of work and finding ways to support workers.
Ron Gantt has over two decades of experience as a safety professional in the technology, construction, chemical manufacturing, and utilities industry. He is the HSE Director for the Americas for Yondr. Ron has his PhD in Industrial and Systems Engineering from The Ohio State University, a Master of Engineering in Advanced Safety Engineering and Management from the University of Alabama at Birmingham, and undergraduate degrees in psychology and occupational safety & health.
