Lean, Green Safety Machine – Part 2

IraqWar is, above all things, an art, employing science in all its branches as its servant, but depending first and chiefly upon the skill of the artisan. It has its own rules, but not one of them is rigid and invariable. As new implements are devised new methods result in its mechanical execution; but over and above all its mechanical appliances, it rests upon the complex factors of human nature, which cannot be reduced to formulas and rules. The proper use of these thinking and animate parts of the great machine can be divined only by the genius and instinct of the commanders. No books can teach this, and no rules define it.

Captain Francis V. Greene, 1883

In ‘Lean, Green Safety Machine – Part I’, I established that high performing organisations, typically command-and-control orientated, are successful because it seems they have a Safety II approach. As Greene alludes to, it seems that Safety II thinking has been around for the last century or more within military operations.

Similarly, there are other professions that have a Safety II approach to adjusting performance in a dynamic environment in order to succeed. For example, the majority of team contact sports are similar to a field of combat environment. Imagine the coach and his team sitting around trying to write a step by step job hazard analysis of each play his team for each play, in both attack and in defence. It’s plausible at this point to opine that it would be impossible to predict all the variability and establish the defined controls for all foreseeable threats and opportunities. Similarly, during the course of ‘play’ there isn’t the luxury afforded to complete a ‘take 5’ risk assessment and document the change in procedure to cope with the change in the field. In these situations time is of the essence, as are the decisions, otherwise the initiative will be lost and the threat will prevail.

These similarities aren’t just confined to the military and sport, as they are also found in other high performing professions such as aviation and emergency services. The other similarity to note at this point also is there is not a safety ‘professional’ at the point of risk in any of the professions I have highlighted yet advising or assessing if a task is being done safety, or with the right behavior.

How does a high performing team make decisions and corrections where they are confronted with variables that are unpredictable and that the path to success cannot be described in a set of predetermined discrete actions?

Detailed and rational decision-making requires time[1]. I equate the military detailed decision making process and tools to a broad brush safety risk analysis which considers the overall scope of work, the workforce capability, the work/occupational environment and the broad or principal hazards in detail. Obviously this process is not appropriate at the point of contact with the enemy, nor is it appropriate at the point of task level work.  It is however an appropriate means to consider all the complex variables from which a detailed understanding of the operating environment can be gained[2]. The decision could be a go or no-go, or one about a specific mission at the tactical level (using techniques and procedures).

However, when a soldier needs to make a quick decision at the point of enemy contact, there is no available time for a detailed analysis. There is no luxury of being able to ‘stop work’ and complete an analysis’ as the tempo and initiative will be handed to the enemy. It is at this point that the soldier needs to rely on their own knowledge and experience in three critical areas:

  • Own force techniques (personnel and equipment capabilities) and procedures
  • The enemy (threats and hazards)
  • The terrain (the occupational environment)

Knowledge and experience in the three critical areas must already be well known. If the soldier is lacking knowledge and experience in any these areas, during the pressure of combat it is unlikely for a good and timely decision to be made. Similarly, in any other non-military workplaces, at the point of ‘hands on tools’ the expectation would be that the supervisor or team leader at least would have knowledge and experience in these three critical areas to allow good decision making to occur.

The knowledge and experience is therefore achieved prior to the point of contact with the enemy, or exposure to the hazards. While techniques and procedures may be known through prior training and experience over several years, the other two critical areas (enemy and terrain) require analysis during the detailed decision making phase. Therefore, the person who leads those directly exposed must be involved in, or have a clear understanding of, the analysis results from the detailed decision making process. However, good decisions do require a combination of analysis and experience – not one or the other[3].

The decision making process, both detailed and quick, can be improved in junior leaders through practical exposure. This increases their level of experience and knowledge, however it is important to note that ‘operational’ experience alone is not enough and cannot be relied upon to provide suitable experience, as the operational environment cannot be controlled to provide uniform experience and opportunity to learn. A fundamental aspect of learning at the individual level is that the brain learns best through error[4]. Therefore, to maximise the learning of leaders it is important for the learning environment to be one that encourages mistakes[5].

In many of today’s workplaces we have a reliance on operational experience alone. Very few organisations provide a controlled environment that encourage learning by mistakes, but also an environment to allow the devising of new methods. Kelvin Genn’s post on ‘Disruptive Safety’ implies that we should make mistakes well, and it appears to be the case that the military actually has a proven method to do this.

In ‘Lean, Green Safety Machine – Part III’, the final blog in this series, I will look at techniques used by the military and other professions to better the decision making process, their relationship with failure and to current safety processes.


