I Wish I Had Thought of That

by Rob Sams on May 8, 2015

in Risk Assessment,Rob Sams

I Wish I Had Thought of That

by Robert Sams

Depositphotos_12189196_xsI was recently talking with someone in the childcare industry who shared their experiences about health and safety, in particular risk assessments. They were frustrated, so much paperwork, bureaucracy and time spent on a process that seemed to be all about covering backsides. I hear the same thing all the time, people frustrated with safety, and I wonder whether risk assessment has become a ‘tick and flick’ exercise or an activity aimed at improving safety?

Risk assessment became a buzz term in health and safety with the introduction of ‘performance based’ legislation (e.g. OH&S Act in 1983 in NSW). On one hand it created a more flexible approach to health and safety, on the other, frustration for employers who just wanted to be told what’s “right or wrong”. Introducing the requirement for ‘risk assessments’ or ‘risk management processes’ was a way of self-regulating health and safety in industry.

When asked questions like the one from the person in childcare, it makes me wonder whether our current approach to “risk assessment” and “risk management” is really meeting with the intent of the law, or have we become obsessed with creating paper trails?

When I talk to people about risk assessment, the focus is often on getting the paperwork done, often copied and pasted from the last task/job/project. There is even a page on popular social media site LinkedIn (http://www.linkedin.com/groups?gid=3750030&trk=my_groups-b-grp-v), and there are many others, where you can share ‘risk assessments’ and other similar safety documents

I have also observed that most risk assessment processes are objective, and there is very little understanding and consideration of how people make decisions and judgements, which is so subjective. More on this later.

Thinking back to the childcare example, the person I was talking with works in a particular part of the industry where people look after children in their own homes. Before you can start up such a business you are subject to a number of safety requirements, obvious things like:

· Police and criminal checks

· insurance requirements

· inspections looking for things like safety glass, gates at the tops of the stairs and locked cupboards for chemicals, medicines and the like.

I thought, all pretty standard and not surprising. I’m sure they could do things a little differently, but pretty typical of safety controls in today’s litigious environment.

Then we started to talk about excursions, taking the kids down to the local park so they can get some fresh air, run around like kids love to do and play on the swings. A great idea right, the kids will love it, they might even learn while having fun. Of course first, you must do your risk assessment, you know the drill.

They have to complete a form, list the hazards, provide a risk score and nominate controls, the usual stuff. Then they send the completed form, first to the parents of all the children they will be taking and finally, send the form into the office where they must approve it. Then off they go, simple really! This alone takes about a week (at best!) to plan.

I’m sure you’ve probably seen similar versions of this in many different workplaces.

This process has some many limitations:

  • How can you think of all the potential hazards when you take a couple of kids to the park? – e.g. will that tree branch fall off today? It looks pretty safe?
  • How can you rank risks using a matrix that requires you to consider the likelihood of that branch falling off a tree? You’re in childcare, not an Arborist!
  • If that branch falls, will it land on the child’s arm, leg or head? e.g. – what will the consequence be, a cut, head injury, bruise?

As noted above, the other thing that is missing in this typical ‘risk assessment process’ is that there is often no consideration of how people make judgements and decisions. Through our studies in psychology and social psychology (for example see Daniel Kahneman’s Thinking Fast and Slow – 2011), we know that most of our thinking is not done in the rational and conscious mind, it is done in the sub-conscious. We develop heuristics to help us get through most our daily life and routine.

Dr Robert Long in his book Risk Makes Sense (2012) (http://www.humandymensions.com/books) refers to Heuristics as “experience-based techniques for problem solving, learning and discovery. Heuristics are mental short cuts used to speed up the process of finding a satisfactory solution, where an exhaustive search is impractical. Heuristics tend to become internal micro-rules”.

Think about when you are driving your car, you don’t “think” in your conscious mind when the brake light on the car in front comes on. You develop a Heuristic soon after you learn to drive that tells you “automatically” that you need to put your foot on the brake in your car. If we had to process this decision in our rational and conscious mind, we would be sitting in the back seat of the car in front before we could make a decision to respond!

