At a recent conference I attended, there was a paper describing an attempt to “manage” the risks involved in rock climbing. This highlighted the desire of climbers to push the boundaries to demonstrate mastery over evermore seemingly “unsafe” situations. (Solo unaided, unsupported climbs reliant only on the courage, skill and wit of the individual climber?). This was a somewhat paradoxical example of a person deliberately putting themselves “at risk” and then looking to apply “safety” methodologies to improve his chances of survival, so they can take on even “riskier” challenges. It highlighted the actions that are crucially needed to deal with emergent dangers and problems and still survive. Inaction (stop the world – I want to get off!) is definitely not an option at the top of “El Capitan”. In such unstable, “risky” environments, anticipation and compensating actions / interventions are essential to ensure and maintain recoverable situations. (Resilience rules OK?).
This contrasts with the traditional view of “Safety”, where the expected “normal” state is “safe” and where actions can result in “failures” which make the situation “unsafe”. Here the “rules” (legislation, regulation, supervision, procedures and standards, etc.) are there to prevent known disruptions and interventions. So actions here can potentially cause problems and are not to be recommended – (if in doubt – do nowt?).
So in this context (inherently stable environments), where everybody is expected to take the “right” (prescribed) action, any other intervention is by definition an “error” which can be a “risk”.
So our traditional “Robens” (HASAWA), Health and Safety thinking, Legal and Regulatory systems are all aimed at preventing these failures and hence could be termed “Health and Safety I”
This is a great and necessary foundation, but it applies to actions which can possibly make perceived safe environments (e.g. domestic dwellings) become unsafe (e.g. by allowing flammable cladding on a high rise tower block?). What became apparent to me was that the rock climbing environment, (inherently unstable, “unsafe”) does not fit this traditional framework.
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One clue might lie in the much told, (hopefully apocryphal) tale of a victim drowning in 3 inches of water because the Health & Safety, (“Work as Imagined”) rules did not allow the responders to wade in, without the proper equipment.
So top down Health and Safety (H&S I) I seeks to prevent any deterioration of the “safe” bubble surrounding an individual. This understandably aims at stopping responders putting themselves at risk. This is enshrined in rules, standards and procedures, and in current behavioural based safety regimes, deviations from which are not allowed and must be discouraged (sanctions, retraining, etc.) in any circumstances.
Here it is relevant to contrast the response of the much maligned NHS professionals at the Manchester Bombing and their response at the Westminster Bridge incident. Here it was all hands to the pump, throw away the rule book, commandeer people, facilities and equipment from wherever it’s available – whatever it takes. Here this response stems from the fact that medical professionals “normally” act in the “unstable” environment, where no action is not an option; and even if reacting to situations inevitably can sometimes increase the chance that a wrong action could be taken, but still, no action is certain to be a disaster.
But isn’t it this situation and the need to act to try to keep the unstable stable, which is the norm for medical, security, emergency responders and the armed forces. This requires an individual to be proactive, resilient, adaptable and resourceful, not just aware of the rule book and prescribed “work as Imagined” procedures, which as General Sun Tzu remarks, rarely survive first contact with the enemy!
So do we need to reassess and allow in our thinking and legislation in this crucial area, for two distinct situations?
1. Normally “safe” – where interventions must be controlled to prevent disruption of the stable status quo; and
2. Normally “unsafe”- where interventions are absolutely imperative to regain the equilibrium of the unstable status quo.
This leads to the conclusion that we need first to reclassify the environments to which traditional safety thinking / legislation appropriately applies.
At Grenfell for example it would have meant making a clear distinction between the professionals involved. H&S I, because it applies to the design and maintenance of a safe environment for the residents, still applies to the designers, builders and Regulators responsible in law.
Those responsible for managing the response to the emergency of a Tower Block fire, however, would be trained/encouraged/empowered to realise that this is an H&S II situation, where action is mandatory and must train and empower the responders to act on what is in front of them (“Work as done”), because no action is not an option. This requires more devolved and proactive leadership to ensure that the “red mist” is not allowed to replace rational decision making.
This distinction could then legitimately be applied to a range of sectors where people are deliberately or voluntarily exposed to and have to act in “normally unsafe” situations – this would include sporting activities, the Emergency Services, the Medical Profession, Police and Security services and The Armed Forces. Separating these out then leaves the existing legislation etc., still relevant and applicable to its historically intended recipients, Industry and the public.
