At social events, when people find outyou’re a psychologist the first thing they ask(after “what am I thinking, then?”) is “whydo you do what you do?” The more of aneffort you make to answer that in a user-friendly way, the more likely they are to say“that’s just common sense, that!”

To be awkward back (when you know theperson asking isn’t doing so out of interest),you could try something like: “Basically, it’sa dynamic interplay between antecedentsand consequences, genetics, dispositions,external stimuli like totems, perceptions,beliefs, values and societal and local norms– all of which are moderated to a greater orlesser extent by the freedom afforded byenvironmental factors and constraints. . .”

Take a slower walk through thatsupercilious response, however, and yourealise that a common-sense holisticapproach tailored to the world of health andsafety is possible. Three recent challengestook me back to first principles: I helpedmoderate a debate on the DeepwaterHorizon disaster in front of a large andknowledgeable audience, was involved in aforum on urban cycling safety, and was thenpresented with perhaps the most difficultbehavioural challenge I will ever encounter.

In simple terms, this article proposes thatfor a robust holistic model we just need toblend Ajzen’s model of ‘planned behaviour’1

with Reason’s ‘Just Culture’ model2 and goodold-fashioned ‘ABC analysis’. (If ‘Just

Culture’ and ‘ABC analysis’ are unknown toyou, see my 2010 article3 in these pages.)

Such a model is, I believe, applicable toanything that involves people and, inparticular, the two infamous ‘elephants inthe room’ in the UK: health and road safety.(I’ll try to illustrate this assertion with threecase studies representing health, safety and‘health and safety’: exposure to drugs in alaboratory, cycle safety, and the DeepwaterHorizon explosion, respectively).

The holistic model of individual actionMy adaptation of Ajzen’s academic model ofplanned behaviour (see Figure 1) suggeststhat in order to understand why a personhas done what they have done we need to

To explain why, in relation to health and safety, people dowhat they do Dr Tim Marsh offers a model we can’t refuse.

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know three things. As with all dynamicmodels these issues interlink and overlapbut a systemic consideration of each willhelp ensure nothing vital is missed.

The first thing we need know about, ofcourse, is the person – what is their attitudein general and to the situation at handspecifically? For example:

Are they health conscious?Are they fatalistic?Are they trained?Are they experienced?Are they easily tempted?Are they well-led and well-coached?

We can impact on this at selection, atinduction and training, and with awareness-raising.

The second factor is control, or perceivedcontrol of the environment.

(Starting with) Any weakness in theabove list?Are there any physical barriers to themacting appropriately? Do they think they can act appropriately?Can we ‘nudge’ them to act moreappropriately with a clever tweak to theenvironment?

Here, we need to consider the environmentfrom a Just Culture/human factors/ergonomic perspective and we can impacton the situation with ergonomic andorganisational changes.

The third and final factor considersnorms:

What are the relevant norms in societygenerally? What are the norms among this person’speers?

We know that the best definition of cultureis ‘what happens around here on a typicalday’ and that it’s incredibly powerful.

Indeed, this ‘norm’ element explicitlylinks the person and the environment and iswhat makes Ajzen’s model so strong, as weall know that we can only change norms viasystemically addressing the individualand/or the organisation. Some relativelyadvanced models of human factors lead youto ‘it’s an unintentional error – get anergonomist’, or ‘it’s a cultural issue, we needto look at leadership’. This model nudges usto think that for a comprehensive solutionwe need to look at leadership and get anergonomist!

An example of the interactionIn the film ‘The Godfather’ the decision ofthe character Michael Corleone to shoot hisfather’s rival and a corrupt policemanillustrates how these factors overlap andinterplay – and hopefully gives the editor a

cracking photo-illustration opportunity!(Cheers, Tim – Ed).

Though he is a trained and skilled killeras a result of his WW2 army experiencesMichael is influenced by society’s norms ingeneral and considered the ‘war-herocivilian’. His brother Sonny is very much theprince in waiting, as far as the ‘familybusiness’ is concerned. However, Michaelfinds himself in a situation where he realisesthat drastic action needs to be taken toprotect his father, that he personally iscapable of taking that action and (crucially)understands that only he has the opportunityto take this action.

