The Petri Dish Effect: Shifting Our Focus From Root Causes to Root Conditions

Our industry’s persistent serious injury and fatality (SIF) statistics indicate that we are aiming at the wrong target, despite our best intentions. A small shift in our industry’s approach to incident investigations, however, could lead to meaningful change.

Decades of professional experience have taught me that when we search for an event’s root cause, we typically get what we aim at. By that, I mean humans can easily fall victim to confirmation bias, choosing to believe seemingly logical but erroneous theories rather than wrestle with uncertainty. But unless we use objective facts to determine what prompted an event, we risk making poorly informed decisions in its aftermath.

Cultivating Tomatoes
Let’s say we decide to develop controls and defenses to prevent recurrence of a catastrophic event. That is a good idea, right? But what if we focused instead on improving the conditions that contributed to the event? Doing so would likely eliminate our need for those initial controls and defenses. Seeking out and improving what I call “root conditions” surfaces different problems that demand alternative controls and barriers – and it tends to improve safety outcomes.

We can think about this in terms of planting tomato seeds. We don’t actually grow tomatoes, do we? Each seed already contains nearly everything a plant needs to flourish. Our job is to manipulate the environmental conditions that enable the seeds to germinate. Healthy plants will emerge given sufficient soil, water and sunlight. What happens when we recognize an unhealthy plant? It is generally understood that we must improve its conditions. We do not yell at the plant or tell it to fix itself. Why? Because we know that will not produce better tomatoes.

Creating and sustaining a healthy workforce culture demands a similar approach. Each employee is a proverbial tomato. For crews to grow and thrive, leaders must establish psychologically safe working conditions in which questions and candid conversations are encouraged. Curiosity is essential to lowering SIF statistics; dismissing or ignoring concerns is toxic to mitigation efforts.

Yet even equipped with this knowledge, we are still inclined to try fixing an employee’s behavior when we are unhappy with their performance, rather than fixing the conditions that prompted it. We must realize and regularly remind ourselves that every individual is the product of a lifetime of conditioning. Thus, performance improvements will require more than error reductions and additional controls. Management has a responsibility to help employees continue their professional development, which includes designing working conditions that allow them to succeed.

Regulatory Blind Spot
To shift our focus, we must spend time looking upstream to find the conditions that have produced unwanted events. This requires assessing both environmental and human factors, although industry regulatory standards have not caught up just yet. For example, per OSHA 29 CFR 1910.269(a)(3), “Information transfer,” a host employer must provide contract employers with the following prior to the start of work:

• Characteristics and conditions of the host employer’s installation related to the safety of the work to be performed.
• Information about the design and operation of the host employer’s installation that the contract employer needs to make required assessments.
• Any other information about the design and operation of the host employer’s installation that is known by the host, requested by the contract employer and is related to the protection of the contractor’s employees.

You will notice that these rules reference various installation conditions, but OSHA does not mention anything about the condition of the people performing the installations, who are naturally prone to distractions and errors.

Under the Microscope
To better understand how human behavior can impact working conditions and employee safety, review the image at the top of this page. Two petri dishes are filled with bacteria; notably, the scientific community calls each one a “culture.” Given the proper conditions, these bacteria will thrive, as you see on the left. On the right, an antibiotic hinders bacterial growth. Did you notice the tiny specks in the dark area around the pill? Those are methicillin-resistant Staphylococcus aureus – commonly known as MRSA – which have been conditioned to resist the antibiotic.

The lesson here is that when we allow a toxin to persist, it can condition others to become toxins, too. Left unchecked, difficult employees will spread their toxicity to those around them. But this also means that other employees will form connections and achieve synchronicity through positive interactions, setting up conditions for improved safety outcomes.

Looking Farther Upstream
If you have ever helped a child use a swing, you understand that energy exists in the arc of their movement. We must be in sync with that energy to make the swing go higher and faster. Out of sync, however, all forward momentum will collapse, and we could absorb the existing energy. Likewise, management pushing frontline workers harder when the two groups are not in sync could produce harmful results.

Conducting a root cause analysis will rarely reveal all the conditions that existed leading up to an event. Yelling at the tomato plant or pushing the swing out of sync does not typically show up anywhere in a final investigation report. While these actions may be intended to increase employee compliance and conformity – which, incidentally, represent the lowest level of human potential – they can create toxic conditions that will not garner better results nor sustain a healthy workforce.

The most effective course of action when we are dissatisfied with a specific outcome is to look upstream (i.e., out of our immediate view) to determine the source of the problem. Too often, we allow unhealthy components of our organizational culture to persist for years. When I was a line foreman working for a large utility, for instance, I applied for a line supervisor position at one of the company’s remote outposts. During my third interview, the lead interviewer told me, “We are probably going to give you this job, but be warned. This garage was on the company radar as a bad place for nine years. We fired the guy who was the problem. If you put this place back on the radar, you will be looking for another job.”

I told the interviewers that it appeared I had it made. When they questioned my response, I replied, “It took you nine years to figure out that guy was no good – and I only have eight years left until retirement.”

In all seriousness, consider what kind of impact the “guy who was the problem” had on the employees at that outpost. Do you think he valued and prioritized their health and safety?

Our Job as Leaders
All of us should expect industry SIF statistics to remain largely unchanged until we (1) identify the conditions necessary for organizational cultures to thrive and (2) apply them at scale. Creating conditions that solely foster employee compliance and conformity robs individuals of their agency. A well-established correlation exists between loss of agency and poor mental health.

But what exactly is agency? At the end of each workshop I facilitate, I ask attendees to complete a three-question evaluation form. The final question asks, “OK, your turn, it matters: What do you think?” Everyone is given a half-page to write their answers. To date, I have received better than a 95% attendee response rate, with feedback ranging from a sentence or two to several paragraphs filling the entire half-page. I partially attribute this to the question being “clean” or unbiased; it does not ask for a response specific to the workshop. Posing simple questions to other people gives them permission to share their answers. That is agency.

As leaders, our job is to ask the workforce what they think, then listen and adjust to their feedback, creating conditions that foster employee success. Culture, performance and profits are lagging indicators of the conditions that produce them. By aiming upstream at condition design, we will also influence downstream outcomes.

Conclusion
In her book “Strong Ground,” Brene Brown wisely counsels readers to “resist the urge to reach for certainty where it does not exist.” From a safety standpoint, this means it is no longer enough for us to identify an event’s root cause; we must also actively search for and improve the conditions that contributed to the event. This is a challenging task, particularly given that unhealthy conditions are frequently nearly invisible. Nevertheless, now is the time to begin. Employee lives are counting on it.

About the Author: William N. Martin, CUSP, NRP, RN, DIMM, is president and CEO of Think Tank Project LLC (www.thinkprojectllc.com) and SAFR LLC. A third-generation electric utility worker and medical professional with extensive experience in high-risk operations and emergency medicine, he served nearly 20 years in lineman, line supervisor and safety director roles. Additionally, Martin spent 23 years as a critical care flight paramedic and registered nurse with cardiology and orthopedic experience. He earned a Diploma in Mountain Medicine and was an instructor/trainer for the National Ski Patrol. Currently, Martin writes and speaks nationally about safety and human performance, with a special focus on unleashing human potential.