(Originally posted September 2016)
There is something disturbingly negative about safety. And I believe there are three main reasons for this.
The first reason is that safety is connected to unwanted outcomes. When most people think about safety they think about (the need to prevent) incidents, illnesses, injuries, disasters, breakdowns, losses, damage and other negatives. So, when we talk about safety, which is something we desire, we bring up the things that we don’t want to happen.
Second, the way we talk about the things that we don’t want to happen is to talk about the usual suspects of how we believe these come about. Errors, mistakes, lapses, violations, breaches, short-cuts, rule-breaking behaviours, malfunctions, sub-cultures, drift, non-compliance, risks, hazards, dangers, slips and many other similar words make up the vocabulary of such mechanisms. So, the way we talk about the things we don’t want to happen, is to talk about other things that we don’t want to happen.
Third, to ensure that neither the triggers nor the ultimate bad occur, the field of safety has a large suite of tools and managements practices at hand to ensure that performance does not deviate into unwanted territory. Procedures, checklists, reminders, barriers, surveillance, best practice, standards, observations, investigations, commitment rituals, mock courts, gap analyses and many other tools and practices are intended to keep problematic behaviours and decisions within desired boundaries.
Collectively, it’s not a constellation of concepts that radiate possibilities for creating a better functioning world. The world of safety is constructed as a world of problems. The ‘objects’ that are understood, managed and talked about are viewed through a deficit lens – only when we have eliminated all deviations, addressed all the deficits, can we finally arrive into the promised land of safety where nothing bad happens. And this economy of deficits has a number of negative consequences for how safety is practiced.
The most important contribution the safety profession can give is, from a deficit management perspective, to point out and correct when things or people deviate or otherwise do something wrong. Put differently, the best compliment you can get from a safety professional about the work you’re doing is that you’re doing nothing wrong.
Judging from the many safety professionals I’ve met over the years, I have no doubt that they share a strong commitment, passion and vision for the preservation or even betterment of human life. Yet, this current approach to ensure safety, seems to have a life-constraining effect in the way it relentlessly points out human shortcomings. It is effectively a suppression of possibilities, an inability or disinterest in learning new things, a belief that the solutions developed for yesterday’s organisations are what will create future success – a discarding of the potentials of what people and organisations can and do contribute with above and beyond doing something wrong.
What is badly needed then, is to develop ways through which we can invite people into more valued ways of being and contributing, to find new ways for organisations to see their employees as assets or resources for sensing, contributing, analysing, creating and adding to well-being, welfare, and to ensure that things go right across varying conditions.
To do this, we need to broaden our gaze to include the things that we want to happen, and sometimes already do happen. We need to include a more appreciative lens. Unfortunately, after years of focusing on what is unwanted, appreciating possibilities and contributions can be difficult.
Below are a few ideas that have been helpful for others in broadening their appreciation for what goes on at work to also include possibilities:
Change the definition of safety. Safety is more than the absence of negatives – it is about the presence of a capacity to enable things to go right across varying conditions. Defining safety this way is not a pop-psychological trick of (over)belief in confirmation bias. Success is difficult. It is not a whimsical walk in the park where nothing bad happens. Success requires disciplined assessment of what needs to happen, where sensitivities lie, and where conditions can be improved. It involves asking questions about what has to go right? What do people do to make things go right? What do people need to be able to deal with the varying demands of the workplace? Where are the challenges going to be? Where can we learn about how this can be done well? It is about building robust, resilient and adaptive practices that can enable people to work toward achieving the purpose of the organisation. (For more information about this change in definition, I recommend Erik Hollnagel’s book ‘Safety I and Safety II – the past and future of safety management’)
See people as a source of insight. Every single employee is a sensor for what is going on within and without the organisation. They have experienced both good and bad performance. They know where resources are stretched thin to meet demands and when challenges have or are likely to occur. People are the recipients of trouble and the inventors of ways to overcome and adapt. As a bare minimum organisations can listen to what people have to say in order to understand more about what is actually going on (rather than simply measuring and enforcing what should be going on).
