- To conceive or fashion on the mind; invent 1
- To create or contrive for a particular purpose or effect 2
My career in the safety and human performance field has taken a circuitous route. Having spent years in military aviation I came into the safety world by necessity. Aviators and aircrew inherently apply safety management to operations because an unsafe mission (or perhaps I should say missions where risk tolerance exceeds accepted boundaries) may be successful in the short term, but in the long term behaviors that encourage unacceptable risk taking will likely result in losses and mission failure. As time went on I ended up in more traditional safety roles, with direct safety and compliance management responsibilities. Still, though, I had an understanding that safety needed to support operations and operations needed to support safety. Again, a mission with major operational losses is an unsuccessful mission even if it accomplishes the main mission objective. So, there is an important interdependence between operations and safety.
As my career progressed I found myself learning more about safety, which helped me to view safety through various lenses, but throughout the process I continued to understand that safety has to work to support the worker and operations. Workers are often placed in a position to make due with sub-par equipment and archaic designs and are often required to work among numerous hazards and distractions. These factors may make it very challenging to perform their work. These are sometimes referred to as error-provocative environments. Despite these issues, there are still accidents, incidents errors, and failures where the employee is blamed and solutions fall into the retraining bucket with admonitions to “pay more attention” next time. These short-sighted approaches often fail to take into consideration the design of machinery, equipment, facilities, or the overall work system. Rather than the work system being designed or redesigned to help the employees do their jobs more effectively, efficiently, and safely, in many cases the workers are expected to excessively adapt to unruly methods. Humans are amazingly capable at adapting, and many times these strategies work… until they don’t.
The importance of design in everything we do in the work environment should not be understated, but for some reason many either feel that design should be left to a key group of people whose specialty is design or they may not even understand what design is or how it fits into the operational or safety context. Designers have a very key skill that is very important and should not be understated. They may possess skills non-designers do not have nor understand, but I do not believe designers can do their jobs alone. They need input from a diverse group who have a stake in the system. I have come to realize that design thinking should be a key skill for safety professionals and others who seek to optimize individual, team, and organizational performance
The book Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation offers some insights into design thinking, even for non-designers. I found this work extremely interesting because I think it helps the reader to understand how design can be used to make systems more useful to the user (or worker). While the book is not specific to the safety, human performance, or operations management fields I think there are many lessons that can help these other professionals from diverse communities and backgrounds learn ways to help design better systems. After all, one of our major goals should be to help front line workers perform their jobs better, so why shouldn’t we consider methods to help design better work systems. Even if safety professionals are not designers themselves, injecting themselves into the process of creating policies, procedures, and work methods may help them to use their expertise to assist other planners and designers to ultimately help the front line worker.
Looking back at the definitions of design listed at the top of this post, although they are both pertinent I think as safety and operations professionals the second one hits close to home because we want to create policies, procedures, and work systems that are used for a particular purpose: namely operational performance that meets production targets within acceptable risk boundaries. So, if considering a design thinking approach and considering whether or not our actions are helping employees perform their jobs better, the following questions may help:
- During the procurement or policy development process do we consider the operational environment, the artifacts (including technology, machines, equipment), SOPs, and rules and how employees will interact with them or do we “design in a vacuum,” where we create things that we think are perfect and simply tell the employees to follow the rules and procedures, to pay more attention, and to stop making mistakes?
- Do we underestimate the need for good design that supports front line workers and teams as they perform their work?
- Do we design the work systems for feedback and use an iterative cycle for improvement, understanding that designers may never get it completely right the first time? How can we expect our crews, teams, and employees to not make mistakes if the designers fail to recognize or anticipate certain challenges with operational performance? Do we get surprised when employees end up creating workarounds?
- Do we design for resilience so that the system is error tolerant, designed to withstand human error and failures, and is able to gracefully fail and then recover rather than experiencing catastrophic collapse through brittleness?
- Do we give consideration to the end-user and the front line operator’s point of view? (Empathy may go a long way and it may help to consider times when we may have been the recipient of a poorly designed product or procedure).
The list above could be much more extensive, but is written to serve as a set of guiding questions to help us understand the importance of design thinking. Design thinking should help us understand the importance of inclusiveness in the design process and that all stakeholders who stand to gain or lose from the work system design results should be included. This means building relationships with numerous stakeholders, including operations, safety, quality, reliability, human resources, suppliers, and others. In many cases it can be easy to get sidetracked with myopic views of safety and in the process it may be easy to forget about a good design process and simply go for compliance-only approaches. Additionally, “pay more attention next time” and “just try harder” strategies will likely not be effective in the long term if the operational environment (facilities, machinery, equipment, processes and procedures) are filled with error-provocative areas that may make it more likely for employees to commit errors. Distractions and hazards make it more challenging for operational teams to do their work and a lack of design thinking may play a big factor in ineffective safety strategies.
Will designers always get the design right the first time and will the end product be fully usable by line operators (to the point where there are no unnecessary workarounds required to make the product or system actually function to meet the competing organizational goals in the operational environment)? A good design process should include users and should include a system safety hazard analysis process that considers the potential for unintended consequences of safe system design, such as features that make a product or system extremely hard to use and meet production and safety goals. Design thinking may help us with these issues.
Some resources that may help safety professionals and practitioners with the work system design process, include the American National Standard for Occupational Health and Safety Management Systems ANSI Z10-2012ANSI/AIHA Z10-2012 and Prevention through Design: Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes ANSI/ASSE Z590.3-2011.
Next time there is an error in the workplace, rather than simply blaming the employee (without first using a system-oriented approach to investigation), perhaps an approach that examines the operational environment and the design of the work system may help to shed some light on the why and how behind the error.
If you liked this post you may find additional posts related to operations and safety performance, human performance, leadership, and Crew Resource Management here.
American Industrial Hygiene Association American National Standard for Occupational Health and Safety Management Systems ANSI Z10-2012. Fairfax: American Industrial Hygiene Association, 2012
American Society of Safety Engineers. Prevention through Design: Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes, ANSI/ASSE Z590.3-2011. Des Plaines: American Society of Safety Engineers
Chapanis, Alphonse. “The Error-Provocative Situation”. In The Measurement of Safety Performance, Edited by William E. Tarrants. New York: Garland Publishing, 1980