If we look in detail at just one example of a Heuristic, there are many, and how it applies to safety, let’s consider the “availability heuristic”. This is where our brain “thinks” that something may be a greater risk just because a story is more familiar to us. For example, in this video (http://www.youtube.com/watch?v=2_wkv1Gx2vM) the question is asked about what animal causes more deaths in the USA, horses or sharks. Most people may think sharks due to the number of dramatic news reports about shark deaths. However, because stories about deaths involving horses may not make national news bulletins, it is likely that this information won’t be as ‘available’ to people as shark deaths, hence that are likely to think Sharks. The “Availability Heuristic” comes into play because our mind will have a bias to go to whatever answer is easier and quicker, in this case sharks appears easiest because we hear of deaths involving sharks so often.

Since we do most of our thinking in the sub-conscious and heuristics drive a lot of what we do, I wonder whether there is any value at in the current method of doing a “risk assessment”. The typical process is that we gather a group of people, we work through the steps of the job/task/process then we come up with potential hazards. Because our conscious and rational mind doesn’t like doing a lot of work, we come up with hazards and their risks based on our heuristics. How can we really think that we have come up with an exhaustive list of hazards when we know that our brain doesn’t function like that? It is always looking for the shortest and quickest way to get to a solution. This has dangerous ramifications if we use this as our only method to understand risks at work. We must realise that the results of our ‘risk assessment’ are so limited because of this.

There must be a better way, and of course there is.

Do we really need to have mountains of paperwork, or should we focus on more effective conversations where we share ideas and experiences?

As an example, during my conversation with the person in the childcare industry, I remember a number of very interesting things they said including:

  • “I always think after someone comes out for a safety risk assessment, I wish I thought of that”
  • “During a safety assessment the other day, I said to the person who was doing the assessment, I was wondering if you were going to notice that”
  • “When the person was here last time for the assessment they didn’t notice that”

I thought these were all gems and got me thinking about whether we can learn some things from this experience in the childcare industry by think about the following:

  • If we asked more instead of telling, would people realise things for themselves rather than have that feeling of “I wish I had thought of that”
  • If we have more conversations about hazards and risks, rather then telling, would our processes become more about sharing information and learning rather than policing?
  • If our conversations were meaningful during safety assessments, would everyone feel a part of “noticing that”?

I think there is a lot we can learn from these examples in the childcare industry. In your work environment, is risk assessment about ‘tick and flick”? Is paperwork more important than effective conversations and learning? Do you focus on objects more than people? Do you know about, and consider, Heuristics as part of your risk assessment process?

There will be those people who say, but we need the paperwork, otherwise how will we prove what we have done. I don’t suggest that we need to do away with paperwork, I say just don’t rely on paperwork. For those people working in fear of the legal fraternity who say things like “if there is no written record, it wasn’t done”, you can be sure the first thing a good lawyer will do if the matter ended up in court is to find a way to discredit what you have written, and find out how things were really done! Keep your paperwork, just make it simple. Spend more time conversing than writing!

Maybe we should think about “risk assessment” as being another way to engage people in more conversations, where they become more conscious of the hazards and risks that they face. Do you think this would create safer workplaces rather than reams of paper that are created to cover backsides?

  • Mark

    Excuse my deep thinking here, but if feel there is a new perspective here.

    Rob, I am going to have to respectfully agree to disagree on this one for now simply because if Heuristics are simply experience based techniques for problem solving, learning, and discovery that give a solution which is not guaranteed to be optimal, then I propose that heuristics used under current pressures could indeed be borne from previous pressured (any form of pressure) experiences, learning’s and discoveries. Maybe there could be such term as slow and fast heuristics not yet acknowledged or studied in the academic world that we need to be open minded too, not bounded by what is known.

    (If the SLSA official did not cancel the event for the 3rd time, then maybe they used the wrong heuristics borne from the last two pressured experiences and not heuristics that are borne from planning and practicing in time of no pressure).

    It could be plausible that there are heuristics learned from system one thinking, and heuristics borne by system two thinking (and anything in-between) and that heuristics used under pressure most likely come from heuristics borne closer to the irrational fast thinking mind, system one thinking.

    I.e. A farmer mostly uses (what I will call) system 2 heuristics to direct his cattle into other paddocks for feeding and this works very well although not optimal as there is better and safer ways. He usually uses whistles and calm hand waves to direct his cattle to and fro and this has worked for years with no issues, his logical heuristic shortcuts are borne from his slower system two thinking in time of little pressure.

