The trouble with labels – combining ‘Resilience Engineering’, ‘Standardized Work’, ‘Procedural and Practical Drift’, and ‘Human Factors / Ergonomics’ (HF/E).
There are so many buzzwords in the world of ‘safety’ and the provision of safe work that it is sometimes hard to differentiate them or make sense of them – either together or as separate concepts and ideas. And yet, are they not all the same thing? I have picked four of the ones that are getting a fair bit of air play in the worlds I am working in and thought it was worth chatting about them a bit and seeing how they all fit together, if they actually do! I am not saying there is a GUT (Grand Unified Theory) of safety but I am tempted to dream of a description of how safe work is prepared and undertaken that we can all get our heads around.
Let’s look at each one and then see if there are common ways of describing them as one concept. Well, we will see how we go anyway…
Resilience Engineering is a concept well covered by Erik Hollnagel in lots of books, papers and conversations. In a recent book of his (Safety-II in Practice: Developing The Resilience Potentials – Routledge 2018) he has proposed that the following four potentials are necessary for resilient performance:
“The potential to respond. Knowing what to do or being able to respond to regular and irregular changes, disturbances and opportunities by activating prepared actions, by adjusting the current mode of functioning, or by inventing or creating new ways of doing things.
The potential to monitor. Knowing what to look for or being able to monitor that which affects or could affect an organisation’s performance in the near term –positively or negatively. (In practice, this means within the time frame of ongoing operations, such as the duration of a flight or the current segment of a procedure.) The monitoring must cover an organisation’s own performance as well as what happens in the operating environment.
The potential to learn. Knowing what has happened or being able to learn from experience, in particular to learn the right lessons from the right experiences. This includes both single-loop learning from specific experiences and the double-loop learning that is used to modify the goals or objectives. It also includes changing the values or criteria used to tailor work to a situation.
The potential to anticipate. Knowing what to expect or being able to anticipate developments further into the future, such as potential disruptions, novel demands or constraints, new opportunities or changing operating conditions.”
To me, this means that a work team (as an example) has an understanding of how they will cope with changes, upsets and other interruptions during work and are able to adjust their performance and bounce back before something actually goes wrong.
Procedural and Practical Drift comes from a few sources. Scott Snook, in “Friendly Fire: The Accidental Shootdown of US. Black Hawks over Iraq – Princeton University Press 2000, talks about the slow and often inevitable changes in the way work is done over time and how significantly it can impact outcomes. Another simple example is related to the way cracked and broken foam was repaired on the Space Shuttle over time. (See Columbia Accident Investigation Board Report Volume 1 August 2003). Sidney Dekker in Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems – Ashgate 2011, talks extensively about changes in the way work is done that occur, not only in practice but that are then proceduralised. This is really brought home as he describes in detail the loss of Alaska flight 261 as the jackscrew lubrication periodicity moved, with complete approval, from 300 to up to 2550 hours resulting in the loss of the aircraft along with the 88 souls on board.
Standardized Work comes from the Toyota Production System and was recently described to me as “a highly defined, documented method which describes how a task should be executed every time. It empowers teams to own a safer, more productive way of working centred on human movement.” In another example, which I like better, Janet Dozier in her blog in 2013 entitled Does Standard Work Destroy Creativity? talks about “Standardized work establishes the best method to perform a task with the least amount of waste while providing the best patient care. It is an agreed-upon method and procedure for the best sequence and timing to perform a task.” Although this is specific to heath care, the analogies seem obvious to other domains and cover the intent better for me.
Last but not least, Human Factors / Ergonomics (HF/E) is all about the understanding of interactions among humans and other elements of a system. It is not simple human movement but the interrelationships between the human and the system that is important here. A book that had a profound impact on my understanding of HF/E was the recent one edited by Steven Shorrock and Claire Williams entitled Human Factors & Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World. Published by CRC Press in 2017. I thoroughly recommend it.
I would like to explore the common elements of Resilience Engineering, Drift, HF/E and Standardized Work in terms of Work-As-Done and Work-As-Intended. These differ only in name from Erik Hollnagel’s ideas of Work-As-Done and Work-As-Imagined and come from my book Simplicity in Safety Investigations: A Practitioner’s Guide to Applying Safety Science. Published byRoutledge 2017. The name change is purely based on what worked in the field as we developed the investigation approach and not from any intent to suggest Hollnagel’s labels are not suited to the uses he puts them, which they absolutely are.
HF/E, Standardized Work and Resilience Engineering are all about setting up the Work-As-Intended. Drift is all about the recognition that whilst Work-As-Intended is all well and good, the real world dictates that Work-As-Done is the real driver of safety and drifts over time.
If we hold that Standardized Work is the bit that lays down how the work is supposed to be undertaken (Work-As-Intended), then the scientific discipline that helps those creating this Work-As-Intended is HF/E and if it is done in conjunction with ensuring that elements of Resilience Engineering have gone into the thinking and that those actually at risk during the task – those doing the work are integrally involved in the creating of the Work-As-Intended and its on-going monitoring, then Drift can also be managed.
In a way that does not use the buzzwords above we might see the following:
A team is about to do a task and they are working out how to do the job so that they get it done productively and also safely. They talk as a team about how they have done the task in the past, what worked, what didn’t work, what could go wrong, what to monitor or look out for as they do the task, and what they could do to adapt the task if it did start to go wrong. They also look back and chat about whether the way they are doing it now has changed over time – have they always done it this way? During the conversation they would also talk about the specific actions they are doing, what they are going to interact with – what systems, equipment or process they are involved in and whether there are bits of that they need some help understanding more. If so they might get some help from a HF/E practitioner (bugger, I used one the terms – unavoidably I think) to help them make sure they are getting the science right.
Once they have thought through all of this, they lock it all down in a Job Safety Analysis or work procedure and then each time they do the task, they check to make sure stuff has not changed or slipped from the method they reckon is the best for the task at hand. If things have changed they stop and work out what to do now. If nothing has changed they get on with job and have a bit of a post-mortem afterwards to see how it all went and whether the way they did the task matched how they thought they were going to do it.
Overall I think we don’t always help ourselves when we try to attach labels to things, or use language that is not well or easily understood. Especially as we all have our own perceptions of what things mean. Labels, apart from tending to take detail away from the concept, can mean different things to different people.
By helping translate technically correct but inaccessible buzzwords and labels into simple stories we can often help people understand what it is we are trying to say or achieve in safety and this can result in a better understanding of what creates safe work.