HUMAN PERFORMANCE / WORK AS DONE
The challenge
Repeated issues were being addressed through familiar responses.
Communication.
Retraining.
Procedure changes.
Additional supervision.
Yet similar problems continued to appear.
The work
Instead of beginning with the behaviour, we explored the work.
We spoke with the people doing it, observed the operating environment and examined the conditions influencing how decisions were made.
What changed
The problem looked different once it was viewed in context.
Attention shifted from repeatedly correcting people to understanding the system conditions making the behaviour more likely.