Ask better questions. Traditional safety investigations and observations rarely generate any new insights for how work could be organised differently. The reason for this is that investigators set out to correct, and not to learn. In order to learn, judgement of any difference between what should be and what actually happens need to be suspended in favour for asking open ended questions that can allow organisations to surprise themselves around both good and bad performance. For example:
- When do/did we have our best performance here? What happens then?
- When is your work difficult?
- What changes over the last year did you find really helpful and you consider steps in the right direction and we should do more of?
- If you could invest $50,000 in making this a better place to work, how would you spend it?
Allow solutions to be challenged. The biggest threat to safety is not the non-compliant workforce. The biggest threat comes from our belief in uniformity, authority and external expertise. The world is constantly evolving, it is complex, competitive and often surprising. Only by inviting (organised) dissent do we stand a chance to improve, innovate and overcome. An organisation interested in betterment allows solutions to be challenged and improved, even when they are not broken.
An organisations that knows how to appreciate and harness the possibilities and the many contributions that happen everyday in order to enable positive outcomes is well equipped for the future. They may not know how to tackle every possible scenario that will come their way. But they know that somewhere in their organisations they are likely to have what is needed to understand, improve, create and innovate.
The new definition of safety that you need is SAFETY II – see Euroontrol publications for a good description.
Thanks David. I have updated the text now with a ref to Erik Hollnagel’s book on Safety II.
Sounds an awful not like a generative safety culture and proactive hazard reporting to me. Great article.
I have to agree with the writer, we need to talk to those who perform the work, really learn from accidents by asking those out of the box questions; most of all we need to listen, really listen – that’s the real art of communication surely?. Personally I have always felt that it is my responsibility to coach and enable our engineers to manage their own safety according to the circumstances prevailing, the environment in which they find themselves and the task they are performing. They are after all adults, skilled in their work and who presumably do not wish to cause themselves harm. Is this a matter of trust? Are we still suffering from the hangover of a command and control culture because we fear to let go and trust our people to get on and do the right thing; and if we provided the right culture wouldn’t that come naturally anyway?
Good thoughts, Linda. One radical way is to take off our safety professional hats and shed our coaching vests. Instead, let’s become anthropologists and just observe people doing their work and the behaviour games being played. As ethnographers, let’s record their stories why safety policies, regulations processes, rules help or hinder. As archivists, let’s analyze the tools and assets being used.
Our thinking is significantly different. It isn’t to provide the right culture since that would be command & control. It’s to understand how variation in worker performance is shaped by sets of learned behaviours and ideas that humans acquire as members of an organization.
In thinking about your closing sentence, I’m not certain that variability in work performance isn’t ultimately and directly related to the environment in which it occurs.
In my experience, those organizations that rail against a “command and control” environment tend toward being “Command and Control” in practice, without clear boundaries or structural controls that facilitate the effectiveness of that structure. Something along the lines of the early days of scientific management, only with a Happy Face affixed to keep folks on their toes (as demonstrated by keeping their resumes current).
There’s nothing wrong with organization or the structure that accompanies it. They all exist in varying degrees and to varying definitions with varying degrees of success. Unfortunately for us, safety tends to be assumed within those structures but for the dangerous people we expose the system to.
In truth, any organization committed to creating and maintaining safe conditions within their structure, need to have the vision, commitment and courage to analyze how that organization does or doesn’t facilitate the creation and maintenance of safety at the functional level. Are we developing appropriate barriers that guard against injury and process disruption when exposed to an inevitable human error? Are we providing the bandwidth of training necessary to support system resilience when our process, predictably and inevitably, begins functioning outside it’s design parameters? Are creating and implementing job-aids and reference materials that anticipate the frailties of human memory and support system reliability? Do we utilize the performance review process to build on strengths and support the power of self-efficacy?