Industrial situations often need both approaches. Here one needs to classify the environment in which the person is employed and trained to work. For example, office work would be considered “normally” safe, while offshore drillers take pride in their skills in managing a hostile environment – and are remunerated accordingly. Working in the normally “unsafe”, needs at least an adequate level of ”situation awareness” just to survive – and to realise, for example, that a natural desire to retrieve an unconscious colleague from a toxic or asphyxiating environment, can only add casualties and problems for the professionals.
This would then go a long way to setting right, the undeserved and negative coverage and criticisms of some of our emergency services in recent events. It highlights the way it can be seen that the problems to be fixed are with the system and the way we legislate, not with the people involved in trying to react. Recognising that these are H&S II situations, enables empowerment of these professionals, and does not just provide a basis for blame in hindsight. No action is more than not an option, it is totally against their instincts and motivation The “Good Samaritan Act” purports to protect well-meaning unqualified bystanders. Shouldn’t we recognise that we need this and more to protect the people whose job it is to protect us?
Acknowledgements – This think piece is a result of discussions and ideas from Al Ross, Ralph McKinnon (NHS), Dave Wales (Fire Service), Bob Pointer (ex-Police) and Gil Kernick (ex-Grenfell resident). I hope we can include comments and feedback on this think piece and if it gains peer support and is deemed relevant, together write a better, more formal paper, later in the year.
Nice David! A rock climber reacts in real time to the situations he/she encounters. If the rock climber was considering all the errors he/she could make, it leaves little room for flow and insights. 6 Sigma drove efficiencies to a point where it left no time for insights. 68 Fortune 500 companies became more efficient but their stock dropped because they couldn’t keep up with the insights and innovation of their competitors.
We with good intentions distract our workers from insights by having them list all the possible hazards with application of critical path weighted potentials.
What we want is optimal performance like a rock climber, that reacts in real time with the appropriate weight.
See Gary Klein, “seeing things others don’t”
William, the Klein quote is very aposite. If I remember rightly In his book he gives a tragic example of firefighters who thought “slow” and followed their insights not instincts survived, whereas and those that followed the rules didn’t.
Hi David,
I think the key that I recalled was the firefighter that followed his insight to react differently and survived. Or the Ski group that acknowledged, something didn’t “feel” right and changed course narrowly avoiding an accident. I’m not recalling the Fast and slow analogy from Klein, but regardless there is a significant amount of neuroscience and cognitive psychology available that I don’t believe we are using in the Safety industry.
Well said all
Thanks for the excellent article!
In my business, driver safety coaching, the content is equally relevant. Legislation seeks to make the roads safer but, in Australia anyway, the road toll continues to increase. More and more traffic policing with increased speeding fines and penalties for minor traffic infringements. This approach only serves to raise revenue without addressing the real problem. Once again the focus is on protecting the “normally safe” without recognising that in driving a car, you are operating in an often unpredictable “unsafe” environment.
Whilst there is an obvious requirement for road rules, just as much focus should be placed on teaching drivers, from the learner driver stage onwards, to recognise and react accordingly to an “unsafe” environment. Situational awareness is key.
Anyone who is trained and competent should be able to dynamically assess hazards and how to avoid or mitigate them, regardless of occupation! Drive a car or ride a motorbike, you are making constant dynamic decisions that affect your safety and that of others!
We have been forced into a culture of health and safety through regulation, even though the Management of Health and Safety Regulations requires us (individually) to assess hazards applicable to us. This is now taken as a Corporate decision that an individual must follow rather than at an individual or team level. We still produce our assessments, but are told that we have to follow “site rules” or other “management regulations”.
This is the same for the Blue Light Services. They are trained and competent, but cannot act on there own initiative, because of the culture of blame and management hiding behind (well meaning) outmoded assessments.
I agree with William that we want optimal performance. The S2 approach is for everyone that does a job; not for the few!
Agree, but we need to syart with the more obvious anomalies
David, thank you for a very insightful article. It triggered one of those “epiphanies” that I told myself that I always knew this, but not really. As you suggest, the work mode (situation) is very important. Previously, I had contacted you earlier (year or so ago) to chat with you about analyzing “Critical Steps” using FRAM. To me, Critical Steps are key transitions points in SOPs between “normal, routine” work (normally safe–“known” risk) to “off-normal, emergency” situations (normally unsafe–unknown risks), if the performer, per chance, loses control–i.e., human error. This is why I emphasize the operator’s recognition of high-risk transfers of energy, movements of mass, or transmissions of information that could trigger serious harm should control be lost. I have to think more deeply about the ramifications of “mode” to Critical Steps. Great Stuff!!!
