Using the brain as personal protective equipment
Why do so many people still get hurt at work even though we do so much to try and keep them safe? For instance, it is estimated that workplace incidents cost the Australian economy $60.6 billion per year, representing 4.8 per cent of GDP in the 2008-09 period (Safe Work Australia, 2015).
Most organisations think of safety in terms of hazards/risks/controls; the worker’s knowledge; and their ability to make deliberate choices with safety in mind. Although these have merit, and are a part of the overall solution, they are not enough to prevent many incidents, even serious ones. What is missing?
These days there is strong evidence that inattention, or human error as it is sometimes referred to, is an important factor when incidents occur. A 2009 study conducted by Clemson University for the Queensland Department of Mines and Energy reviewed 508 reportable incidents in Queensland mining during 2004-08 and concluded that ‘human error leading to an unsafe act was an underlying cause of 95 per cent of accidents and incidents in Queensland Mining’ (Patterson and Shappell, 2010).
Competency – having the required skills to do a task – is not enough. Using road safety as an example, car incidents are not the result of people all of a sudden forgetting how to drive. Data from a 100-car naturalistic driving study (Dingus et al, 2006) – these studies measure real-life driving using in-car video cameras, eye trackers and sensors – found that inattention was a factor in 78 per cent of all crashes and near misses.
Traditional safety management and the principals of safe design are important in incident prevention, but there is always some residual risk. Managing inattention reduces the residual risk by limiting the potential for exposure.
People are accustomed to blaming tiredness, problems at home, outside distractions and other external factors that are beyond the control of the workplace for inattention. Some of these factors could be dealt with as part of a traditional safety management approach; however, there is also an opportunity to minimise inattention by teaching the individual the cognitive and neurological processes that drive what they do and providing training with coaching to help them become more attentive.
What we do is key, but not what we do consciously
Most organisations have worked out that what people do in the moment (as opposed to what they plan to do) has a lot to do with incidents and injuries, even with the serious ones. There is an unstated belief that people are rational and that incidents result from people making deliberate choices. This approach focuses on the self-management functions of the conscious mind as having the greatest influence on what we do. Many workplace initiatives such as safety leadership, safety observation programs or ‘cultural’ programs provide approaches that are based in improving conscious thinking. This helps but it is not enough to prevent all incidents.
Neuroscientific research estimates that up to 95 per cent of our everyday actions are subconscious. When we think about it, we realise that a good deal of what we do is below our conscious awareness – taking a shower, brushing our teeth, how we put our clothes on, driving a car, as well as all sorts of everyday things – happen without a lot of conscious thought. In other words, sometimes we know what we are doing through our awareness of it – but at other times it is the subconscious processes that drive what we do, something people refer to as being in ‘autopilot’ mode. So, if we want to keep ourselves safe, we have to be aware of how our subconscious mind works and ensure we have the safest skills and habits possible.
The automatic inattention pattern
It has been reported (Wilson and Higbee, 2012) that when people who had been involved in an incident were asked how they hurt themselves at work, at home or on the road, most of them replied that they made a mistake doing something they had done plenty of times before. When these people were asked what mistakes were made that lead to them getting hurt, over 90 per cent of the responses came back along one of four themes, which were named ‘critical errors’. Wilson identified these mistakes as:
- eyes not on task
- mind not on task
- line of fire
- (a loss of) balance/traction/grip.
When people were asked what was going on with them when they made one or more of the four critical errors, over 90 per cent of the responses came back along one of the following four lines, which were named as ‘states of mind’ or ‘attention disruptors’:
Once people are made aware of this, many realise for themselves that they are most likely to make one or more of the four critical errors while in one or more of the four states of mind. When they make one or more critical errors, they are increasing their risk to hazards and potential harm (Figure 1).
Traditional safety management practices include hazard elimination, engineering controls and the use of barriers to keep the hazard separated from the person, thereby reducing the probability of an interaction between the two. The problem is that there is always some residual risk, and inattention increases this by increasing the potential for exposure when (for any planned or unplanned situation) the traditional risk mitigation is breached. It is also worth noting that inattention in and of itself could be the cause of this breach.