We hire people for their unique characteristics, skills, experiences and talents. To my mind, it’s counterproductive to attempt to then homogenize those attributes to meet the expectations of what the organization thinks it is. When it comes to nebulous “safety culture,” I think it’s less about controlling and more about shaping. Safety is, and will likely always be, a transient characteristic of any activity, process or system. As such, I don’t believe “safety culture” exists on it’s own. I tend to believe more in a culture that, through their actions and reactions, can be described as one that values safety.
Just my opinion from my perspective. I apologize in advance if this sounds preachy…not how it’s intended. I have an enormous amount of respect for everyone who reads and posts here.
Best regards to all of you!
Great article Daniel! In defence (slight defence) of risk management, risk relates to uncertainty and not necessarily to something bad. Many safety professionals use the word risk too simplistically and are generally only referring to nasty outcomes. Risk is a dirty word and often used, wrongly, interchangeably with hazard or other equivalent negative word. Risk should be applied equally between positive opportunity (do something better) or possible negative outcome. Undoubtedly a more productive, more positive approach to safety is required. I guess we can all start by looking at what goes right!
Thanks Daniel for another great article. I think, from a professional perspective, ours is still largely in its infancy without really taking hold as something of value until the start of this century. That being said and acknowledged, as a new science/profession, I believe it’s critical that we challenge all of our paradigms for effectiveness in the world in which we work. Across the board, we HAVE to get people to recognize that safety does not exist in the world unless we create and actively maintain it so that there’s enhanced understanding that safety is NOT something done to an individual but something that individual does to ensure their success and return from the hazard interface.
There are some great tools out there. Models such as Hollnagel’s Functional Resonance Analysis Method or Leveson’s Systems Theoretic Process Analysis that better fit the closely-coupled realities and technical specializations of the modern workplace. I’m a huge fan of resilience engineering and the focus on “what” is done during work to prevent system breakdowns or process failures. We would do well to ensure an understanding of Deming’s 14-points, paying particular attention to the importance of driving fear out and the fallacy of attempting to inspect quality in.
You are absolutely right about the negative spin on our profession that is worrisome and the need to speak in the new language of possibility. I will likely never be a big fan of probabilistic risk analysis because of the speculation and subjectivity to cognitive bias and distortion. From a practitioner perspective, I’m much more in favor of considering individual and team vulnerability to injury or system disruption because I believe it better communicates the exposure and the need to take action against it. Do we really care about the million to one likelihood when we’re the victim of occurrence?
Thanks again for another thought-provoking and important article.
Excellent piece Daniel. The traditional perspective on safety is demoralizing to staff, and only gives senior administrators the illusion that their organizations are ‘doing just fine thank you” until of course an event occurs and culprits are sought. Your suggestions, following the lead of Safety II are right on and are congruent with a number of ideas Bob Wear and I presented at the recent Resilience Learning Network meeting in Denmark and the paper for publication that is being drafted. The way you have characterized how to create the possibility of Safety II will certainly be cited in that paper. That presentation and paper addressed is the issue of whether Resilience can be made practical. We argued that since resilience is an emergent property of “work as done”, practical resilience is an oxymoron. Resilience does not exist as a tangible property until it is called forth by challenges or opportunities; one simply can’t say we will increase the organization’s resilience by 20% by dong some specific activity like introducing check lists or new policies.Such statements make no sense. But facilitating communication, questioning, vigilance, seeing staff as assets not potential error prone weak links in the “perfect” organizational world, reflecting on performance, challenging pat solutions (it seems everyone has a solution these days) would go a long way to empower staff to use their clinical expertise and create a context in which resilience can emerge. Well done!