I enjoy reading the responses and interaction from a well written article. “It’s the journey we seek, the destination will reveal itself in time.”
Thanks for improving the journey David.
A rock climber, fire fighters, other emergency workers and even defence personnel are continually learning, training and developing their skills to ensure they are at the top of their game and able to meet any challenges and manage risks as they arise. Commercial could learn a lot from this form of risk management and put investment in ongoing instruction and training of staff, as rock climbers do then people would be able to make proactive assessments of risk. Field-based employees (service technicians, truck drivers, installers, meter readers, inspectors, etc.) who work remotely from the organisations base, face changing risks and are required to consider all possibilities for error prior to undertaking a task. You can’t give a solar panel installer a work instruction and say this is how you will do the job, because every installation is different and you can’t train someone for every possible error they are going to come across. What organisations need to do is train employees to dynamically assess the risk and to ensure all foreseeable errors and considered.
Currently in a diploma course in the work & health space, I can confirm William’s view in his last comment. I also confirm the nice text prepared by David. Safety I is still the core mindset in EHS. Or responded differently from a human factors point of view, how somebody shall react differently than in the way he or she has been socialized and training? In the EHS I – world the risk assessment follows established epidemiological and toxicological exposure limits and scientific approaches introduced by Gruber and James Reason’s linearity etc.. Alternatives are available with the concept of Antonovsky’s “salutogenesis” (dating back to 1979) compared to “pathogenesis” (the phenomenological dealing of “diseases”). Each branch of science still contributes individually to a “problem”. No system-of-system approach, no OODA or interdisciplinary “holistic” approaches are common. No time-consuming FRAM process that needs time and effort to understand “work as done” nor respect the “work as it has been done”. Hard facts, no philosophical excesses are required. ETTO-ing is common mainly due to time AND money saving “arguments” (at the point of the decision). YES, to be and become sustainable and resilient (engineered), be able to adapt rather than to react on the bad apple, “EHS II” is just needed (in the sense of a “just culture” and “A Just Transition”). – There are good news. Small plants are growing. I take this opportunity to draw everybody’s attention to the “Safety Leadership at Work Program” and its material proposed by Workplace Health and Safety Queensland (AUS) (with a Dutch Professor well known to us from Griffith University in the expert group) as well as to the “The Handbook of Salutogenesis” (Mittelmark et al. Springer, available by open access from the publisher’s website). With a FRAMily salute
Hi Romano, look forward to helping you cultivate your small plants to giant oaks to support our cause!
Thanks for the thought-provoking posting, David. My concern is about extra cognitive loading on first responders. Is it adding one more step they need to go through thinking if this a H&S-I or an H&S-II environment?
Ivan Pupulidy has just posted an article on the Parkland school shooting. The resource officer is now being charged for failing to protect students. Would classification legislation help move us away from finding fault and blaming?
I agree that situations often need both approaches. Cognitive-Edge has been training first responders, SWAT teams, military organizations to use the Cynefin Framework for situation assessment. H&S-I resides in the Cynefin Obvious domain or the Complicated domain if expert analysis is required, H&S-II resides in the Cynefin Complex domain where we Probe,Sense,Respond to make sense of complexity in order to act.
Gary,My concern is that emergency responders are trained / conditioned / (“licensed”?), to comply with H&S I legislation and thinking. This encourages/ predisposes a “bias” (“if in doubt, don’t”) to inaction. This is understandable and needed in “normally safe” situations. (if it ain’t broke —–). In emergency (Normally unsafe) situations, however, this bias conditions us (Kahneman 1 ) to “freeze” (inaction rather than fight or flight action). Whereas what is needed urgently is intervention / action, preferably informed by the more “difficult”, (non instinctive), Kahneman 2, more rational, thought processes. (your probe, sense, respond fits well here). So how do we change / modify our legal framework, rules and procedures to recognise that these emergency situations are indeed different. And in this H&S II scenario start to train and empower our responders to be prepared to throw away the book (Hudson River?), which cannot possibly cover every possible scenario they will encounter and its OK / expected that they will use their initiative. This recognises that in H&S II there is the potential in humans to think on their feet and adapt to the unexpected and recover seemingly irrecoverable situations. In these situations where no action is not an option, there will inevitably be failures and miscalculations, but it is surely better to have tried?