He makes the shift to operating from thelocal norms of the Corleone family – thecorrupt policeman and his father’s rivalcome to a sticky end – and it all makes for ahugely entertaining and Oscar-winning film.Note that Sonny lags behind Michael in histhinking initially – still seeing Michael as acivilian, so he laughs dismissively at thesuggestion – but he then steps back, looks atthe bigger picture and sees it makes sense.(The use of humour in this way will make animportant reappearance in a short timewhen we discuss Deepwater Horizon, butthat’s as far as I can stretch this metaphor!)

To leave Hollywood and return to thethree practical studies introduced above:

The behavioural health problem to endthem allI recently spoke to a company that makeshighly effective cancer-fighting chemicals.These drugs are hugely powerful – with theactive element of the drug in question sodiluted its concentration levels are close tothat claimed for homeopathy. The problemis that as well as not being visible to thenaked eye we haven’t got the technology toswab and screen. (The company scientistsjoked, in classic Monty-Python style:“Radiation? Pah – how easy is radiation?!We can make it click loudly and set offalarms at levels not even all that dangerous!I wouldn’t even get out of bed for radiation.”)

Worse, the lag time between exposureand illness is years (usually decades) and, ofcourse, there’s a huge financial imperative.This isn’t the Atomic WeaponsEstablishment run by a governmentdepartment and which will still be here,accountable and able to be sued 30 yearsfrom now. The suits – who aren’t scientists,let alone hygienists – running this companynow will be long retired to the golf coursesof Spain and Florida (or in the Lords) whenthe crap hits the fan.

Being faced with this ‘perfect storm’ of a

behavioural problem inspired me to go backto first principles. How exactly do we get thetechnicians in these labs to follow protocolsthat will keep them safe?

Starting with control, we have to askfrom a ‘Just Culture’ perspective whether ornot the technicians have the tools toimplement the training they have beengiven and understand the risks. (Actually,yes they do.) Next, we can ask if it is actuallypossible to follow the protocols given thetime constraints – i.e. a ‘situational’violation (again, yes it is). Finally, is thereunspoken pressure to finish up and turn tosomething the organisation values andrewards more strongly than hygiene – whatReason would call an “optimising” violation.(Here it gets interesting, and we’ll return tothis.)

What there is most obviously, it seems, isan ‘individual violation’ – a classic ABCsituation, where there are no short-termconsequences at all for a little corner-cutting, or lack of thoroughness. (They can’teven set off alarms and ‘beep’ as they arescreened. The work surfaces look spotlesseven if they aren’t, and no one looks or feelsthe slightest bit ill – not even after workingthere for years.)

My analysis of the problem is thatalthough the workers are ‘fully’ trained andtherefore worried about their health theyaren’t as out-and-out paranoid and scared asthey should be! Thus, a two-pronged attackwas suggested. The first was to deliver somevery intense and visceral training illustratedwith the effects of contamination they couldnever forget. In other words, to completelymaximise the “why” element of training aswell as the “what” and “how”, as I havepreviously described in these pages.5

The second element was to follow this upwith a series of intense observation andfeedback sessions regarding thedecontamination protocols and usingtrained coaches to fully embed thebehaviours requested. In other words,treating the health protocols with theintensity it would require to treat a key setof behaviours that could cause a catastrophiccrash in share prices next week.

This intensity of follow-up needs to bemaintained long enough for the protocols togenuinely become the norm – ‘part of theway we do things around here’ – and,therefore, partly self-sustaining. However,they must still be followed up often enoughfor this standard not to degrade. Thisinvestment is vital and this is wheremanagement’s long-term commitmentcomes in. The point I want to make is that

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since this is, under the currentcircumstances, exactly what is required totackle this health issue effectively thenanything less than this is, indeed, the“optimising” violation I alluded to above.

Urban cyclingThe second practical example I’d like toaddress is the multi-faceted attempt to getmore people using bikes to get to work forthe various health and congestion-easingbenefits. As well as ‘Boris bikes’ andpromotional campaigns there are also‘bikemobility’ lessons for older riders toimprove their skills and confidence. Thereare technological advances, such as warningsensors on lorries and side-protectionengineering. There are awareness-raisingcampaigns, where cyclists sit in cabs and aresneaked up on via blind spots and frightenedby a slap on the window. Amusingly, thereare even squads of terrified lorry-driversbeing taken out into London traffic on bikes.