A thoughtful piece Daniel and agree on the key principles. I also think there is something about Safety which has a power to itself, what Jung called an ‘Archetype’. There is a certain ‘force’ about things beyond just the method of that thing. It is in this worldview that these ‘things’ seems to have a life of their own, and I think this is the current state of evolution in safety. Even re-anchoring a vision of safety to safety plus 1 or safety 2 still keeps one anchored to safety as a first principle as well as the principles, semiotics and discourse of safety. Perhaps we need to break those ties and speak of safety less and much more of people, work, risk and life, your Art of Work brand certainly does this and I think is a great step in a good direction. Being anchored to the Archetype still leaves the fundamental dynamics of safety untouched. It then becomes simply more or less of the same thing (eg. systems, engineering, regulation) and this is reflected in the ‘new’ language and discourse, which doesn’t speak of shaking the very foundations of what generated the evolution of Safety to this state. Perhaps few in safety are ready for a discourse of disruption and prefer the discourse of engineering that continues to dominate the worldview of safety 2.
Thanks for the response Dr. Long. I always enjoy reading your thought provoking ideas and comments. I think to your point on whether or not safety people, or any specialty for that matter, is ready for a discourse on disruption, my professional belief is that the discussion is long overdue. To my mind, safety is ultimately one of the measures of our effectiveness at managing the inevitable system or process disruptions through resilience. I can’t say that safety would qualify as an archetype outside of the small group of professional but I do believe that there have been sufficient missteps in regulation, engineering, behavioral observation and enforcement under the label of “Safety” to have created a fairly negative stereotype of what safety “is” to most people.
I believe that safety is not only a transient characteristic, but also a product of what we create and maintain in the performance of our activities, be they work or play. I’m convinced that our human abilities at evaluating risk, particularly as subjectively and variably as it’s performed in the typical Probabilistic Risk Analysis does little to facilitate success in creating and maintaining safety. There are, I believe, too many cognitive biases and distortions that influence our perception of risk to make it reliably manageable. I also believe that the practice tends to create a blind spot to vulnerabilities from the individual to the high impact/low probability of a “Black Swan” event.
I agree with you that we need to shift the discourse on safety away from the current tone of engineering and incorporate the lessons and foundations of social and cognitive science that play such an important role in our eventual success. Safety will ultimately always be about people. Not from the perspective of what is done to them, but how we, as professionals, prepare them to respond effectively and resiliently within the context of imperfect systems. I also believe that we need to recognize the fallibility of the human (including those that design, finance, budget and build the systems) so that we can develop better indications and control mechanisms that prevent a relatively predictable human error from creating a system disruption. If our current computerized or automated control mechanisms are so closely coupled so as to eliminate human intervention, at the very least, we shouldn’t look to place blame on anyone who’s been dealt a losing hand.
Thank you again Sir for this and your other works on Risk and the Social Psychology of safety.
Ronald, yes I agree, the need for a new discourse that is disruptive is most necessary and this site and the discourse of safety Differently certainly does this. As you say, it is long overdue. Unfortunately, the foundations that have been put in place in what has become the safety tradition will be most difficult to move. There is a great deal of sunk cost in the reductionist-engineering- mechanistic discourse that now dominates the industry. However, I don’t think one can pour new wine into old wine skins, the new discourse has to have a more radical semiotic than using that same reductionist-engineering- mechanistic discourse to reform itself. I think the language of resilience is a good start in this except it is not something that is ‘engineered’ nor can we use mechanistic models to refocus the archetype of safety onto the primacy of people (subjects) over objects. Ellul calls also names ‘technique’ as such an archetype. It is little wonder that the discourse of behaviourism remains so popular in safety because it maintains the mechanistic worldview.
