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Todd Conklin, Ph.D., is senior advisor, environmental safety, health and quality, at Los Alamos National Laboratory. In this interview, Conklin discusses his views of human error in the workplace and how an understanding of human behavior and culture can help improve workplace safety.

Please provide a brief description of your professional background and of your position with Los Alamos National Laboratory (LANL).

I have been with the lab for about 22 years. I work in the safety improvements initiatives office. We work mostly with human performance and systems and align our organization toward the ability to learn from events.

My background is in organizational culture and behavior. I hold a doctorate in that area. When you work at a place like LANL, everyone has a Ph.D. The doctorate allows me to be a part of the crowd at LANL. LANL is a great place to look at the effects of our culture on worker behaviors.

I travel and am fortunate to get to work with many organizations and to help them understand the complexities of safety programs and cultures of organizations.

I also conduct investigations around the country, serving as the human performance “set of eyes” on the event understanding activity.

What are the most common misconceptions about human error in the workplace with respect to occupational injuries and accidents? How do these misconceptions vary among management and employees?

The one that bugs me the most is the belief that if you simply ask workers to try harder or to care more, that will somehow magically equate into some type of better outcome.

Error is just that, error. We cannot fix error by punishing people for doing something that they did not intend to do to have them come back to work the next day and not do something they did not mean to do in the first place. It does not make sense. In a way, asking or expecting workers not to make errors is not a problem that workers own—it is a problem that management owns.

Errors happen all the time. In fact errors happen in spite of us knowing that errors happen. Mostly, these errors do not create any type of problem, so we do not even realize an error happened until an error happens that has some type of consequence.

I strongly believe that we cannot (nor do we want to) stop errors from happening. What we can do is create survivable space around our workers. We want workers to fail; in fact, that is how we learn about our organization’s safety program and about the world around us. When they fail, we want a soft landing, a graceful failure. We want to defend against error outcomes, not the error itself.

How can an understanding of physiology help prevent human error and, in turn, injuries and accidents in the workplace?

I think one is better served by an understanding of human behavior and culture. Leaders create culture, and culture drives behavior.

Knowing how events happen is becoming much more important than knowing why events happen. That is controversial and flies in the face of the old-school way we have all been taught to understand events, the “why staircase” and all. It seems that the “how” question gets us to different levels of the failure story.

I am done with cause and blame, but I am super-interested in the story and how organizations tell those stories.

Do certain work environments increase the chance of human error? If so, what can be done to change these, especially if certain elements of a work environment appear to be beyond management’s and employees’ control?

That is a good question. I do not know about work environments per se, but workers’ performance modes (that is, how they think about doing the work they are about to do) dramatically impact the chance for error. I attended a meeting recently, and the person who introduced me said, “Error is.” I think he is right on that.

Based on your experience with organizational behavior, what approaches can be used to change perceptions of human error in the workplace?

Manage systems and behavior in parallel. Be fixated on where the next failure will happen. Reduce operational complexity. React aggressively to pre-event indicators. Respond deliberately to actual failure.

Do you believe standards, such as “Occupational Health and Safety Management Systems” (ANSI/AIHA Z10-2005), can help prevent human error?

Not prevent human error. We cannot really prevent error. Error is error. It is unintentional deviation from an expected outcome.

We must manage for the inevitable error that will happen. The good news is error happens often enough that we can learn from it.

Which industries do you believe can benefit the most from changing their perception of human error and its impact on human performance?

Probably all of us can benefit from better organizational learning. I cannot think of an industry that would not want to get better and be more effective.

Once an organization has changed its perception of human error and its relationship to workplace safety, how soon can the organization expect to see a difference in injury and accident rates?

It is a journey, but if I can get an organization to do one thing, I see quick results. Move from a crime-and-punishment view of safety to more of a diagnose-and-treat model.

If you change the way you investigate failures, you will change the way you manage safety. It is that simple, and it works. We must care more about learning from events than we do about finding blame.      

What aspects of human error and workplace safety do you feel warrant further research and study?

We have just started this ride, and we have many places to go in this field. What interests me is the difference between the way we plan, program and imagine how the job will be done and the actual work that workers face when they get to the jobsite. We have convinced ourselves to believe that if we can identify all hazards on a job we can do the job safely. The only problem with that idea is that we cannot see into the future, so we never know everything that will fail until it fails.

Sidney Dekker’s new book on drifting into failure is also interesting as are complex-adaptive behaviors, or problem-solving, in the field.

I am so excited to invite other people into this thought community. We need you to think about error and failure right along with us.

Todd Conklin, Ph.D., is senior advisor, environmental safety, health and quality, at Los Alamos National Laboratory in Los Alamos, NM. He may be contacted at bigtodd@lanl.gov or (505) 665-8650.