    There has been two occasions though in the past when he has had to move his cattle quickly between paddocks due to storms and flooding and when he has done this, he rushed around waving his hands erratically and shouting out loudly instead of calmly whistling and walking. At this time, cattle also panicked and the farmer was in a more risky scenario (but no incidents happened). Today there is a fire storm coming fast, and he is under lots more pressure to save his cattle and needs to move the cattle out of one cattle yard into another real quick. Due to this extra pressure, his mind automatically refers back to system one heuristics that were learned from the past two occasions when he was in a rush and panicking. He runs around yelling out loudly and waving his arms ferociously while clapping his hands. The cattle panic just as they did the last two times, but this time, due to the extra pressure and the farmer acting more erratically, the cattle panic and charge over the farmer injuring badly.

    The heuristics choices used in this case were borne from pressured experiences and embedded into the mind.

    System One Heuristics (more irrational) System two heuristics (more rational)
    System One Heuristics (fast thinking) System two heuristics (slow thinking)
    System One Heuristics (more risky) System two heuristics (less risky)

    Thinking outside the square.

    PS- my comments on legal/compliance sector of our world employs a lot of people, what would these people do if we just accept…was in fact spiffballing here, just in case some thought this was a logical point of view.

  • Mark, heuristics are not generated by any ‘pressure’ and the idea of a poor or good heuristic lacks any sense that context (social psychology) determines choice. To narrow the development of heuristics to either time or production pressure is imputed onto the concept of a heuristic, it is much more complex than that. The confusion of time pressure with pressure to produce as if each is the same is also an odd match, being human is not about just time or production, there are many purposes and meaning for humans in other pursuits.Heuristics are a natural state of what it is to be human, we develop them under no pressure but as a condition of being human. The quest to control others, manage fallibility and eliminate all mistakes is not possible for humans but helps promote a disposition of frustration and judgement over others as if we put in the same circumstance would not make a similar choice.

  • Mark

    I have been looking for answers for over 30 years (and still as stupid as I ever was), and when questions I ask go deep, people go quite (or they just say that its all in the books) because thinking/creativity goes past the known and already hindsighted studies and therefor goes outside their realm of knowledge (a complicated and mind-consuming arena for which much time in solitude is required). Far too many people are text book gurus, smart by what they read, know every study ever done, can write their own books listing a new old approach, they a memory smart but not novel.
    Here is an example I wrote over 10 years ago and I use it when discussing the topic of memory, it might fit in here to help make my point;

    There was once a very smart scientist named Dr Knowledge who had an IQ of 150. Dr Knowledge was at the top of his profession, highly regarded as the guru of his field. He was very knowledgeable from all the books he had read, and just like a computer, he had gigabits of memory. He could recite with great accuracy everything he had learned from those books using this vast expanse of memory. Everyone would go to him for advice, as it was easier to get the advice from him than read about it for themselves. These people would walk away from Dr Knowledge and say “he is so smart”.

    Then one day Dr Knowledge started to forget things, his accuracy on information seemed to becoming less accurate and his IQ dropped below 80. He visited the doctor and was diagnosed with Alzheimer’s disease. Over a 5 year period, Dr Knowledge became unknowledgeable and was no longer a guru in his profession. People would ask him a question and he could not give an accurate answer, he stumbled about and paused trying to find the answer in his memory, but to no avail. These people would walk away and say “Dr Knowledge is stupid, he has no idea what he is talking about.”

    So what made Dr Knowledge so smart? His memory. Everything he read, every intellectual conversation he had with others was stored in his memory bank for easy retrieval. Now that he had lost his memory, he was no longer full of information and was now classed as dumb.

    I understand quite well the quest to give people/society a new concept, and a different way of thinking, raise voice to hope mark a place in history, but you should be able to back up claims with your own thinking and with some sort of solution, good or bad. Continually saying it’s all there, you just need to find the answers is lazy and simple, it’s like the psychiatrist who says “I can only help you if you want to be helped” in fear of their failure to transform the mind through advice.

    You say you agree with Rob – there is no novel in Rob’s prescription, you should say that you agree with Risk Management Principles outlined in ISO 31000. And what is critical by the way?

    Anyone who writes their philosophy is lecturing and preaching, don’t delude yourself with this fact or hide from the fact, it is great to be open and preach your thinking, don’t be ashamed of it. Don’t be afraid to debate, challenge, question, there is nothing to fear form learning.

    Now, if we are to accept death as natural, regardless of any factors, as prescribed by accepting human fallibility, can someone please explain why the need for all the rules, education and control to are there to make us conform to the requirements of social expectations. The legal/compliance sector of our would employs a lot of people, what would these people do if we just accept.

