Behavior can be ALARMING!

Behavior can be alarming!

I had an opportunity to discuss a hi-po close call with a plant manager at a petrochemical plant recently.  He was alarmed at his people who ignored an alarm.

The temperature in a processing tank had reached unacceptable levels and the alarm went off in the control room.  Nearly two days later, the tank was still online, alarm sounding as the crews sought to bring the temperature down…as temperatures continued to go up.  

Operating procedures required the processing unit to be shut down if the problem could not be mitigated immediately.  Running at these high temperatures for more than a couple hours ran the risk of chemical reaction and release.  For nearly two days the alarms sounded without shutting down the unit. 

Why didn’t the people in charge of the unit shut it down?  

First of all, let’s acknowledge that it was not only the front-line operators and their maintenance support who were involved.  Undoubtedly, all levels of management throughout the plant knew of the ongoing incident.  The omission of behavior occurred across the “consequence chain” of command.

Behavior is a product of the environment  

So let’s break this down.  The alarm is an antecedent meant to discriminate a set of behaviors targeting analysis and immediate fixes … then the behaviors related to stopping work and shutting down.  Undoubtedly, these professionals knew procedure and jumped to action trying to analyze the situation and get the heat down.  But after a couple hours of operating in high heat, they failed to turn the unit off.

We look to the negative consequences of turning the unit off.  If they turn off the unit, production ceases for an indefinite period of time. Starting the unit(s) back up can also be a dangerous time in a chemical plant rife with challenges.  Other downstream parts of the plant dependent on this unit’s output will also have production hampered.  This negative outcome is pretty certain to happen. The operators and management want to avoid this (at all costs?).  

The effects of the shut down will be felt for a long time as reliability and financial metrics will be effected directly related to everyone’s bonus.  A lot of important people will be asking questions.

But wait! Another possible consequence could be much worse…chemicals could be damaged or even be released violently causing potential serious injuries and damage.  This is why the alarm should be so alarming!

I’ve worked with industrial chemists who tell me alarms go off all the time in their hooded work stations and it is common knowledge that many of them have been disconnected.   Professors in my University got reprimanded for not leaving their office during a fire alarm.  Hell, my brake light is on in my car now until I can find time to schedule an appointment at the dealer.  What alarms do you ignore? Why do we ignore these alarms?  Because of our history.

Behavior is also a product of TIME

Behavior scientists don’t consider behavior to be what happened in the moment.  Instead, we see what happened in the moment to have been shaped by everything leading up to that moment, our learning history.  For the individuals involved, this includes their history of experiences with alarms, heat in the unit and management reactions.

Let’s go back in history.  We can imagine the new operator on the unit floor, readily trained in alarms and protocol, coming into contact with their first alarm.  What do you think happened?  I bet it is different than what you wished happened but behavior management is not about wishing and hoping.  

The alarm sounded, the new operator gets alarmed and probably looks around to see what others are doing.  They, don’t seem so alarmed because of their history with alarms.  Others begin work and the new operator notices that hours are going by, no foremen or management are calling down to stop the unit, no operator is using their stop work authority.  The new operator defers to the judgement of these experienced folks and does not stop work either.  

Then what happened during this historical event?  Most likely… nothing.  What gets learned over time is that alarms are very conservative, you have plenty of time and usually nothing actually happens (I’m sure I’ve got hundreds of miles left on my brakes).

The issue gets resolved, work was not stopped and the new operator has learned the cultural practice which itself was born out of normalization of deviance.

Alternatively, what are their histories of experiences with stopping work?  Even though we have authority to stop work, the experience is probably not to swell.  Your work life becomes a hurried mess, overtime is forced, questions need answering, forms need filling out, and you wonder about the real repercussions of your soured reputation.  In some cases, most don’t have any experience with stopping work but have certainly seen the ungracious grilling folks receive for production failures and generalize a negative fantasy about anything that gets in the way of production. 

The way out of this alarming mess?  

Everyone in the plant probably knew about the unit running hot with an ongoing alarm.  The consequence chain from the plant manager through operational leadership have an opportunity, in these instances, to change history going forward.

Instead of leaders participating in the normalization of deviance by simply getting updates, asking questions and raising the pressure of getting it done, exhibit some real leadership.  You have an opportunity to go to the operating unit floor and ask “who is going to use their stop work authority.”  After giving this implicit permission, someone will, and you have the chance to change the story.  

Make the stop and startup process manageable and professional, not hurried.  You’ve already decided to take the production hit.  Run the ‘political interference’ from leaders wanting answers by taking the questions on yourself instead of letting them punish the front line.  

Finally, and most importantly, publicly praise those who stopped the work in the face of an alarm.  Let it be known throughout the plant that this is the cultural practice that you want all new operators (and old) to see going forward.

This is a learning moment that you can’t squander.  The crew must practice the behavior of stopping work during the alarm, not after.  Then they have to experience certain and positive personal consequence for doing so.   

Before asking our front line to be courageous in the face of an alarm by stopping work, you’ll have to first take that step yourself.