Further up the safety hierarchy there areexperiments with bike lanes and bike-friendly roundabout designs, as used incountries like Holland and Denmark. All ofwhich are aimed at:

making individuals feel more positiveabout cycling;reassuring them that they can achieve thehealth benefits safely; andturning urban cycling into somethingthat is very much the norm – a part ofUK life in a way that it is in Denmark andHolland.

This is a holistic approach that evolvespiecemeal rather than by design. However,with different factions arguing still, aholistic approach is needed. For example, itis suggested that night deliveries will ease

congestion but theshift systemsrequired will meanthat, inevitably,many of the driverswill have theirphysiologyscreaming ‘I shouldbe asleep!’ at them.This isn’t ideal whenyou’re behind thewheel of a 55-tonlorry.

Deepwater Horizon– a catastrophicprocess-safetyfailureMost people knowwhat happened on

the Macondo well: the ‘mud’ seal failed andthere was all sorts of evidence to let theteam there know it had failed but theymissed it – even dismissed it. Mostinfamously, perhaps, they dismissedpressure readings that made it clear thatsomething was wrong as the ‘bladder’ effect(there is no ‘bladder’ effect).

BP wasn’t alone here, of course, and itshould be said it was rather ‘scapegoated’(President Obama being the first person fordecades to refer to the company as BritishPetroleum) but its employees certainly madesome basic mistakes, too. How could they dothat so soon after Texas City and thefindings of the Baker Report ringing in theirears? How could they have been part of ahigh-level safety visit just the day before andnot spot there was something wrong? Well,very easily, as it happens.

I’ll just pick on some of the pertinentpoints to illustrate. Starting with theindividuals, we can see that although theywere described as fully trained and qualified,what they actually were was highlyexperienced and with impressive-soundingjob titles that might better have beendescribed as ‘foreman’. None had a degree inengineering, or any training in lateral orcritical thinking – or in the ‘non-technical’skills of dynamic problem-solving in teams.On Macondo, they could – even should –have consulted with the engineers on the‘beach’ but, in practice, the norm of self-sufficiency meant that they rarely did.

Interestingly, it was actually the BP manwho was most concerned and whochallenged the ‘bladder-effect’ explanationof the warning readings. His peers foundthis amusing and ‘robust humour’ wasinvolved – basically, they took the rise out of

him for his ‘timidity’. Teasing is, of course, akey lever of ‘groupthink’ and he fell in linewith the local norms, and a classic group‘risky shift’ occurred (this being themechanism by which a group, seeingreassurance in numbers, makes a riskierdecision than an individual would).Addressing this, BP now has a new protocolthat the team leader consults with the team,and then retires to make an executivedecision for which they are responsible.

It’s also worth considering the role thatleading indicators played in the explosion.Following Texas City, BP rolled out someexcellent process safety-specific leadmeasures. Unfortunately, these were idealfor a production platform but requiredtailoring for a drilling platform. Thefinancial imperative remained strong, andwe know that ‘what gets measured getsdone’ and directs attention. In consequence,although personal safety was excellent, thelack of specific lead measures meant that therisk of an explosion on a drilling platformwas, with the benefit of hindsight, a blindspot.

In a previous article on Reason’soverstretched elastic-band model6 I madethe case that the best organisations spotquickly when they are drifting towardsvulnerability and have mechanisms to snapback quickly. For example, a really obviousissue to focus on re: a drilling explosionwould be to look at ‘kicks’ (an increase inpressure in the well that will precede ablow-out). Ideally, there would have beendata collected regarding how quickly thesewere spotted and how effective theresponse.

In addition, during the site visit, theexperienced visitors had severalopportunities to initiate conversations thatmay well have identified the problem, butthey kept to personal safety issues. Why?Because challenging such competency wasconsidered rather insulting; it simply wasn’twhat they did during these visits.

Therefore, a number of warning signswere missed and the famous ‘gorilla on thebasketball court’ was able to walk straightpast. The workers weren’t looking forgorillas with a healthy paranoia, as describedby Andrew Hopkins;7 they’d already decidedeverything was alright and could only seethings that confirmed that mindset. Theywere looking forward to getting off the rigand some down time/the next challenge.

In short, on Macondo, there wereunintentional errors caused largely byenvironmental cues, mixed with individualissues and local norms. As they always do.