Dekker, S.W.A., (2011). Drift into Failure: From Hunting Broken Components to Understanding Complex Systems, Ashgate Publishing Co

Greene, F.V., (1883). “The Important Improvements in the Art of War During the Past Twenty Years and Their Probable Effect on Future Military Operations,” Journal of the Military Service Institution of the United States 4, no. 13

Holmes, C., (2012). Decision Making at the Tactical Level, Australian Army Journal, Volume IX, Number 3 cited online 1 Oct 2014  at http://www.army.gov.au/Our-future/Publications/Australian-Army-Journal/Past-editions/~/media/Files/Our%20future/LWSC%20Publications/AAJ/2012Summer/08-DecisionmakingAtTheTact.pdf

Lehrer, J., (2009). The Decisive Moment: How the brain makes up its mind, Text Publishing

Smith, C., (2011). Design and Planning of Campaigns and Operations in the Twenty-First Century, Land Warfare Studies Centre, Canberra

Storr, J., (2009). The Human Face of War, Continuum Books

[1] Storr (2009) p. 137 and Dekker (2011) p. 13

[2] Holmes (2012) p. 94

[3] Storr (2009) pp. 148-149

[4] Lehrer (2009) pp. 44–45, 237

[5] Lehrer (2009) p. 55



  1. Shane Durdin Post author Reply

    Rob – for me personally the military approach, the centuries of learnings, and the evolution of technological systems and understanding of human factors in battle is very much consistent with safety differently. In Steven’s post on ‘What Safety-II isn’t, he explains that its not about something completely different, and no about leaving the past behind. The military practices safety-II theory. In combat there is a need for performance variability, trade-offs, emergence, etc. As the nature of technology changes, the emergence in new threats etc means that the military has to adapt and overcome to be successful. They know the past is not necessarily a guarantee of the success of the future, however the learnings are just used differently to find the the future path. Finally, believe me there is nothing rational about decisions in the heat of combat.

  2. roy Reply

    Rules of engagement (strategy) and rules for opening fire (operational plans) are rational, well thought out and form the control (system) for sub-unit command; and hence the decisions through the command and control (process). This is not safety-differently but merely a ‘traceable’ rational process. One that is documented and maintained on record. However, the ops experiences do not necessarily reflect anything ‘differently’ and in this blog perhaps the description is a little too simplistic. The sequence of events are conducted along lines of ‘known’ ways to do things (procedures), which are rational, trained for, learned, practiced and re-practised to provide an experiential base for repeating actions to a range of risk-sources (drills). This is rational and not that different to any corporate structure. The military metaphors used here are not really ‘safety differently’. Peacekeeping missions do not necessarily engage in the ‘fog-of-war’ and are based on rational decisions with strict controls disallowing any ‘freedom-of-action’ especially by what is referred to as ‘junior’ leaders. The blog misses key concepts of mission-control and / or directive-control; originally based on auftragstaktik, a freedom to apply rational thinking within responsible areas. It would appear that on ‘contact’ that nothing is rational, yet hopefully not irrational decision making. Perhaps there are arational aspects not highlighted here.

    1. Shane Durdin Post author Reply

      Thanks for the feedback Roy. My question to you and the readers then based on your comments and an association towards ‘safety-differently’ is whether you believe that the safety-II philosophy is safety-differently, or is safety-differently something else. I do not mention the military doing safety-differently, but I do see that the ideology that variability and trade-offs, and other safety-II traits have been a part of military thinking for over a century. My post hasn’t missed directive control or mission control, there was a point at which writing had to stop. The point of the blog, which may be missed, is that I believe that there are safety-II principles that the military use, which are in practice and perhaps can be learned from rather than people commonly theorising ‘safety-differently’ and not putting anything into practice.

  3. David Provan Reply

    Hi Shane, thanks for posting. We have played with the Military example in relation to Safety ll principles and I would agree with you that there are many aspects which can be learned from for how organisations think about Safety Management. For example: battle readiness, field testing, simulation training, building adaptive capabilities and leadership in the front line.There are of course other aspects of the Military that are squarely Safety l – HQ bureaucracies, operating protocols … And my favourite – the mission (“read production”) comes first. Looking forward to part 3. Regards David.

  4. roy Reply

    Command + Control. I just don’t think that command and control is necessarily a good example for your Safety II. It is filled with rigidity and binary thinking fixating decisions to a formula. Safety discourse requires improved understanding how decisions are made and how motivation works instead of command strategies, plans, systems and controlling processes used training and practice.

    1. Shane Durdin Post author Reply

      I think the discussion should consider that for those organisations that have a command and control approach, but allow variability at the point of ‘contact’, as to why they are successful the majority of the time. These organisations do not hunt for causes of failure, but look for solutions for success. So, should we cast the command and control approach to the side completely? Again, its a case of looking for practices that work and improving them to increase success, and the military model does actually explore how decisions are made at a number of levels, but also has methods to improve the decision making process by exploring why decisions are made. Many time myself in completing quick decision exercises or war-gaming plans, the question is asked ‘why did you make that decision’? Personal motivators, experience, knowledge, logic etc are all explored whether the impact was positive or negative so all involved could learn.

Leave a Reply

Your email address will not be published. Required fields are marked *