Complacency Is Not a Root Cause

Complacency as a concept in safety has been around for some time. That said, I’ve noticed an uptick in client discussions highlighting employee complacency as a contributing factor in recent incidents and injuries, including those characterized as serious injuries and fatalities (SIFs). Under the right circumstances, acknowledging that people became complacent over time in performing a task and positioning complacency as a precursor to an incident can be useful as a starting point in identifying cause. However, the term usually is poorly defined resulting in lack of agreement about what people are referencing as a causative factor. Furthermore, complacency often carries a pejorative connotation, implying a state or condition in which human behavior trails off into error or possibly some sort of “personal failing”1 at the individual performer level. In either case, such usage is more in line with blame than fact finding and unlikely to be productive.

One approach to complacency that might offer some clarity suggests the term is descriptive rather than explanatory1. Complacency simply describes a pattern of behavior in which previously safe or desired behaviors have “drifted” or deviated over time to the point where the changes now expose people to incidents and injuries. And this pattern of behavioral drift can occur at the front line (e.g., violating lockout/tagout procedures) or any level of management (e.g., prioritizing production-related work orders or capital projects over those impacting safety). Labeling this pattern of behavior change as complacency simply captures that the change or deterioration in safe behavior happened, but it doesn’t explain why. The point was stated nicely in a recent article conceptualizing complacency from a behavior science perspective:

“Complacency cannot be a root cause; it is a behavioral phenomenon that itself must be explained by reference to the conditions that produced it.”1

When conducting a root cause following an incident, stopping at complacency as a causative factor doesn’t go far enough. It’s not unlike arriving at human error as a root cause without explaining why the error developed in the first place and persisted until an injury occurred. Stopping at behavior or a pattern of behavior halts the search for true, systemic root causes, usually results in blaming the worker, and leads to ineffective solutions that won’t change behavior in the desired direction.  

So if behavior or patterns of behavior described by terms like complacency aren’t root causes for incidents and injuries, what are the root causes? Adopting a systems approach2, which lines up well with a behavioral approach, to understanding safe and at-risk behavior holds the answer. As Sidney Dekker stated in his classic Field Guide3, “Human error is a symptom of trouble deeper in the system.” Recognition that at-risk behavior at any level played a role in an incident is the starting place, not the endpoint. The system is the workplace, and the true causes influencing safe and at-risk behaviors are the features of the work environment including physical space, tools, equipment, management policies and procedures, PPE, employees at all levels and their behavior, customers, suppliers, the larger economic market in which they compete, and policies and regulations with which they are asked to comply. These elements of the system are the sources of antecedents and consequences that affect patterns of safe and at-risk behavior over time. If the problem is in the system, then that’s also where organizations will find their solutions. Focus on changes in relevant areas of the system to better understand why complacency develops and what your organization can do to maintain reliability in critical safety behaviors.

1 Hyten, C., & Ludwig, T. D. (2017). Complacency in process safety: A behavior analysis toward prevention strategies. Journal of Organizational Behavior Management, 37(3-4), 240–260.

2 Agnew, J., & Uhl, D. (2021). Safe by design: A behavioral systems approach to human performance improvement. Atlanta: Performance Management Publications.

3 Dekker, S. (2006). The field guide to understanding human error. Aldershot, England: Ashgate Publishing, Ltd.

Posted by Bart Sevin, Ph.D.

Specializing in performance and systems analysis and the development of behavior-based implementation strategies, Bart Sevin helps clients create long-term organizational change.  As a highly trained and experienced Board Certified Behavior Analyst, Bart helps organizations examine systems, processes, and people strategies to ensure that their motivational initiatives are aligned to promote business success and drive their desired outcomes.