Why Minor Accidents DON’T Predict Major Ones

Over the last two decades safety improvements across a number of industries have largely flatlined

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…(as measured in fatalities and serious injury rates, for instance) despite a vast expansion of safety investment, compliance and paperwork.

The cost of compliance and bureaucratic accountability demands are mind-boggling with every employee working on average 8 weeks (!) per year just to be compliant.

It has also stopped progressing safety.

The Case for Doing Safety Differently

‘Safety differently,’ an approach developed by Sidney Dekker, is about halting or pushing back on the ever-expanding bureaucratization and compliance of work. It sees people not as a problem to control, but as a resource to harness.

Today’s standard model of safety, systems are already safe and need protection from unreliable human beings? Sidney says that’s an illusion.

It’s not true that the only thing we need to do to make systems safer is to provide more procedures, more automation and tighter monitoring of performance. Emails from managers imploring people to stop making errors. Imploring people to follow the rules. Saying ‘if we just ask everybody to try a little harder, we’ll have a safe system’.

“Safety is not the absence of errors and violations”

Sidney says what you need to do is to invert the perspective. Safety is not the absence of errors and violations. We need to see safety as the presence of something. Presence of what?

When you get into the messy details, what you see is under difficult circumstances people can still make things go right because of their adaptive capacity. Resilience is this people’s adaptive capacity. Resilience is the ability to bounce back. To accommodate change and to absorb disruptions without catastrophic failure.

Recent research back this up: the risk of fatalities and life-changing events hide in normal, daily routine practices.

Heinrich: minor accidents predict major ones

The ‘Safety Differently’ movement views accidents like the BP Deepwater Horizon as too much focusing on near misses instead of critical issues, and so finds fault in Heinrich’s idea that minor accidents predict major ones.

Safety should be rather an ethical responsibility for people, assets and communities, instead of a bureaucratic accountability to managers, boards and regulators.

Safety Differently doesn’t just want to stop things from going wrong, but is curious about discovering why things go well and helping organizations enhance the capacities in their teams, people and processes that make it so.

Watch ‘Safety Differently – The Movie’ for an online snippet at http://sidneydekker.com/safety-differently-movie/

According to Sidney, organizations looking to excel at safety must do the following:

  1. never take past success as a guarantee for future safety. The fact that this went right yesterday doesn’t mean it will go right today. Past results are no reason to be confident that adaptive strategies will keep on working.
  2. keep a discussion of risk alive even when everything looks safe. Sources of risk may have suddenly shifted in ways that are very difficult to be recognized.
  3. bring in different and fresh perspectives. Listen to minority viewpoints and take them seriously. Invite doubt. Manage to stay curious and open-minded.

Work as imagined vs Work as done

Erik Hollnagel, approaching from a different perspective – health, points to a key distinction of ‘Work as imagined vs Work as done’ and how Safety-I is out of date and why we need to switch to Safety-II.

Safety efforts usually aim to eliminate or reduce unacceptable risk and harm. According to this definition, called Safety-I, a system is safe if as few things as possible go wrong. A problem with this approach is that safety management is based on evidence from random snapshots of failed system states.

Resilience engineering argues that safety should be viewed differently with emphasis on things that go well. According to this definition, called Safety-II, a system is safe if as much as possible goes well. Safety management and the understanding of safety should be based on a systematic understanding of how performance succeeds, rather than on how it fails.

According to Erik, Work-As-Done focuses on how people adjust their work so that it matches the conditions. Instead of only looking at the few cases where things went wrong, we should be looking at the many instances where things went right and try to understand how that happened.

“We need to stop solving problems in isolation”

We need to stop looking at problems in isolation. We need to stop using separate vocabularies, models, methods, organisational focus and organisational roles for each problem. This is the situation now with safety, quality, and profitability as examples. It is convenient in the short term but detrimental in the long term. We need to stop solving problems in isolation.

What caused a particular accident is not answered by listing things that would have prevented it. Erik founded the ‘Developing the resilience potentials’ idea digging deep into Safety-II, when a system is safe if as much as possible goes well similarly to Sidney’s ‘Safety Differently’ thematic but through different perspectives.

Sidney, founder of the ‘Safety Differently’ movement, world-class expert on human factors & safety and Professor of Psychology at Griffith University in Australia, will be flying to Europe to present at the 2020 EHS Congress next April along with Erik Hollnagel, authoritative voice on human reliability analysis, author of more than 500 publications and Professor at University of Jönköping in Sweden.

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