There are two main ways that people interact with a hazard. The first is when the hazard is moving towards them. Under these circumstances, traditional safety management practices are very effective because we can guard or separate people from the hazard. The second is when the person is moving towards the hazard. Under these circumstances, if the person is not looking at or thinking about what they are doing (eyes and/or mind not on task) many everyday things can become hazards. People bump into chairs (tables, other people, etc), they slip on wet floors, they trip on uneven surfaces, etc. When there are hazards with potential for considerable harm, the consequences of these critical errors are also increased considerably.
The issue is that most of the time when we are inattentive while moving – eyes and mind not on task – nothing bad happens, so we become used to not looking and not thinking when moving and do it habitually (that is, it becomes a habit).
While we may be able to address the sources of the states of mind at times, we cannot eliminate them from the world. Unfortunately, telling people not to rush, not to get frustrated, not to get fatigued or not to become complacent does not work. To get people to pay more attention, or move more mindfully, we need to enable them through deliberate practice to deal with the four states of mind as they arise, in the moment. But before we can do that we need to understand how the four states of mind influence our cognitive abilities.
How rushing and frustration come about
When we start to rush or become frustrated, physiological changes take place within our bodies and we start to feel different. Research at the Yale School of Medicine (Arnsten, Mazure and Sinha, 2012) found that our non-essential neural systems for survival, like our ability to reason, are sidelined to prepare us for action. This diminishes our cognitive ability to process information, making our focus narrower so that we can deal with the immediate threat more effectively.
The research showed that neurons in the prefrontal cortex (where conscious cognition resides) disconnect and stop firing after being exposed to high levels of neurochemicals such as norepinephrine and dopamine. This effectively shuts it down. Even small changes in the level of neurochemicals can instantly weaken connections. What this means is that the higher the level of neurochemicals, the more impulsively we act and the more difficult it is to consciously override or control what we do.
How fatigue comes about
Fatigue is an unavoidable physiological condition that cannot be overridden. A good night’s sleep is always desirable to start the day fatigue-free, but fatigue also builds up during the day.
Thinking, especially conscious thinking, generates certain ‘waste’ products (adenosine mainly) that hinder normal electrochemical activity in the brain. When the mind works hard for a sustained period it generates more wastes than can be diffused away, and this progressively hinders the firing of neurons in our neural networks, manifesting itself in the ‘brain fog’ feeling that we get. One of the effects of this waste accumulation is the reduced ability to concentrate on a task, which is when many incidents take place. The afternoon nap (especially popular in southern European and some Latin American countries) or the recommended ‘power nap’ may be ways that we can ‘buy time’ for our diffusion process to catch up with the build-up of wastes before overnight sleep comes around.
Research at the University of Groningen assessed the effect of mental fatigue on our ability to be attentive (Boksem, Meijmen and Lorist, 2005). The research found that, when driving a car while mildly fatigued, the driver’s ability to:
- focus on the road and other vehicles (goal-directed attention) was diminished
- operate the car (stimulus-directed attention) was not affected.
In other words, because the activity of driving (operating the car) is not inhibited while we are mildly fatigued, we think that we are paying as much attention as we normally do and this is ‘enough’ to drive safely, when in fact, this is unlikely to be the case.
How complacency comes about
Although it is enticing to believe that we can get people to always think consciously about all their actions and to always make deliberate choices, we need to appreciate that because of human neurobiology this does not happen often.
In our distant past, resources were a lot scarcer than today and our brains built a preference for doing thing automatically. This ability helped us to survive and was passed on to our descendants. The result is that we have a brain structure very similar to our ancestors.
A way to look at how this happens is provided by Charles Duhigg, author of the book The Power of Habit. He defines habits as ‘the choices that all of us deliberately make at some point, and then stop thinking about but continue doing, often every day’ (Duhigg, 2012).
Research at the Okinawa Institute of Science and Technology (Shibuya, Cleal and Kines, 2010) has uncovered the role of dopamine, referred to as the ‘pleasure chemical’, in habit formation. Dopamine plays a significant role when we are learning new things but subsides once a skill or habit is established. Dopamine acts like the spark plug that helps to increase the focus and attention required to build the neural networks that will enable the skill or habit. The reason why this is an important brain function is that what we do habitually, we do more reliably and more energy efficiently.