Deep down people know that the spin of safety doesn’t match people’s experience. I don’t really understand safety as either a ‘product’ or a ‘value’ and I think such language assists the mechanistic discourse. I couldn’t agree more with your comment ‘ I also believe that we need to recognize the fallibility of the human’, I find the denial of this throughout safety as such a significant issue. It leads to the most absurd and nonsensical thinking and language, much of it religious/fundamentalist in nature. I can’t see how this fundamental denial assists safety in any way indeed, the more one denies ones reality, the more ones mental health condition becomes apparent. I think the binary oppositionalism that dominates the sector contributes significantly to this. This mode of thinking is so deeply entrenched in safety training and formation I have no idea how it could be turned around. All of this is evident in the ZAV in Europe where such absurd logic sustains remarkably religious discourse about safety http://www.zeroaccidents.nl/wp-content/uploads/2016/03/TNO-publication-Sustainable-Safety-Visions-and-Perspectives-symposium-at….pdf
This kind of discourse only makes sense if one accepts a binary understanding of ethics. It is also maintained with very little consideration of by-products or trade-offs embedded in such discourse. The contradictions within the ZAV discourse are so -faith-based it is remarkable, all premised on the nonsense that injury rates are a measure of safety. As you read the ZAV literature the reductionist assumptions, the engineering language, the Bradley Curve semiotics and the behaviourist definition of culture all stand out as completely unquestioned and accepted. Some big challenges ahead.
Rob: I couldn’t agree with you more that the reductionist-engineering- mechanistic discourse dominates the industry. As a professional engineer I learned to break down an object into its parts, fix each component, and then reassemble. The whole is equal to the sum of its parts. Works fine when dealing with inanimate things like bikes, cars, airplanes. Unfortunately complicated systems thinking approach was applied to complex human systems. My experiences started in the mid-1990s with Business Process Reengineering and Enterprise Resource Planning (SAP, Peoplesoft, Oracle) IT installations. We were trained to break down a system involving humans into people, process, technology. To put the parts back together, we bolt on change management stuff. No wonder BPR, ERP projects have a 70% failure rate.
I do have concerns that the word “Engineering” is used in Resilience Engineering. When I read promising RE articles I’m hoping not to see a linear, reductionist approach but one that recognizes that parts do interact with each other. These relationships mean the whole is greater than the sum of its parts.
I agree the era of Systems Thinking and Engineering as the dominant metaphor continues to be very powerful and tends to crush any new ideas or solutions. I sense the safety paradigm will eventually change because of folks like us at safetydifferently.com. We’ve seen it before when Frederick Taylor’s Scientific Management succumbed to Systems Thinking. What’s the new paradigm? I think we’re entering the era of Ecology with Cognitive Complexity as the real world metaphor.
Thanks Gary…do you have any thoughts or recommendations on how to better “model” the complexities common to the modern workplace? As much as we’d like to simplify via a reductionist approach, when it comes to creating and maintaining the characteristic of safety, the sum, as you implied above, is far greater than the sum of the parts. Recognizing the challenge of representing 4 dimensional interaction via a two-dimensional graphic likely reinforces the reductionist approach. I also tend to believe that the Illusion of Control coupled with Fundamental Attribution bias have great influence on decision-makers establish organizational expectations of what safety “is.”
Personally, I think it’s overdue to start considering the invaluable lessons of the “soft” sciences that have recognized our cognitive limitations, group dynamics, biases, fallacies and distortions so that they (we) can work in concert to create resilience and control mechanisms that tolerate human error without injury, incident or system disruption.
Hi Ron. The model that I use to represent the modern workplace and its complexities is the Cynefin Framework. It acknowledges there is an Ordered side where linear reductionism applies, standards work, and best practices exist because you deal with predictable known knowns and known unknowns. The Cynefin Framework also recognizes an Unordered side of chaos and complexity, the domains of unknowns unknowns, unknowables, and unimaginables. It’s the side where diversity and disruption are welcomed to enable creativity and innovation.
There is a 5th domain called Disorder. An event has happened, you don’t know why, and a decision leading to action is required. The first decision is determining in which Cynefin domain does the event reside. This is the time when personal cognitive biases, past experiences, and habits have a good and bad impact. If you come from a strong “fix-it” background, your propensity is to immediately move to the Ordered side and use a linear problem-solving method. All well and good. But if cause & effect relationships are unclear or perhaps don’t exist, then trying to fix it could do more damage.
If you have “soft” science skills in your toolkit, you are better equipped to move to the Ordered side and use complex problem-solving methods. You probe the system to understand why, discover behaviour patterns that emerge from self-organization, non-linear feedback loops, and learn from experiments.