  • Mark – I won’t even try to attempt to run through all of your points, they are pretty exhaustive and I’m not sure that I would provide you with satisfactory answers. You ask for examples, if I could suggest, perhaps the answers are there if you go looking. There are a lot of great references and a lot of reading to be done. I’ve read more on the topic in the last 18 months than in my life. I’ve found that finding the answers and examples to questions myself, rather than others spoon feeding is much more satisfying.

    The intention of my article, and the target audience are safety/risk professionals & practitioners who are looking for a different way of thinking. My aim is not to lecture or preach (who am I to do that), rather encourage people to think about things differently, hence the questions. In response to your comment about lets see how easy it is, my simple view is, that its not easy at all.

    Rob – I agree, consultation, effective consultation that is, if critical.

    Thanks for the feedback and thoughts. Have a great day

  • Mark

    Let me then say then in the name of Risk/Safety (not general psychology), unfortunate Events are borne from bad Heuristic choices that occur when one or many has not the time to think logically.

    Research has been conducted in the influence that time plays in decision making. In two experiments by Finucane, Alhakami, Slovic and Johnson (2000), studied the affect heuristic under time pressure and the influence that providing risk and benefit information has on the affect heuristic. Researchers compared individuals under no time pressure and those with time pressure. They predicted that individuals under time pressure would rely more heavily on their affect in order to be more efficient in their responses whereas those under no time pressure would use more logic in their decision making. To do this, university students were randomly assigned to one of the two conditions (time pressure or no time pressure) and one of the two counterbalancing orders (risk judgements followed by benefit judgements or vice versa). They were then given a task in which they had to make judgements about the risk or benefit of certain activities and technologies. As they predicted, individuals in the time-pressure condition took less time to make risk judgements than did individuals in the no time pressure condition. In their second experiment, students again had to make judgements about certain activities, but this time were given additional information about the risk and benefits. Information was framed as being high risk, low risk, high benefit or low benefit. Researchers found that this additional information did in fact influence their judgements.

    So in “TIME PRESSURE” (pressure to produce) we use level 1 thinking (The Unreflective Thinking). In Risk Management, this is a serious issue. In many instances, the use of mental maps or heuristics can be applied to complex decisions under pressure to arrive at a seemingly workable decision, sometimes the pressure applied cannot make for rational choices.

    Unless you want to also discredit the great thinkers, you need to accept this a fact; Heuristics (the wrong heuristic decisions) are born from pressures.

    Why do people need to make shortcuts in the first place?

    Again, you have described part of Risk Management, listening and learning (consultation), and this is already in there. So can you explain how to make sense of psychological risk management?

    In fact;

    This would be a perfect case for you to prove how we can make sense of risk through the use psychology, and is an open invitation for you to help those, (mainly me) with simple minds and simplistic views become more enlightened so we can prevent accidents like this from occurring. I am not interested in what you have written in your books about how we can make sense because is just explains studies and ideas. The world needs more than this, we need to mitigate bad judgment both now and for foresight.

    Again ,this is a repeated accident, and look, there is the enforcement of procedures (to be done right away)…tis the world we live in! Go the blame game, it surely keeps a lot of people employed (Safety and Lawyers and people with brilliant plans to make safety protective), great stuff.


    Can you please provide a psychological insight report into why someone would run over two people on a beach and why would the legal system would not excuse this act as just poor human decision making and fallibility. I mean the poor guy made a human mistake didn’t he, probably showing off, maybe looking out into the surf for drowning people.

    Also can you please provide how this act could have been managed through psychological risk management and how would you know that this person was a person that may make a mistake like this or how you would identify this risk?

    I have more questions but will wait for the first report.

    Maybe SLSA need to employ a dedicated risk manager or psychological therapist!


    Another black and white fundamentalist point of view (I won’t ask of it a question)
    You child wants to take up Billy Cart racing as there has been a local club operating for 10 years. After a few competitions, for which your child is pretty good in his fast red mobile, you attend a day that is a bit wet from rain. You have some concerns, but it not enough to be serious enough to pull out of the race. As your child speeds down the steep road in first place, they come to a corner and slide off the road where they plummet 20 meters down a cliff, smash their head on a dead old tree and die. You say to yourself accidents happen and let it go, even though your wife is distraught. Now unbeknown to you, you find out a few days later that there were two previous deaths on the same corner and same rainy wet conditions, in the last ten years. You find that there has been repeated concerns raised about this corner and safety issues but nothing was done. There were no controls and no management of risk.

    What would a psychologist do?

