What Was He Thinking?

You would have to be a serious golf geek to have caught this story: over the holidays, the top ranked player in men’s professional golf suffered a hand injury that kept him out of competition for the opening weeks of the season.

Possibly you recognize his name: Scottie Sheffler.

There was a time when these cases were known as “off the job injuries.” Some operations took to reporting and tracking non-work injuries, either because they believed in a holistic approach to safety – if you’re hurt, you’re hurt, no matter where you were standing at the time – or because injuries cost a lot of money, not matter where the cost was assigned.

If nothing else, it’s one more example that motivation doesn’t really matter: it’s doing that counts.

When Scottie showed up for the press conference before teeing off in his first event, he told all; that’s the kind of person he is. Wouldn’t it be nice if everyone did the same when they got hurt: the world would be a safer place. Instead, leaders often have to play detective to come to a proper understanding of what went wrong.

One more tough safety challenge.

In Scottie’s case, it seems on Christmas Eve someone decided ravioli needed to be on the menu. One small obstacle stood in the way of making that happen: the family was staying at a rental house and there was nothing to be found in the kitchen drawers to cut out the pasta.

Voila: a wine glass, held upside down did the trick.

You already know how this story ended: the solution worked until it didn’t. Suddenly, there was glass and blood all over the counter.

As Scottie later explained, he was lucky to have escaped with only the injuries he did.

Improvised Tools and Methods

When we’re teaching how to recognize hazards, we routinely ask class participants what they look for as the warning signs of danger. At a class many years ago, a very wise person explained he was always careful when the tools and methods were improvised. It was a conversation like so many others I’ve been fortunate to have been a party to; when those with wisdom share what they have learned, you pay close and careful attention.

We’ve been passing along his wisdom ever since.

It’s all so obvious, isn’t it? Things improvised aren‘t proven tried and true. As a practical matter, the odds of failure run higher, and, if things do go wrong, the potential damage is seldom mitigated. That’s something you do, after the fact, for the next time.

To the point of playing close and careful attention, please take note that mitigate means “to lessen the effect of.” In managing safety performance, it’s consequences that are mitigated, not the risk: aka, the probability of an unwanted event taking place. Risk is something you reduce.

Or increase.

Scottie’s wine glass is the perfect illustration of both. Stamping pasta with a wine glass is pretty likely to fail. Gloves might have helped mitigate the consequences, as long as they weren’t the ones he carries in his golf bag.

In his press conference, he admitted he was lucky the stem didn’t go into the palm of his hand.

What Was He Thinking?

Presented with a problem, we humans are geniuses at coming up with innovative solutions. Except for the injury thing, Scottie’s wine glass served the task of cutting pasta on a granite countertop perfectly. It’s the potential downside of the solution that too often goes missing in action.

It happens all the time: it can happen at home; it can happen at work. How many times have you seen the cause of an injury labeled, “failure to recognize the hazard” or “wrong tool for the job”?

In this case you would think that if anyone were to to pay careful attention when their hands were going into harm’s way, it would be a professional golfer: like a concert pianist, they make a living with their hands. Makes you wonder, “What was he thinking?” Apparently in that moment, none was taking place.

If only it were that simple.

Human Thinking

Longtime friend and good colleague Dr. Pete Robison has a different take on the matter. Ever the curious scientist, of late Pete’s become a student of the work of Daniel Kahneman. Kahneman was a professor of psychology, widely recognized for his study of how humans make decisions; you might have heard of his book, Thinking Fast And Slow. It was a bestseller, and his research earned him a Nobel Prize – in economics!

In Kahneman’s research, Pete sees a logical explanation for behavior such as Scottie’s. “We humans have two different systems of thinking going inside of us. One operates automatically, reflexively, reflecting our experience and intuition. That’s our “inside voice” which works very well, it’s very hard to turn that off. Most of the time, we’re in system one.

System two is thoughtful, but it’s more effortful. You have to slow down; it takes concentration. Time is key, and system two is “lazy.”

Hence Kahneman’s “thinking fast” versus “thinking slow.”

So, now you know what happened with Scottie Sheffler. He’s got a dinner planned, got the family waiting. He knows how to do this. In Kahneman’s terms, he didn’t say “Time out. I need to slow down, engage my system two, and ask ‘What kind of a risk am I taking?’”

Pete’s conclusion: “That is exactly what happens when you are laser focused on system one. In Kahneman’s words, the intense focus on the task at hand at hand ‘can make people effectively blind.’”

Long story short: don’t be too harsh in judging Scottie. He may be a peerless golfer, but when it comes to decision making in real time, he’s average, just like the rest of us.

Pete adds that, in Kahneman’s view, while we aren’t that good at being a self-critic, we are very good at judging others. That begins to suggest a solution: the keen eye of someone else in the kitchen might be the best means of prevention.

Imagine a conversation having taken place along these lines. “I’m watching you as your making the pasta. I see that you’re about to turn that glass upside down to cut out the raviolis. You know stamping a wine glass on the granite counter makes it very susceptible to shattering. If that happened, you’d be spending Christmas Eve in the Emergency Room, and there’s no telling when you might be back to playing golf.”

You might recognize that intervention as SORRY.

Implications for Leaders

As you know, actually getting followers of yours to slow down and think differently – i.e., engaging Kahneman’s system two – is a big ask. Of course, you are a follower of some other leader, so you have the ability to slow down your thinking, at least for the amount of time you’re investing in reading this edition of the NEWS.

That’s one small example of the application of system two thinking to your practice of leadership. Unless you’re one of those “born leaders” who doesn’t need to give any conscious thought to your practice, it’s time well spent. I would point out that many of those seemingly natural born leaders gave their process a lot more thought than most of their peers.

Pete offers two more observations.

“Kahneman won the Nobel Prize by relating his research to how people make economic decisions. Since most of the time people operate in System One, they need to be nudged to make better judgements and decisions.”

Procedures like Safe Work Permitting and Management of Change do more than nudge people along. So does leadership training.

Giving leaders real life scenarios, the way we do in our classes, pushes participants into System Two thinking. We take situations that happen in the moment and get leaders to slow down and think about them. That makes them better prepared to handle them in system one thinking.

As Pete sees it, “System two is the remembering self, the part of us that carefully and mindfully executes a leadership best practice. Looking for positive examples where people are working safely and giving them positive feedback is a perfect example.”

So would realizing that an improvised tool or work method is more likely to fail – and fail miserably – and therefore stopping the job.

As to investigating one of those kinds of cases when they do fail and produce harm, Pete’s advice to root cause investigators is that behavior like Scottie’s may not be desirable, but it is normal. “So much of the problem is about time. I look at Scottie’s case as classic ‘production versus safety.’  People are waiting on dinner, and doing it this way will only take a minute.”

The better approach: “take the time to do it right.”

The Last Word

That advice is more likely to be put into practice with the help of others. It’s one more reason why safety is always better when played by a team.

Paul Balmert
March 2025