If you’d like to see a video of the Cynefin Framework: http://gswong.com/?page_id=13
Thanks Gary! Lots of good stuff there. I’ve been trying to use Dr. Hollnagel’s FRAM model to represent the complexity but beyond a few frames of FRAM, the model gets a little cluttered and cumbersome.
Gary and Ronald, thanks for your posts. I think the idea of wicked problems and collective coherence are important for thinking more clearly about ‘the dialogic organisation’ and about a dialectical idea of what safety is about. Certainly Taleb’s idea of anti-fragility runs against the discourse and semiotics of resilience engineering. Despite calling all this safety ii or whatever, it still a mechanistic paradigm, discourse and semiotic that negates any real forward movement. I really can’t see much difference in assumptions and discourse of this supposed ‘new’ approach. Certainly the model of FRAM I find of no interest whatsoever.
This term used for safety means what?
“Safety; the presence of a capacity to enable things to go right across varying conditions.”
Can I ask what is the capacity? and what are the things?
What I mean by capacity is the organisation’s ability to maintain control over the physical processes involved in their operations (aka the things).
Good article and I don’t think too many people would argue the key principles.
Interestingly, many organisations have bits and pieces of those principles already in place either functioning or semi functioning, and are still struggling to move forward. In the main, this is because the key ingredient is missing – the leadership.
Until we fully understand the complex interplay of leadership behaviour, key motivating factors in operational decision making, risk trading in planning and execution of work and meta meaning in communication and interaction vertically and horizontally at stratum levels, we will never be able to inflict drastic change. Moving forward is not only dependent on the issues associated with definition of safety or positive and proactive practices outlined in this article. That is only the beginning.
Safety is neither technical, philosophical or behavioural problem. From the organisational context, safety is a leadership problem and as such it can only ever be drastically changed if it is tackled from the context of organisational behaviour.
Great article, and good to see it being reposted. Love the Safety-II style of questions that you propose. I guess, many times, management and front line workers get excessively hung up on fixing the holes in the cheese and pointing out the negatives, respectively, and this make us blind to the presence of the everyday adaptive capacity that gets the job done and brings everybody home in one piece at the end of the day.
There is no doubt that there is an “Obsession with Outcome” that is being driven by regulatory agencies. industry groups, and our own narratives in this domain. There is a false belief that the lack of an apparent incident somehow means that the task was completed successfully. In actuality, this is never the case since there are always unchecked errors, management and cultural systems that are failed, weak, or non-existent but needed, and for the Safety-II folks, steps in a task that went correctly but possibly not captured for future socialization. Every single tasks has learning potential; however, the majority of safety personnel are not looking at these tasks. It is well accepted that a learning culture is a necessary element in maturing of safety. I’ve never taken a personnel injury definition of what is safety, rather viewing this as a collection of capability and capacity to design and complete tasks with acceptable outcomes inclusive of quality, efficiency, profitability, shareholder value, and customer satisfaction. I can’t and will not separate them. I know that I can create management systems that can intervene between unavoidable cognitive errors in observation, assessment, design, implementation, and feedback and an unacceptable outcome, but I can also put a company out of business by implementing too many management systems. Risk management is crucial. I know many will have issue with this, but personal injury is usually the lowest cost of any of the other losses, most of which are hidden. They don’t have to be hidden. I developed my own causation models along with processes to analyze tasks, pre, during, and post, to identify to error-likely situations either managed or not, system performance for awareness and intervention, or not, worker performance including risk exceeding aspects, scope changes not reassessed air the time, etc. This process also includes the synergistic impacts of various combinations. The future of safety will require a significant change in many of our narratives.
A great article on Safety 2.0 (Positive view of optimizing and improving) is found in an article in Forbes:
In Focusing [Just] On What Pilots Do Wrong, We May Be Missing Valuable Lessons From What They Quietly Do Right!
“Trying to fix accidents by focusing on errors is like defining marriage by studying divorce”
–David St. George (SAFE)