How we should talk about and promote Safety Differently
All of the concepts below are from the great works of Sidney Dekker, Eric Hollnagel, Todd Conklin and Daniel Kahneman.
Defining safety as the presence of positive capabilities, capacities and competencies that make things go right and not as the absence of things that go wrong.
Resilience. Resilience is often described as the ability to bounce back, to accommodate “unexpected” change and to absorb uncertainties without falling apart. In the face of potential disturbances, changes and surprises: For either the safety system or an individual/team:
o The ability to anticipate (knowing what to expect)
o The ability to notice (knowing when and what the disruptions are and look like)
o The ability to respond (knowing what to do, or at least to plan to respond)
o The ability to learn (knowing how to adapt the work to prevent the disruption now and next time)
Reduce procedural complexity
o Understand ‘Complex’ versus ‘Complicated’
o Simplify complexity slowly, carefully and mindfully
Work-As-Done versus Work-As-Intended (WAD vs WAI) and the fact that there is virtually always a mismatch between actual work and written guidance.
o We need to understand how we do work normally.
o Get into the habit of seeking out and explaining drift during normal work.
o Drift usually results in safe work – A TRIF of 10 equals 99.999% safe work.
How people make decisions in the work place:
o Answering a different question
o Intense task focus – Cognitive fixation
o What you see is all there is (WYSIATI)
o Good gets worse. Bad gets better – Regression to the mean
o Using the right expertise?
Continually asking how things can go wrong.
o Past successes in safety is NOT a guarantee of future safety
o A Preoccupation with failure
In relation to incidents and investigations:
o Recognise that “Loss of situation awareness” or “failure to recognise the hazard” are just fancy words for “human error” that do not help during investigations.
o It is very difficult, if not impossible to recreate events. The outcomes are simply stories that fit our hindsight views.
o Allow flexibility in event reporting, with a narrative of explanations. Even multiple narratives that result from multiple perspectives.
o We need to stop;
- Believing in a simple relationship between causes and effects.
- Thinking there is one version of the truth and one best way of doing a task (or one best procedure).
In relation to core competency training:
o When and how (and when not) to adapt procedures to local circumstances
- Resilience
- The capability to recover from a loss of control if it does occur.
- Management of unanticipated and escalating situations
- Decision making (how to make handle sacrificing decisions)
- Drift, including the fact that deviation can lead to safety. And that it is not always possible, or sensible to follow a specific procedure.
o Communication
o Coordination, including task assignment
o Problem solving
o Risk conversations (including when it all seems well)
o Generating and allowing different perspectives including WYSIATI
o It all looks obvious when you know the outcome (Hindsight bias)
o Note:
- Inductions and core competency training should only be partially classroom based and more in-the-field, on-the-job based and must always be well-connected to the work and risks of the people involved
“I think people get uncomfortable when I say that if we want to change safety, we have to look into ourselves. We should not look at all those other people (who, we might believe, need to ‘pay more attention and be more careful’). I believe that if we in safety don’t change, nothing is going to change in safety.” – Sidney Dekker “The ‘failed state’ of safety” www.safetydifferently.com. 7 Oct. 2014