Knowing what actually causes the majority of serious injuries and fatalities is a good start, certainly much better than guessing or assuming that it’s due to a lack of management commitment. However, in order to prevent serious incidents and fatalities we need to know “when”. When will be most likely to make a critical error? This article explores the concept of Anticipating Error™ and provides practical tools for helping you and your employees to Rate Your State™ when in a situation where there is a high risk for making one or more critical errors that could cause a serious injury or expensive mistake.
Thanks for coming back. Lots of ground covered so far: hazardous energy and movement, three sources of unexpected events (over 95% in the Self-Area), the counter-intuitive nature of dangerous activities vs. actual outcomes and then why: because when both our eyes and mind are not on task, for that moment, we are defenseless. So as mentioned in an earlier article, it’s not that we are totally defenseless, it’s that from time to time, we are “momentarily defenseless”. which is why you hear so many people talking about car wrecks or serious injuries, saying that I really wasn’t doing anything wrong, I wasn’t really speeding or rushing. Okay, I was a bit tired and I was thinking about a problem at work, or home, or whatever… and then (car wreck, bad fall, serious cut, blown knee, concussion, etc.).
So, figuring out “when”, becomes the crux of the matter. Unless we know when those moments will happen, knowing why we get hurt badly (eyes and mind not on task/no reflex) won’t help to prevent the next one. So, figuring out the “when” part is the key. And unfortunately, for so many years, the focus has been on “what” the people were doing and how much hazardous energy they were dealing with (which is important) but not, which is the main paradigm shift here, not nearly as important as figuring out when. When will you or me or the next guy in line— when will we be most likely to make both critical errors at the same time—where there is also a significant amount of hazardous energy involved?
Well… it will likely be doing something that you have been doing for a while, because at the beginning of any activity where there is a fair bit of hazardous energy and the potential for injury – “awareness“ or “eyes and mind on task” – is very high (see Figure #1).
During this first period of time with an activity or skill it is possible and normally quite natural to self-trigger or to be able to self-trigger on the amount of hazardous energy. And as a result, it’s easy to stay focused. It may even seem, at least when you first start out, that it would be impossible to become complacent. However, as we all know, the initial fear rarely lasts forever. And over a period of time, depending on the activity or skill required, we come to the first stage of complacency. This is where the fear or skill is no longer pre-occupying. And as mentioned in previous articles, we don’t give our minds permission to wander. It happens without our permission or without making a decision to think about something else (Figure #1). So even if you don’t have anything else you need to think about or want to think about, your mind can still drift away. But if you’re rushing, chances are it’s for a reason. It might be because you want to get there early. More likely, it’s because you don’t want to be late. Either way, that’s what most people think about when they’re rushing—not what is the risk in the moment – right now (driving really fast on a city street). And if the consequences for being late are going to be really bad (late for meeting at work).
Then the stronger the “pull” to go back or to start thinking about that again (like how many people are probably in the meeting room already). So self-triggering on rushing – when the rushing is intense – is easy in terms of it not being difficult to notice. It’s easy enough to realize that you’re moving really fast or doing way too many things at once. What isn’t so easy is how compelling it is to let your mind go back to the reason you’re rushing or the problems being late will cause.
The same thing is true for frustration. When you’re really angry, it’s easy to recognize, so you can self-trigger, come back to the moment and make an effort to keep your eyes and mind on task (driving to work). But depending on how much frustration, it might be difficult not to keep drifting back.
However, the good news (at least) is that if the state is intense you can recognize it easily and self-trigger on it quickly. This is also true for fatigue. When you’re really tired, it’s easy to recognize. But the problem is that when you’re just a bit tired, it’s not so easy to recognize, and we all get tired here and there during the day so it’s not unusual. But if you now add a little bit of rushing and frustration with that fatigue, the combination of all three could easily be enough to cause mistakes, which will likely cause more frustration and usually more rushing.
So, the concept of self-triggering on the state may sound simple or easy enough to understand, but in reality it’s not always so easy: like when you’re really tired and really complacent, it can be so easy to have periods with your eyes shut for a second or two – or three or four…
And obviously if you’re driving when your eyes are closed or worse, when you were actually asleep for a few seconds, it’s easy to see the concept of being momentarily defenseless.
It’s probably one of the best examples. And unfortunately, it’s far too easy for most of us to relate – because we’ve been there. But we didn’t fall asleep at the wheel when we first started driving. It took a while before we would become complacent enough. Although nothing ever really stops us from reminding ourselves or thinking about the amount of hazardous energy and the potential for injury, it won’t happen naturally like it did at the beginning. However, once you pass the first stage of complacency, self-triggering on the state will be more reliable than trying to self-trigger on the amount of hazardous energy.
As time goes on, we get to the second stage of complacency. By this time, there is no more internal fear (like when we first started driving). However, if we nearly get hit by a big transport truck, then we will start thinking about the risk. But it required an “external stimulus”. Another thing that’s interesting about this second stage is what it does to your decision-making. And it’s fairly easy to recognize too, because you’ll likely hear something like this: “Oh yeah, well I’ve been doing it this way for 20 years and I’ve never been hurt yet,” (probably had a bunch of serious close calls but never mind that). And because they haven’t been hurt yet, they may not be motivated to change, or to use an additional layer of protection, etc. And with some individuals, it’s more than “may not be motivated to change”. Stubbornly refuse to change may be more apt.