Figure 1: planned behaviour model

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Continuing professional development is the process by which OSH practitioners maintain, develop andimprove their skills and knowledge. IOSH CPD is very flexible in its approach to the ways in which CPD can beaccrued, and one way is by reflecting on what you have learnt from the information you receive in yourprofessional magazine. By answering the questions below, practitioners can award themselves credits. One,two or three credits can be awarded, depending on what has been learnt – exactly how many you awardyourself is up to you, once you have reflected and taken part in the quiz.

There are ten questions in all, and the answers can be found at the end of the online version of thisarticle at www.shponline.co.uk/features-content/full/cpd-article-mysterious-ways To learn more about CPDand the IOSH approach, visit www.iosh.co.uk/membership/about_membership/about_cpd.aspx

QUESTIONS

1 Which models does the author suggest be combined for a holisticapproach to behaviour? (Tick all that apply)a) Ajzen’s model of planned behaviourb) The Hale and Hale modelc) ABC analysisd) Reason’s ‘Just Culture’

2 In order to understand why a person has done what they have done,what three things do we need to know? (Tick all that apply)a) The personb) Perceived control of the environmentc) The salary level of the persond) The norms in existence

3 What would we NOT need to know about the person?a) Whether they have been trainedb) Whether they are health consciousc) Their career aspirationsd) Whether they are easily tempted

4 Whether the person thinks that they can act appropriately would beclassed as what type of factor?a) Their degree of job satisfactionb) Perceived control of the environmentc) Societal normsd) Shift patterns

5 In addition to norms among the person’s peers, we would also needto take account of norms in society generally:a) Trueb) False

6 Not following protocols because of time restraints would be classedas what?a) An optimising violationb) A rule-based errorc) A situational violationd) An individual violation

7 What would NOT be part of an effective strategy for encouragingurban cycling?a) Making individuals feel more positive about cyclingb) Putting in strict controls on cyclistsc) Reassuring individuals that they can enjoy the benefits safelyd) Turning urban cycling into a norm

8 Why might a group make riskier decisions than an individual?a) They see themselves as more powerfulb) They see other groups making decisionsc) They see reassurance in numbersd) They have no concern for safety

9 Why might visiting safety inspectors avoid questioning whatworkers are doing?a) They only have to be concerned about documentationb) It is not their concernc) They do not wish to question people’s competenced) Nobody expects them to ask

10 Organisations can predict their accident rates from the perspectiveof: (Tick all that apply)a) How strong the organisation’s systems areb) How strong the safety leadership isc) The financial costs of accidentsd) The number of people employed

ConclusionIn previous papers, I’ve suggested thatpredicting organisational accident rates iseasy if you know three things: how strong acompany’s systems are; how strong thetransformational safety leadership is(coaching, praising, leading by example andinvolving); and how committed theorganisation is to mindfully learning aboutits weakness from a ‘Just Culture’perspective. This paper suggests thatpredicting individual behaviour with asimilar triptych makes for a robust human-factors model that can be applied to anysituation.

We simply need to understand the

individual’s knowledge, mindset anddisposition. We need to understand whichenvironmental issues can impact onindividuals and which factors might actuallyprevent an individual from actingappropriately. Finally, we need tounderstand the cultural link between thetwo – the societal and local norms.

People are very unpredictable – but oftenin a very predictable way.

References1 Ajzen, I (1991): ‘The theory of planned

behavior’, in Organizational Behavior andHuman Decision Processes 50 (2):179–211

2 Reason, J (1997): Managing the Risks ofOrganisational Accidents, Ashgate

3 Marsh, T (2010): ‘It’s a kind of magic’, inSHP Sept 2010, Vol.28 No.9, pp40-42

4 Dekker, S (2008): The Field Guide toUnderstanding Human Error, Ashgate

5 Marsh, T (2012): ‘Go forth and multiply’,in SHP Aug 2012, Vol.30 No.8, pp45-48

6 Marsh, T (2010): ‘Stretch to the limit’, inSHP Feb 2010, Vol.28 No.2, pp39-42

7 Hopkins, A (2012): Disastrous decisions,CCH Australia

Dr Tim Marsh is managing director of Ryder-Marsh Safety Ltd – see page 4 for more details

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