  • Heuristics are not borne from pressure to get the job done, they are a necessity for humans to make decisions automatically in all situations. Human bounded rationality or fallibility simply cannot rationally cope with the complexities of continuous decision making and so develop mental short cuts to do things without thinking. We don’t need to ‘overcome heuristics’ but rather live with them and understand why they are necessary. There is no cure for humanness nor cure for fallibility, there will always be accidents, always be risks and always be death. There is no complete solution, there is no absolute answer and no absolute control, otherwise humans would be god. When safety people learn to apply the test of fallibility to themselves first, then they will be less god-like in their demands to control others. As for including psychological factors in risk assessments, best to start with the simple act of listening and learning.

  • Mark

    You have basically described the risk management process in a nutshell. The purpose of a risk assessment is supposed to include everyone who is involved, it’s called consultation, yet I have yet to see this in action. It is supposed to prompt one to ask whys, hows and what ifs, it is supposed to get one or many to open up to the world around and see it at a different angle, give you situational awareness and risk perception.

    Yes, risk assessments have mostly become a tick and flick exercises (that are not taken serious), because people/organisations don’t allow time for practicable safety, nor do they give the proper training on risk principles or for that matter, why human make mistakes. Risk Assessments are mostly objective because laziness and time restraints have led to this through system 1 thinking. Objective because we are not granted the time to get all the facts.

    We don’t need mountains of paperwork (a result of the more the better to prove safety fallacy), we just need guidelines, advice, information, etc (much is based on how long is a bit of string). How we are supposed to get this is through affective communication and consultation as you say, which is sadly as I keep saying; there is little time given for this as luck is just easier to rely on (although not that cost effective in the long run).

    Once we have this information we need to “tell” it, this can be through procedures or verbal communication. If it is through verbal communication that fine, but you should make a note in your diary in case you have to justify or give reason to prove you innocence against a failure (this is a result of our blaming culture, that will never go away) or ensure you have piles of paperwork to cover your actions.

    “risk management” is meeting with the intent of law, the law requires leaders to protect people, and if you don’t and if you cannot prove it, then you are at fault, this is law (guilty until proven innocent), and our whole existence from a single cell to now has laws, don’t fool yourself or allow your thinking to be like an utopian.

    Paperwork trails are better evidence than hearsay, particularly when the once friend/worker now wants to sue your ass and tells the judge an untruth to gain favorable following.

    On Heuristics
    Heuristics are simply born form pressures to get the job done/make up mind for whatever reason and for whatever task, and mostly from laziness of system 2 to get involved. So if heuristics are a fallible entity with all of us, then this is why accidents will always happen, and until some prescribes a practical solution (not advice or religion) for fallibility, we will have to accept accidents will always happen and we need to get over the fuss of deaths and understand it’s a natural occurrence…but hang on, if only the dead person just followed the procedure and advice from the risk assessment that addressed the risks then maybe he would not have died…time to go to court.

    To help overcome heuristics, we need to learn from “hindsight” and then we need to somehow make people not motivated by laziness or try to make people to avoid the sin of intellectual sloth and become “engaged”.

    Now, again we have this point raised about the need to include (psychology) human factors or human judgment in the risk assessments process with no solution given. We cannot even get the basics of risk assessment right (as currently prescribed) without having to understand the complexity of psychology and or having to employ psychologists to evaluate, diagnose, treat, and study human behavior and mental processes so to make rules or give advice on controlling/directing whatever human behavior may result in harm and poor decisions (be it for every single person for which you would have to do to ensure the whole process is complete).

    So, can you please give me an example of how we can include human judgments, bias, cognitive thinking, decisions making (plus including all the other long list of human factors) into the risk assessment process, and if you can, can you describe how you did. Can you explain how you managed to understand all those participating in the task intrinsic and extrinsic motivations and how you know what choices they would make in the uncertainty of the all the risks involved. In fact this is an open challenge to any clever psychologist, because I cannot find anywhere how to do this.

    It’s so easy to say we need this, we have to do that, let’s see how easy it is, then. I would like to see when people raise their concerns they also offer to solve a problem and apply some novel thinking. To many books, papers written are just dictionary’s based from the hard work others have done.

  • I like this article, but with the requirements for consultation (both legal and common-sense requirements) surely the ‘conversation’ is the requirement and the documented risk assessment just the record. I do think companies should put more emphasis on the consultation. There seems little point in training people to conduct risk assessments if they can’t effectively consult.

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