At the second stage or beyond, unless the individual knows about self-triggering, then he or she will almost undoubtedly become preoccupied with why they are rushing or what will happen if they are late, who or what they are frustrated with, or when they can take a break or get some rest. In other words, mind almost totally off task. And it’s this high level of complacency that can affect their decisions with eyes on task. They can decide to look away from the road to pick up their phone or get something out of the glove box, and now you have another “defenseless moment”—when someone’s eyes and mind are both not on task for a second or two… or three or four. And although these moments of defenselessness may be happening more frequently as someone moves into the second stage of complacency, when their mind is mostly off task, chances are they won’t notice it… unless something bad actually happens.
I can remember when I first got into the safety business, many years ago. I was selling safety videos and I couldn’t understand why I would keep hearing that, “The young guys get hurt more than the old guys… but it’s the old guys that die.” And I couldn’t figure out why, since it was also common knowledge that people got hurt because they didn’t have safety training or proper safety training, which is what our company was selling. So I couldn’t understand why well trained, experienced workers, who obviously knew what they were doing, were experiencing so many serious injuries and fatalities. And I was hardly alone. It didn’t seem like anyone I met in management or the safety profession had a good explanation either. But in retrospect it’s all so simple: more time or repetition means more complacency, and more complacency means more defenseless moments when the person’s eyes and mind are not on task. And although older, more experienced workers may not be as inclined to rush as much as a young worker or with as much intensity, they could easily be feeling a bit of each state – every day – which makes self-triggering much more difficult.
So as mentioned earlier, when the state is intense, figuring out the “when” part is not difficult because the state is easy to recognize. But if the state isn’t intense or if there is more than one state involved, then it (the combination) might not be very easy to recognize. And if all four states are involved, then even if it’s just a bit of rushing—combined with a little frustration and a little fatigue, it can be very difficult to recognize and self-trigger quickly enough to prevent the error.
However, if someone asked you, “How much are you rushing, right now, on a scale of 1-10?” you could think about it and say, “Maybe a six,” because you know you’re under a bit of time pressure. So even though you might not have noticed it yourself, if someone asked you the question, or you asked yourself, you could easily identify the times when you were in a bit of a rush, a little frustrated or tired. So the problem of the less intense state or combination of states is not insurmountable. But you need to ask the question, especially for complacency as you can never really feel it in the moment. This process is called “Rate Your State”. Most people are familiar with the 1-10 rating system. Typically, it’s what they ask you at the hospital: can you rate your pain on a scale of 1-10? Only with rushing a 10 is going faster than you’ve ever gone before. A 9 is “as fast” as ever before and a 1 or 2 is really slow or stopped. Same thing with frustration or fatigue: A 10 is more frustrated than ever before and a 9 for fatigue would be as tired as you’ve ever been before. Complacency is a bit different. You could think of a 10 as concentrating very hard on something else like a problem at work while you were doing something else – like driving to work…
The main thing is not to worry about decimal point accuracy in terms of pinpointing your level of frustration or fatigue as being a 6.5 or a 7. What’s important is that you recognize that you are dealing with a bit of frustration and a bit of fatigue, which – could increase the risk that you might say something negative to a co-worker or customer. So, we have a simple tool that will help us to recognize the combinations of states even if the individual states by themselves are not that intense. All we have to do now is try to figure out when we will likely be in these states, or when we will be in more than one of them at the same time.
The easiest and best person to answer this is you (or me, him, her) because we know when we normally get tired during the day. We know who or what normally gets us frustrated. We know what makes us rush, like just before shift change or just before leaving on a long trip. And we know what the worst-case scenarios would likely be in terms of most expensive mistake you could make or what would waste the most time, damage customer relations, etc. So we can anticipate the time or the times during the day that the states could cause us the most trouble in terms of safety, quality, production efficiency or customer relations (inside or outside).
All you need to do now is set an alarm so you can “rate your state” at that time. So, even though the mistake or critical error is always unexpected, the states that cause them are not. We can anticipate when and where we will be in one or more of the four states. And if you set an alarm and then you rate your state at that time, even if it’s only a bit of rushing, or a bit of frustration combined with complacency, you’ll be much more aware and much less likely “to get hit with your guard down” (when you make both critical errors at once).
Yes, it takes a bit of effort. But it doesn’t take very much time and it certainly doesn’t cost any money. However, if you make the effort to ask yourself these questions, then set an alarm to rate your state at those times, or you organize this into the pre-shift routine at work, you can minimize or prevent many of these moments of defenselessness. Which will begin to occur after the first stage of complacency and will likely become more frequent after the second stage.
So, this helps to answer the question of when.
When will we have these defenseless moments where our eyes and minds are not on task? And if you think about it or if you think about all of the injuries you’ve had, which is thousands if you count all the bumps, bruises, cuts and scrapes, there was probably a much stronger pattern in terms of “when” than there was for “what”.