The problem, of course, is that whatever habit we establish tends to drive our actions. Most of these are fine, but people do end up with habits that are not the safest.
The evidence for a different approach
There is no silver bullet to keep people safe, and anything we can do to mitigate the risks of personal safety is worthwhile. However, the subconscious processes that drive as much as 95 per cent of what we do are relevant and these processes have not featured at all in many current safety initiatives.
Although recognising the states of mind and the critical errors is the first step, this alone does not result in people doing things habitually safer. The reason is that the states of mind and critical errors are ‘baked into our brain’ through endless repetition over the years – neither the states of mind nor the critical errors can be ‘decided away’ very easily. They are part of our DNA.
If we want people to be safer, we also need to influence the subconscious processes that drive the autopilot mode. This is a very different approach to training people to have the right knowledge or to make safer, deliberate choices. We need to get people to change their autopilot habits to safer ones – this is not just a matter of training people but getting them to practice specific techniques that help them avoid an incident.
Attention improving programs have been implemented in a variety of industries (manufacturing, power generation, construction, mining, service providers and others) and local governments with comparable results.
Figure 2 shows the total recordable injury frequency rate (TRIFR) achieved by a global coal mining organisation that implemented an attention improvement program. An excellent correlation was observed between safety performance improvement at each of the ten sites and the roll out of the program. Cost savings were observed with respect to other operational issues (quality, equipment damage, etc), indicating that dealing effectively with inattention can also have broader business benefits.
A typical attention improvement program involves:
- leadership session (one day)
- champions training (three days)
- employee sessions (two hours each; five sessions, one every two to threeweeks with practice tasks)
- post employee session review and development of sustainability plan (half day)
- coaching training (half day)
- advanced employee sessions (two hours each; three sessions, one every three months with practice tasks)
- 50 tool box talks
- refresher sessions (two hours).
The sessions explain how mistakes are made and what can be done to make fewer of them; they utilise specific language and there is a series of practical exercises designed to improve personal safety skills and habits. There is a take home component so that participants can teach these skills and habits to the people they care about the most: their family.
At most sites, over 99 per cent of participants rated the program as beneficial or better, as evidenced by the common use of the specific language.
Cristian Sylvestre is the author of the recently released book Third Generation Safety: The Missing Piece. The book is available now from www.habitsafe.com.au.
Arnsten A, Mazure C and Sinha R, 2012. This is your brain in meltdown. Scientific American, 306(4):48-53.
Boksem M, Meijmen T and Lorist M, 2005. Effects of mental fatigue on attention: An ERP study. Science Direct Cognitive Brain Research, 25:107-116.
Dingus T, Klauer S, Neale V, Petersen A, Lee S, Sudweeks J, Perez M, Hankey J, Ramsey D, Gupta S, Bucher C, Doerzaph Z, Jermeland J and Knipling R, 2006. The 100-car naturalistic driving study. Virginia Tech Transportation Institute. DOT HS 810 593.
Duhigg C, 2012. The Power of Habit – Why We Do
What We Do In Life And Business, (Random House: New York, USA).
Patterson J and Shappell S, 2010. Operator error and system deficiencies: Analysis of 508 mining incidents and accidents from Queensland, Australia using HFCAS. Accident Analysis & Prevention, 42(4):1379-1385.
Safe Work Australia, 2015. The Cost of Work-Related Injury and Illness for Australian Employers, Workers and the Community: 2012-13 [online]. Available from: www.safeworkaustralia.gov.au.
Shibuya H, Cleal B and Kines P, 2010. Hazard Scenarios of Truck Drivers’ Occupational Accidents on and Around Trucks During Loading and Unloading. Accident Analysis & Prevention, 42(1):19-29.
Wilson L and Higbee G, 2012. Inside Out – Rethinking Traditional Management Paradigms, (Electrolab Limited: Belleville, Canada).
Feature image: Adwo/Shutterstock.com.