An Introduction to the 4D's from Jeffery Lyth
A few years ago, I had a huge ‘A-ha!’ moment at a Todd Conklin seminar. Since then, I have been telling companies in various industries about something called the 4D’s. Many have experimented with the idea, and some even initiated 4D conversations across the whole scope of their (international) operations! Workers like it, leaders like it, and many proactive improvements are being made to the places where many people work.
It’s a simple and easy conversation to have, but the act of asking the questions (and then making improvements based on the information received) has led to greater engagement, better worker perceptions of leadership, and numerous opportunities to improve the operational capacity for achieving more reliably successful work outcomes.
I believe this is because despite their simplicity, whom we are asking, what we are asking about, and how we are using that information to improve the system of work is a practical application of many of the concepts emerging from ‘new view’ safety as well as contemporary leadership thinking. You might say it’s just asking Better Questions or a simple way of having a mini Pre-Accident Investigation, and you’d be right!
DUMB (Sense Making/Frustration)
The word ‘dumb’ may not always be the best choice, but it can be useful in starting conversations about things that don’t make sense. In today’s diverse and informed workplaces, leaders must pay attention to how people understand their tasks and environment.
Shared understanding doesn’t just happen—it needs to be encouraged.
Weick and Sutcliffe describe sensemaking as the process of giving meaning to experiences. It’s about looking back and making sense of what people are doing.
Leaders should actively ask how people make sense of things and encourage them to speak up when something doesn’t add up. This helps both the leader and the team work more effectively.
DANGEROUS (Risky/Challenging)
DANGEROUS (Risky/Challenging)
Oxford Research defines ‘hazard perception’ as the ability of a person to detect potential hazards, and ‘risk perception’ refers to people's subjective judgments about the likelihood of negative occurrences. Both are important to discuss because it will surface which hazards people care about and how they deal with them. It is an important precursor to operational performance, and experts recommend that leaders keep an open dialogue about risk alive.
Typical safety management approaches are not likely to catch this, but an open conversation about people's perception of danger may.
This lowers the perceived threshold of risks worth talking about (i.e., worth a potential stoppage and accompanying fallout, formal and otherwise) and lowers the risk of retaliation for pausing work.
DIFFICULT (Hard/Demanding)
When a work task is difficult or demanding, many will simply just ‘soldier on’ and ‘make do’, possibly assuming that difficulty is just the nature of the task. But task difficulty can be an important sign that the task is being done incorrectly or that something is amiss elsewhere in the system.
Field leaders benefit from creating an open dialogue about the difficulty of work. Sometimes it's just difficult, sometimes it's being done wrong (righty-tighty/lefty-loosey!), and sometimes that difficulty is a red flag, but you don't know if you don't ask, and you really want to lower the threshold on what your crew feels is worth talking about.
DIFFERENT (Change/Surprise)
A weak signal of change can be a quiet early indicator of an emerging issue that may not appear significant at the time but may become significant in the future. Weak signals can be identified as a part of ‘scanning’ the operational environment, can supplement trend analysis and can be used as a foundation for detecting emergent critical risk.
Change is interesting. We can create and achieve incredible things in business, but it's not the magnitude of the work that makes it interesting; it’s the surprises and changes along the way and how we navigate them.
Why use the 4D's
Enhanced Communication and Engagement
One of the biggest challenges in workplace safety and learning is getting workers to speak openly about their experiences. People hesitate to report concerns because they fear blame, doubt that their input will lead to change, or believe that difficulties are just part of the job.
The 4Ds address this by providing a structured yet simple language for discussion—workers can "speak up" when something seems "Dumb" (doesn’t make sense), "Dangerous" (poses a risk), "Difficult" (is challenging to perform), or "Different" (involves change).
By framing these conversations around common workplace realities, the 4Ds help break down communication barriers between frontline workers, supervisors, and leadership. This encourages a more honest exchange of information, which is crucial for identifying improvement opportunities.
Proactive
Risk Management
Many organizations rely on reactive safety measures, responding only after an incident has occurred. However, by incorporating the 4Ds into daily operations, companies can shift toward a proactive approach, identifying weak signals before they escalate into serious problems.
For example, if multiple workers report that a particular task is "Difficult," it may indicate a need for better tools, training, or work process adjustments. If something is perceived as "Different," it could mean an unnoticed procedural change that introduces new risks.
The ability to detect and address these small but significant issues in real-time helps organizations mitigate hazards before they lead to injury or operational failures. This not only improves workplace safety but also enhances overall efficiency and reliability, reducing downtime and costs associated with accidents and near-misses.
Bridges the Gap Between Work As Imagined and Work As Done
A common challenge in workplace safety and operational management is the gap between Work As Imagined (Black Line)—how leadership and policymakers believe work should be done—and Work As Done (Blue Line)—how workers actually perform their tasks in real conditions. This gap often leads to unrealistic expectations, ineffective procedures, and overlooked risks.
The 4Ds help bridge this divide by capturing frontline workers' perspectives on what is really happening. For example, an operation that looks well-structured in a procedure manual might be significantly more "Difficult" in practice due to real-world constraints such as space limitations, outdated equipment, or time pressure. By identifying these discrepancies, organizations can make practical adjustments to their systems, ensuring that policies and safety protocols are grounded in reality rather than assumptions.
Encourages a Culture of Learning Over Blame
Traditional safety approaches often focus on identifying human error as the cause of accidents, leading to blame-oriented investigations and disciplinary actions. However, modern safety science, including Human and Organizational Performance (HOP), recognizes that errors are inevitable and that focusing on blame does not prevent future incidents.
The 4Ds align with this progressive approach by encouraging a learning-based culture rather than a punitive one. When workers feel safe discussing what they find Dumb, Dangerous, Difficult, or Different, organizations gain a more accurate picture of their operational realities. Leadership can then focus on system improvements rather than individual punishment. This shift enhances trust, boosts morale, and encourages workers to engage more openly in safety discussions.
By treating frontline employees as partners in risk management rather than subjects of enforcement, companies create an environment where learning from everyday work leads to meaningful and lasting improvements.
Promoting a Psychologically Safe Culture
Promoting a Psychologically Safe Culture
The 4Ds technique promotes an organization's positive, engaging, and psychologically safe culture. By encouraging open communication, recognizing work and safety successes, learning from events, addressing gaps, and learning and improving, the 4Ds helps to foster an environment where safety is done with people, by people, compared to the traditional approaches of doing safety to people or for people.
Practical Application of the HOP Principles
The 4Ds technique applies the HOP Principles in recognizing that;
- Error is a consequence of an event and a symptom of system complexity, degrading controls or brittle system rules.
- System, work design, and conditions in work need to support normal everyday work.
- Blame degrades psychological safety, silences the voice of workers to share about work, and prevents learning from happening.
- Leaders can listen and learn from the outcomes of the 4Ds, and lead the organization in sustainable improvement.
- Learning supports change at the worker, workgroup, and organizational levels, which drives the improvement of better work and better operational outcomes.