This is really interesting stuff. As a flight Nurse/Paramedic we are trained to respond to what we find. In situations where “system 1” (Kahneman) is going to overload, we overcome with simulation training. Sully landed in the Hudson, which was a prepared response from simulation training. Simulation training dulls the adrenal response from first time exposure and allows “System 2” to evaluate and respond with more appropriate actions, overcoming the freeze potential. Actions of high consequence that need immediate action require simulation training. In medicine, High Fidelity Mannequins are used to create the simulated “realness” and angst created by a myriad of conditions where patients crash unexpectedly. We are trained to identify the “system” that is failing while maintaining the basic requirements for life support. Without experience we are forced to follow the “book” as you mentioned. Simulation offers experience.
I have seen new responders, pilots, managers “freeze” as you mentioned without proper exposure to the situation encountered. When in doubt “do nothing” does not work.
My opinion to the how do we change question, is possibly too simple. If we can be educated in Neuroscience and Cognitive Psychology, through simple Object lessons (Hollow mask illusion) that demonstrate our human frailty, and make us self aware, it may increase our “free Will” making us able to reason where biases, priming and anchoring are shaping our decisions. If this type of training was mandated as part of curriculums in all educational ventures…maybe we can change the way we think.
Thanks for your original post and response…very interesting and thought provoking.
William, I am entirely in agreement with your comments. In the UK, an enlightened CEO of the Thames Tideway Tunnel Project, put all its employees through a 2 day fully immersive (professional actors, sets, etc) simulation course to expose them to fatality situations which included telling the bereaved relatives, etc. Without exception they were full of praise in the way it equipped them with the “experiences” which changed their inevitably naive mindsets and they all felt better prepared for the real “Work as done ” (not just Work as Imagined!). I hope there will be much more appreciation and awareness as you guys obviously are, of this need for H&S ii and High Fidelity Simulation Training!
Well said William, organisations need to realise that health and safety training should be part of a whole of work training which should include what to do if things go wrong, and not just something you provide to employees because the legislation said so. Employers need to see the value in simulations training or training for failure.
Exposure to simulated emergencies allows the limbic predispositions to be experienced and the rational adjustments made and learnt naturally (unconsciously?), so that they can cope with the real thing. I like to think its training for successful management of emergencies, not failures. Resilience not recriminations?
Interesting David. I am wondering on your perspective of training to avoid failures and conditioned response. I’m in Boston, where all the crosswalks in a four way intersection are activated at the same time (engineered safety). There are white crosswalk indicators and there is an associated loud sound so visually impaired people will know when to cross. The people crossing give all risk to the system. They do not look both ways, in fact, they often have their ear buds in and are staring at their iPhones while they cross. I found another cross walk with the white lines and no sound or traffic light. Many of the people exhibit the same behavior as if they are in the controlled crosswalk. Yet, when observing people crossing where there is no crosswalk, almost all stop and calculate the best time to cross. So my query is if we are humans, training for emergencies is the case where “failure is not an option.” (taken from another post). If we are conditioned to behave a specific way or protocol to avoid failures, does resilience create other problems from conditioned response?
The conditioned response assumes that the crosswalk is controlled – normally safe – so habit and familiarity encourage “confidence” ( and complacency?. The fact that some are not, is a variability – (work as done) – that may escape conscious notice (we often tend to do routine things on autopilot and only consciously override if we notice discrepancies – which we often don’t – confirmation bias?). An uncontrolled or no crosswalk is the “normally unsafe” situation where we have to “stop and calculate” (classic Kahneman 2) – in other words use our ability to adapt, avoid, spot openings and solutions. In other words display our natural resilience to variation?
So training for emergencies is best aimed at preparing the responder to deal with the unexpected (Work as Done); and the immersive aspect “conditions” the responder to expect the full emotional / hormonal “noise” to be assailing their senses and realise that it is not necessarily “Work as Imagined” (the crossing is uncontrolled?) and must be dealt with by consciously applying natural resilience.
Thanks again for your insight David! My thought is that we have to be careful not to erase “natural” resilience with over loaded distraction of training and conditioning.
We create new biases and can easily prime our workers to distraction from the critical path.
Appreciate all your input
Agree – Thanks for your insights also – its invaluable to have feedback and stimulation from actual hands on points of view!