Judging Outcome vs. Behaviours Bias

We’ve all seen hockey players take a dive and stay down on the ice after being hit in order to try and get the referee to call a penalty. They are hoping the referee sees what is an apparent bad outcome, a potential injury; and makes the link that there must have been some bad behaviour to cause this, and a penalty is called.

We often do the same thing in our investigations and the more serious the incident the more likely we are to look for “bad behaviour.” However, we should not consider the incident outcome in our investigation. After all, the worker did not know what the outcome would be, and therefore did not use this information as part of his decision making.

For example, a worker uses a forklift tagged out of service due to faulty brakes to move a pallet just a few feet. He may have thought that he could do this safely if he took his time. He didn’t expect a pedestrian to step in front of him and that this would result in a serious injury.

The behaviour we should focus on is the use of tagged out equipment, not the injury to the pedestrian. We tend to turn a blind eye to rule violations until someone gets hurt, or the outcome is significant -- then it becomes a serious matter! Management’s reaction to the rule violation should be the same regardless of the outcome.

What if (counterfactual thinking) Bias

In every accident scenario there are always things that if changed would have prevented the accident. For example, a female coworker in a hurry to deliver a bulky file to another department falls on the stairs and is injured.
The “what if” questioning takes over. What if she had waited for the elevator? What if she had put the file in a briefcase so she could use the handrail? What if she had been wearing sensible shoes (always the male question)?

If there are things that she could have done differently, then we tend to blame her for the accident even if the other possibilities are not practical. It’s not a big leap from “well if you could have done something different, then you should have done something different!”

This thinking leads us to faulty conclusions and only focuses on what the employee didn’t do, not on what they may have done properly. This oversimplifies the situation and accidents are never that simple.