A story is an accounting of an event as experienced through the eyes, ears, cognitive biases, and paradigms of one person. This is my story about attending the Day with Sidney Dekker ’ at the Vancouver Convention Centre on Friday September 19 2014. The seminar was sponsored by the Lower Mainland chapter of CSSE (Canadian Society of Safety Engineering). I initially heard about the seminar through my associations with RHLN and the HFCoP.
Where are we today in safety thinking?
Here is a recent article announcing a new safety breakthrough [http://bit.ly/1mVg19a] LIJ medical center has implemented a safety solution that will be all to end all
A remote video auditing (RVA) in a surgical room developed by Arrowsight [http://bit.ly/1mVh2yf]
Late Victorian Era
Beginning of measurement (Germany, UK) to makes things visible
Discover industrial revolution kills a lot of people, including children
Growing concern with enormous injury and fatality problem
Scholars begin to look at models
1905 Rockwell: pure accidents (events that cannot be anticipated) seldom happen; someone has blundered or reversed a law of nature
Eric Farmer: carelessness or lack of attention of the worker
Oxford Human Factor definition: physical, mental, or moral shortcoming of the individual that predisposes the person
We still promote this archaic view today in programs like Hearts & Mind [how Shell and the Energy Institute promote world class HSE]
campaigns with posters, banners, slogans
FAITH-BASED safety approach vs. science-based
In 2014, can’t talk about physical handicaps but are allowed to for mental and moral (Hearts and Minds) human deficiencies
SD: I find it offensive to be treated as an infantile
It’s no longer just a Newton-Cartesian world
Now we know the world is complex, full of perturbations, and not a closed system
[Science-based thinking has led to complex adaptive systems (CAS) http://gswong.com/?wpfb_dl=20]
SD: We pay people more money who have experience. Why? Because the 1 best method may not work
There is no checklist to follow
Taylorism is limited and can’t go beyond standardization
This is not complacency (a motivational issue) but an attenuation towards risk. Also may not be aware the margins have moved (example: in electric utility work, wood cross-arm materials have changed). Unlearning, teaching the old dog new tricks is difficult.[Master builder/Apprenticeship model: While effective for passing on tacit knowledge, danger lies in old guys becoming stale and passing on myths and old paradigms]
1920s & 1930s – advent of Technology & animation of Taylorism
World is fixed, technology will solve the problems of the world
Focus on the person using rewards and punishment, little understanding of deep ethical implications
People just need to conform to technology, machines, devices [think of Charlie Chaplin’s Modern Times movie]
Accident Proneness theory (UK, Germany 1925)
Nuclear, radar, rocketry, computers
Created a host of new complexities, new usability issues
Example: Improvements to the B17 bomber
Hydraulic gear and flap technology introduced
However, belly-flop landings happened
Presumed cause was dumb pilots who required more training, checklists, and punishment
Would like to remove these reckless accident-prone pilots damaging the planes
However, pilots are in short supply plus give them a break – they have been shot at by the enemy trying to kill them
Shifted focus from human failure to design flaws. Why do 2 switches in dashboard look the same?
In 1943 redesigned switch to prevent bellyflopping
Message: Human error is systemically connected and predictability so to the features of tools and products that people use. Bad design induces errors. Better to intervene in the context of people’s work.
After lunch exercise: Greek airport 1770m long
Perceived problem: breaking EU rules by taxiing too close to the road
White line – displaced threshold – don’t land before this line
Need to rapidly taxi back to the terminal to unload for productivity reasons (plane on-the-ground costs money)
Vehicular traffic light is not synced with plane landing (i.e., random event)
Question: How do you stop non-compliant behaviour if you are the regulator? How might you mitigate the risk?
SD: Select a solution approach with choices including Taylorism, Just Culture, Safety by Design
Several solutions heard from the audience but no one-best
1980s Systems Thinking
Many people carry an idealistic image of safety: a world without harm, pain, suffering
Setting a Zero Harm goal is counter-productive as it suppresses reporting and incents manipulation of the numbers to look good
Abraham Wald example
Question: Where should we put the armour on a WWII bomber?Wrong analysis: Let’s focus on the holes and put armour there to cover them up
Right analysis: Since the plane made it back, there’s no need for armour on the holes!
