Safety: Monkey business and human error

  • Published
  • By Lt. Col. Travis Zimmer
  • 908th Safety Office
In last month's installment, we covered psychologist James Reason's "Swiss Cheese" model to understand how most accidents can be traced to human error. In every safety investigation, we investigate unsafe acts as well as latent (existing but lying dormant until circumstances are suitable for manifestation) conditions or failures that lead to mishaps.

Let's consider one of the more common areas where investigations have found latent human factor failures - Organizational Culture. This is found to be a factor when explicit or implicit actions, statements, or attitudes set a culture that allows an environment where unsafe demands or pressures exist.

I can't count how many times during our investigations I have heard the phrase, "That is how we have always done it around here". That attitude reminds me of another famous psychologist named Harry Harlow and his experiment using monkeys to explain the creation of organizational culture. 

In Harlow's experiment, five monkeys were put into a regular monkeys' cage, with a banana hanging from the roof of the cage (outside the reach of the monkeys). The researcher then put up a step ladder enabling the monkeys to reach the banana. Whenever one of the monkeys attempted to climb and reach for the banana, ALL monkeys were sprayed with freezing ice cold water.

After a few attempts, they all learned the association between reaching for the banana and the group collective punishment of being sprayed with freezing ice cold water. From then on, none of the five monkeys tried to reach for the banana anymore. There was no need for the water treatment from that point on.

At this stage, the researcher replaced one of the five monkeys with a new monkey. The new monkey, not aware of the icy water treatment, tried to reach for the banana. Within a fraction of a second the other four monkeys pounced on him and beat the hell out of him - again and again, until he stopped and did not try anymore.

Note, that icy water treatment was not used anymore. The same process was repeated; one of the four monkeys who experienced the original icy water treatment was replaced by a new one, and again all the monkeys beat the new monkey to submission.

Finally, the cage was populated by five monkeys of whom none have experienced the icy water treatment. The experimenter then introduced a new monkey to the cage. When this monkey tried to reach for the banana, all five monkeys jumped on him and beat the hell out of him.

None of these monkeys knew about the collective punishment of icy water, none knew why they are not allowed to get the banana, but somewhere along the way they learned that reaching for the banana is not allowed. They become the guardians of this rule without knowing its purpose.

Food for thought: Swiss Cheese to bananas.