While occupational health and safety has come a long way in the last 50 years, it hasn’t been all sunshine and daisies. There are a number of aspects which still cause safety professionals and practitioners difficulty in the workplace. While some of these issues are directly related to how organizations and work are designed, some of them are self-inflicted. Recognizing our sphere of control and influence, it seems necessary to address these issues forthwith.
Erik Hollnagel (2017) describes the two largest problems with safety, and in order to advance safety as a profession and a science. It would be wise for us as an industry and safety leaders, to address these problems in short order. Historically, we’ve approached safety as we do most problems: break it down, analyze the issues, apply fixes, and monitor or tweak as necessary to improve performance. In short, the scientific method.
This type of approach produces results to a certain extent. Education loves this model; we learn in early in grade or middle school, and spend the first part of our academic careers using the model to address problem solving. While it creates a recognizable model and provides a basis for collaboration when it comes to dealing with issues in the workplace or theoretical situations in the classroom, it also drives us into a one-size-fits-all approach to problem solving.
Using the analogy of hammer and nails with respect to problem solving, if all you have is a hammer to fix the problem, all you see are nails. The majority of educated society has been given hammers to fix problems that require a different tool. How do we know this? We try to fix safety with more safety right past the point of diminishing marginal utility with respect to the application of resources, e.g. time, money, human capital. But as my friend Tom McDaniel says, ”you can’t fix safety with more safety.”
Hollnagel (2017) refers to this phenomenon as the causality credo which forms the theoretical basis for the application of root cause analysis. Speaking plainly, that means if we experience an adverse event in the workplace, that we’re able to identify the conditions, elements, etc., that caused the event, apply controls, and voila! Problem solved. Or is it?
Safety leaders recognize and understand that often times the root cause analysis process fails to address some or all of the elements that actually caused the event. As safety leaders, we can attribute this to a poor quality of investigation or root cause analysis, lack of training / experience of the investigation team, insufficient time and/or political pressure for rapid completion, or a litany of other issues that can plague investigation processes.
In order for safety or other leaders to fix anything, there has to be something to fix. Whether event comes as an issue, near miss, incident, or other form. This brings us to one of safety science’s fundamental problems: how we research and study safety (Hollnagel, 2017).
There is not a safety professional alive that has not been involved in an incident or near-miss investigation during the course of his/her career. This is the central tenet of the find-and-fix approach and what Sidney Dekker (2015) refers to as Newtonian-Cartesian reduction: find what is causing the problem and change it to prevent recurrence. Rinse and repeat.
Here’s the rub: when we look at people as the problem, e.g. behaviors, not following procedures, etc., then the natural response is to add/tighten procedures and controls. When safety leaders approach work this way, it is all predicated on the assumption that people come to work with the intention of not working safely. It doesn’t take much to convince me that people make mistakes, but if you tell me that people come to work to put themselves in harm’s way, that will be a difficult conversation.
The bigger problem, however, is how we look at the event. In any kind of research, it only makes sense to study the phenomena when it exists. When there are incidents, safety is not present, it’s absent. If we as safety leaders only look at situations where there were incidents or near-misses, what do we really learn about safety?
Glossing over the work-as-imagined versus work-as-done performance gap, all we can really ever confirm through incident investigations is that the gap is present, and it is real. Anything after that runs the risk of adding ineffective, and possibly harmful, controls and barriers to work. We can make assumptions about what caused the event through a root cause analysis, but since the same elements of work and behavior likely existed prior to the event, there’s no way for us to actually determine which of the root causes actually contributed to the event.
The benefit of incident investigation comes from the assumption that the causes for incidents are not present when work is successful. Humans, like all forms of life, are naturally self-optimizing and there’s a tendency to drift to a more efficient model cognitively and physically. This manifests itself as local rationality and drifts to failure.
So where does this leave us?
Recognizing the challenges with the way we approach incidents, barriers, and controls, we need a different way of looking at how work is done when incidents and near-misses are absent. Safety is about how to support, augment, and facilitate the everyday activities that are necessary for acceptable outcomes on all levels of an organization (Hollnagel, 2017). We can learn about incidents from studying incidents, but as safety leaders, if we want to truly learn about safety, then it is time to look at safety as a phenomena when it is present.
Dekker, S. (2015). Safety Differently: Human Factors for a New Era (2nd ed.). Boca Raton, FL: CRC Press. ISBN: 9781482241990.
Hollnagel, E. (2017). Safety-II In Practice: Developing the Resilience Potentials. New York: Routledge. ISBN: 9781138708921.