Safety implication: Holes represent near-miss incidents (bullets that fortunately didn’t down the plane). We shouldn’t be covering the holes but learning from them
Safety management system (SMS)
Don’t rest on your laurels thinking you finally figured it out with a comprehensive SMS
Australian tunnelling example:
Young guy dies working near an airport
There were previous incidents with the contractor but no connection was made
Was doing normal work but decapitated finishing the design
An SMS will never pick this up
Don’t be led astray by the Decoy phenomenon
Only look at what we can count in normal work and ignore other signals
Example: Heinrich triangle – if we place our attention on the little incidents, then we will avoid the big ones (LTA, fatality) [now viewed as a myth like Accident Prone theory] Some accidents are unavoidable – Barry Turner 1998 [Man-made Disasters] Example: Lexington accident [2006 Comair Flight 5191] when both technology and organization failed
Complexity has created huge, intractable problems
In a world of complexity, we can kill people without precursory events
[If we stay with the Swiss Cheese Model idea, then Complexity would see the holes on a layer dynamically moving, appearing, disappearing and layers spinning randomly and melting together to form new holes that were unknowable and unimaginable]
Safety has become a bureaucratic accountability rather than an ethical responsibility
Amount of fraud is mounting as we continue measuring and rewarding the absence of negative incidents
Example: workers killed onsite are flown back home in a private jet to cover up and hide accidents
If we can be innovative and creative to hide injuries and fatalities, why can’t we use novel ways to think about safety differently?
Sense of injustice on the head of the little guy
Advances in Safety by Design
“You’re not lifting properly” compared “the job isn’t designed properly”
An accident is a free lesson, learning opportunity, not a HR performance problem
Singapore example: Green city which to grow must go vertically up. Plants grow on all floors of a tall building. How to maintain?
One approach is to punish the worker if accident occurs
Safety by Design solution is to design wall panels that rotate to maintain plants; no fall equipment needed
You can swat the mosquito but better to drain the swamp
Why can’t we solve today’s problems the same way we solved them back in the early 1900s?
What was valued in the Victorian Era
- People are a problem to control
- We control through intervention at the level of their behaviour
- We define safety as an absence of the Negative
Complexity requires a shift in what we value today
- People are a solution, a resource
- Intervene in the context and condition of their work
- Instead of measuring and counting negative events, think in terms of the presence of positive things – opportunities, new discoveries, challenges of old ideas
What are the deliverables we should aim for today?
Stop doing work inspections that treat workers like children
It’s arrogant believing that an inspector knows better
Better onsite visit: Tell me about your work. What’s dodgy about your job?
Intervene the job, not the individual’s behaviour.
Collect authentic stories.
[reinforces the practice of Narrative research http://gswong.com/?
Regulators need to shift their deliverables from engaging reactively (getting involved after the accident has occurred), looking for root causes, and formulating policy constraints
Causes are not things found objectively; causes are constructed by the human mind [and therefore subject to cognitive bias] Regulators should be proactively co-evolving the system [CAS] Stop producing accident investigation reports closing with useless recommendations to coach and gain commitment
Reference SD’s book: Field Guide to Investigating accidents – what you look for you will find
Question: Where do we place armour on a WWII bomber if we don’t patch the holes?
Answer: where we can build resilience by enabling the plane to take a few hits and still make it back home
[relates to the perspective of resilience in terms of the Cynefin Framework http://gswong.com/?
Resilience Engineering deliverables
- Do we keep risk awareness alive? Debrief and more debrief on the mental model? Even if things seem to be under control? Who leads the debriefing? Did the supervisor or foreman do a recon before the job starts to lessen surprise? [assessing the situation in the Cynefin Framework Disorder domain]
- Count the amount of rework done – can be perceived as a leading indicator although it really lags since initial work had been performed
- Create ways for bad news to be communicated without penalty. Stat: 83% of plane accidents occur when pilots are flying and 17% when co-pilots are. Institute the courage to speak up and say no. Stop bullying to maintain silience. It is a measure of Trust and empowers our people. Develop other ways such as role playing simulations, rotation of managers which identify normalization of deviance (“We may do that here but we don’t do that over there”)
- Count the number of fresh perspectives and opinions that are allowed to be aired. Count the number of so-called best practice rules that are intelligently challenged. [purpose of gathering stories in a Human Sensor Network http://gswong.com/?page_id=19]
- Count number or % of time re human-human relationships (not formal inspections) but honest and open conversations that are org hierarchy-free.
Spend less time and effort on things that go wrong [Safety-I] Invest more effort on things that go right which is most of the time [Safety-II]
There were over 100 in attendance so theoretically there are over 100 stories that could be told about the day. Some will be similar to mine and my mind is open to accepting some will be quite different (what the heck was Gary smoking?) But as we know, the key to understanding complexity is Diversity – the more stories we seek and allow to be heard, the better representation of the real world we have.