Root Cause Tip: What is “Behavior” and is it a “Cause” of an Accident?
Here’s the Meridian-Webster On-line Dictionary definition of “behavior”:
1. a : the manner of conducting oneself
b : anything that an organism does involving action and response to stimulation
c : the response of an individual, group, or species to its environment
2 : the way in which someone behaves; also : an instance of such behavior
3 : the way in which something functions or operates
Another definition that I think that management has in their heads is a “behavior” is:
“Any action or decision that an employee makes that management,
after the fact, decides was wrong.”
Why do I say that mangement uses this definition? Because I often hear about managers blaming the employee’s bad behavior for an accident.
For example, the employee was hurrying to get a job done and makes a mistake. That’s bad behavior!
What if an employee doesn’t hurry? Well, we yell at them to get going!
And what if they hurry and get the job done without an accident? We reward them for being efficient and a “go-getter.”
Management doesn’t usually see their role in making a “behavior” happen.
Behavior should NEVER be the end of a root cause analysis. Behavior is a fact. Just like a failed engine is a fact when a race car “blows it’s engine.”
Of course, a good root cause analysis should look into the causes for a behavior (a mistake) and uncover the reasons for the mistake and, if applicable, the controls that management has over behavior and how those controls failed when an accident occurred.
A bad decision or a human error that we call a “behavior” isn’t the end of the investigation … it is just the beginning!
TapRooT® helps investigator go beyond the symptoms (the behaviors) and find the root causes that management can fix. Some of the most difficult behaviors to fix are those so ingrained in the organization that people can’t see any other way to work.
For example, the culture of cost saving/cutting at BP was so ingrained, that even after the explosions and deaths at the Texas City Refinery, BP didn’t (couldn’t?) change it’s culture – at least not in the Gulf of Mexico exploration division – before they had the Deepwater Horizon accident. At least that is what I see in the reports and testimony that I’ve reviewed after the accident.
And with smaller incidents, it is even harder to get some managers’ attention and show them how they are shaping behavior. But at least in TapRooT® tries by providing guidance in analyzing human errors that leads to true root causes (not just symptoms).
Want to find out more about TapRooT® and behavior? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. You’ll see how TapRooT® helps you analyze behavior issues in the exercises on the second day of the training. And you will learn much more. For a public 5-Day Course near you see:
http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training
