Context, in Safety and Learning, is Everything
A simple task is not always simple, despite how it may look in hindsight. Everyone knows the old expression "hindsight is 20/20." In fact, I think we have all heard it so much that we have become numb to the fullness of it's implications. Fully understanding a situation as complex as a safety incident depends on also understanding the context.
The 80s and 90s had a plethora of action films and I used to love watching them as a boy. In almost every one of them there is at least one scene where a hero, perhaps played by someone like Arnold Schwarzenegger, is holding onto the edge of a cliff struggling to climb up or on the ground reaching for the switch to deactivate the bomb but because of their fatigue it is taking every ounce of effort they can muster just to perform what would, in isolation, be an easy task. I remember thinking, COME ON! JUST REACH, ITS EASY! JUST DO IT! DO ITTTT! The mistake I was making was one of context. I was in a comfortable air-conditioned house, completely rested and feeling fully energized. The character had been through hell and back and was mentally and physically drained. It wasn't until later in my life that I would be tested similarly, serving in the USMC, that I would fully understand what it is like to be completely fatigued to where even simple tasks require monumental effort.
The first experience I had of this was during a relay race against other recruits. I was running the first relay, which was 50 yards down a field, around a cone and back. 100 yards total. Then I would pass the baton to the next recruit in line. There was a tall athletic runner going first for the team on my left. I decided I just needed to try to keep up with him and I would do alright. The gun fired and we sprinted off the line. I managed to keep up with him for the first 45 yards went the first wall of fatigue hit me. I remember the feeling of having burned up almost all of my energy and being *almost* half way done. I didn't want to slow down but my body didn't give me a choice. I pushed myself harder to try to keep up speed as the tall athletic runner began to pull away. I abandoned my mission to keep pace with him and now it was a matter of just getting back.
As I turned around the cone and started the return trip my team came into view - they were cheering me on which helped a lot. Going a little slower now but still giving it my all I had made it about 90% of the way back when my muscles simply decided they were out of fuel and I started to lean forward. As my muscles completely fatigued, it felt surprisingly good to hit the ground, flopping like a rag-doll, even at speed. At that point, my body didn't care about smacking the ground and sliding on the grass. It only cared about resting and refueling my muscles. It took everything I had to peel myself off of the turf and crawl toward the finish line. After an immense effort I finally got close enough to pass the baton and I was done. This is how I earned my first nickname in the Corps: Highspeed. I eventually made my way away from the group and puked my guts out. Is handing a baton to someone an easy task? Normally, yes, but maybe not after you just ran so hard that it made you throw up. It depends on the context.
We have all had days when we were overwhelmed, exhausted, pushed to our limits physically and mentally. Do you remember your last day like that? When you were so mentally exhausted that it was difficult to focus or complete any of even the simplest tasks with confidence that you were not making errors? Maybe it was because you have an overwhelming to-do list. Maybe it was because you have a micromanaging boss. Maybe it was because you had a medical scare in your family at the time. There are people around us at work at all times dealing with issues like these and more every single day.
Imagine a simple task. Lets say you are to take a brass ring and hang it on a hook. Is that an easy task? Depends on the context. How big is the ring? How big is the hook? How close can you get to the hook? Where is the hook? Some of you imagined an office space with a clean flat floor and a hook that is easily accessible. Some you probably imagined something else, depending on the context of your jobs. If the hook is at the bottom of the ocean, or the top of a mountain, things just got a lot more complicated. It also depends on the person's mental state. If they just ran (or currently are int he process of running) a mental relay race and have only a few ounces of energy remaining, their decision making will be altered by it. What looks simple in hindsight may not be so simple in actuality, given their current reality. It depends on the context.
When performing an investigation or simply looking back with your pristine 20/20 hindsight vision, you must remember that you are viewing the events in a completely different (usually much simpler and easier) context than that person was experiencing in the moments leading up to the incident. If your primary goal is learning so you can prevent a similar incident from reoccurring in the future (if this isn't your primary goal, you should consider a job in a different industry), shouldn't you be interested in the context of the situation? Wouldn't it be wise to figure out why the decision made by that employee made sense to that person at that time, given the context?
This is why I am dissatisfied with root cause analysis (RCA). RCA may work well for machines and equipment which operate the same way one day to the next, but it does not work well for analyzing human behavior, which is NOT consistent from one day to the next. Humans are "wired" to be inconsistent, actually. (Sorry engineers, you can't apply your tools to people the same way you do machines. Please stop trying to force it.) RCAs do not allow us to learn fully about an incident or the context in which it occurred. RCA also begins with the incident and works backward toward the "root causes." This backwards-looking approach uses hindsight...and is thus affected by hindsight BIAS - hence the expression "hindsight is 20/20." What seems clear and obvious in hindsight is never clear and obvious in the context of foresight. To learn fully, one must start from the beginning and move forward toward the incident. There are much better techniques than RCA to accomplish this, but I will save those for another article.
Nate (#RedBeard) Braymen