During a running training with 15 fellow runners, we had a half hour work-out on stairs that ran along the fire station of my hometown (see picture). The question that arose, after having done this intense but fulfilling training, was about safety. Was this a safely performed training exercise? And this depends a lot on your definition of safety. I will approach this question using the two perspectives Safety I and Safety II.
Safety as the absence of negatives
The traditional way of looking at safety is based on the absence of negatives.
What do we look for?
Incidents, accidents, injuries, near misses, causes attributed to those negatives, malfunctioning of ‘components’, failures, etc.
So what was the outcome of this exercise?
The definition steers us in the direction of the outcome of the process. Usually the process itself is looked at with a set of assumptions associated with this perspective (i.e. causality, bi-modal functioning, etc.). In this case, at the end of the exercises nobody suffered from injuries or had an incident or accident. But I think everybody had one of more near-misses in the form of almost tripping due to ‘false steps’ and the combination of mentally coordinating the steps and physically executing them.
What ‘caused’ the near-misses?
Near-misses could have had bad consequences like injuries and should be investigated to learn from them. The question of causes of failures steers you in the direction of failures in the process that led to the near-misses. Things such as: Unclear directions by the trainer, the demonstration was too short, supervision during the exercise was lacking, the runners were not focused enough or too eager in their performance or in general didn’t have the competencies to perform these kinds of exercises.
Was this a safely performed training exercise?
There were no incidents and injuries, so in that sense the exercises were performed safely. Near-misses did happen and while they were adequately handled they could have resulted in injuries. So measures to ensure that these don’t happen again have to be taken.
What kind of actions do we undertake?
We want to get rid of those near-misses (the zero vision) because of the risk of injury that is present. We will do this by both additional training for the trainer and a slower built up of the competencies of the runners.
Safety as the presence of capabilities to ensure success
An additional perspective on safety is that safety is defined as the presence capabilities that ensure success.
What do we look for?
Capabilities, adjustments to accommodate variations, performance variability, daily operational practice, moment to moment ways of addressing the challenges and risks, etc.
So how did the process of this exercise look like?
The definition of safety in this perspective is oriented towards the process and the context and not so much toward the actual outcomes. In this case, the exercise was preceded by specific running education exercises that addressed the capabilities that were needed during the stair endeavor. After explanation and demonstration of the stair exercise by the trainer, the group would start execution. The first steps were mostly trial and error to get a feel for the ‘rhythm’ of the exercise and the way to do it successfully. Thereafter we ascended further using focused attention on the exercise while constantly adjusting rhythm, speed, height of the steps and relative position on the stairs.
During descending, the tempo was lower using normal steps to regain your breath and ensure successful arrival at the bottom of the stairs. Sometimes this part is even more risky since the muscles have had intense exercise and you have to regain your breath. Coordination can then be quite challenging even during normal walking down of stairs.
What capabilities resulted in ‘failing safely’ (after podcast 34 by Todd Conklin)?
In case of ‘false steps’, most of the participants used the other leg or both hands to regain balance and continue with the exercise. Others also used the walls on either side of the stairs to regain balance.
Was this a safely performed training exercise?
The group took part in a complex and challenging exercise that was both mentally and physically challenging. The trial and error start and the occasional ‘false steps’ of the runners served the important purpose of learning. The competencies were effective to ensure success during most of the many steps that had to be taken. Performance variability was a critical part of this success so that small variations in the execution or the environment were dealt with properly. So yes, the exercise was performed in a safe manner.
What kind of actions do we undertake?
The exercise was during the fourth training in a series of seven trainings. The level of performance throughout the group was sufficient to start with and performance improved visibly during the execution of the exercise. Ways of adjusting performance were quickly picked up during the trial and error start and during the handling of ‘false steps’. For the future, the level of performance of the group prior to undertaking such exercises should always be taken into account but no specific actions are required at this time.
Reflections
Hollnagel uses ‘What-You-Look-Is-What-You-Find’ as a way of expressing that our attention is guided by the assumptions and worldview we bring to situations. The first perspective tends to steer us in the direction of malfunctioning, normative language and simplistic explanations. The information that you gather is very specific and focused on a small part of the outcomes. The associated zero vision, which goes hand in hand in most cases, steers us further down the path by eliminating negatives based on the same assumptions that have guided our information gathering and investigation.
The second perspective steers us in the direction of a broader view on the whole process and on the capabilities that have been shown throughout the execution. A richer understanding of the mechanisms and patterns allows us to see the way that the runners handle the challenging exercises. And what should be removed according to the first perspective, is a very important source of learning in the second perspective!
I’m eager to learn thoughts of others regarding the perspectives and the reflection on them. And if you want to we can discuss running as well!
David,
I enjoyed your perspective. I currently manage my facility’s process whereby people report and investigate according to Safety I. Our first line supervisors performing the investigations inevitably get tripped up (see what I did there?) when prompted to investigate a near miss like your false step example. They know something bad could have happened and it meets the definition we give them, but they also resist that this near miss is ‘worth investigating.’ They understand intuitively that we still managed to run the steps safely.
We teach safeguard identification and breakdown when classifying an incident’s potential outcome: did luck or a safeguard prevent this near miss from becoming an incident? I wonder if there’s room to expand this conversation to identify capabilities as safeguards as well. I am not sure how well we learn from successful capabilities or how well we share effectiveness across the facility. I am reminded of Todd Conklin’s podcast on Dr. Jim Joy’s work on critical controls.
Just some thoughts. Thank you David for sharing yours.