All posts by Gary Wong

UBC BASc 1971

Radical Innovation in Mining Management – The Industrial Age fuelled by Myth 1

The following article was published on 2019 June 27 at  Austmine is the leading industry body for the Australian Mining, Equipment, Technology and Services (METS) sector. 

In the last edition we introduced how yesterday’s solutions have led to three myths that control current mining thinking.

Myth 1: The best way to run a mine is to focus on cost certainty and manage people as if they are parts of a machine.

Myth 2: Mine operations should be optimised from start to finish to produce the best results.

Myth 3: We can achieve social licence acceptance and safety aims within our current management paradigm by pursuing effective culture change.

Each myth began as a solution for a specific era of time.


A myth follows a life-cycle S-curve pattern. It slowly begins as a new idea in the embryonic stage. A growth spurt occurs when people embrace the idea; the adoption rate rapidly increases. A myth can perpetuate for many years, decades, centuries. As time passes and the myth matures, it succumbs to changes in society, technology, and environment. Methods founded on the myth struggle to solve prevailing problems. Different solutions emerge, some based on research breakthroughs and some unfortunately based on pseudoscience. This crisis period is pictorialised by the “yellow bubble.” As the myth is still the dominant paradigm, myth protectors attempt to maintain the status quo by denying, challenging or crushing the rise of disruptive ideas.

It sounds wise for organisations which are generating big profits to show reluctance to change. Everyone has heard the story about Kodak whose managers didn’t recognise soon enough that digital technology would decimate its traditional business. According to these managers, it’s a myth. They were very aware of the new technology. The failure was not convincing Kodak executives to provide R&D funding. The finance decision-makers did not want anything to disrupt the flow of money coming from film.[1]

For consultants who have created a lucrative business, it’s reasonable to keep “milking the cow.” After all, the myth has not reached the peak yet. Enticing spinoff solutions are sold to clients such as “train the trainer” to institutionalise the myth and strengthen the consulting relationship. Late maturity is often marked by a professional certification program with stepped levels of knowledge attainment. Learn all there is to know and earn a badge. But it’s also a signal the declining stage of the S-curve is nearing.

Others realise earlier in the life-cycle the ground beneath is dramatically shifted. They appreciate the myth’s thinking has been valuable and still delivering results. However, they also know why clients are staying awake at night thinking about unresolvable problems. As Peter Senge said: “Today’s problems come from yesterday’s solutions.” It’s time to “jump the S-curve” and explore what the next Age and its solutions has to offer.

Our intent is to not criticise the past by searching for root cause, blaming someone, but learning from it. We have the pleasure of hindsight bias. In this article we will turn back the clock to see what made logical sense as the Industrial Age unfolded. We delve deeper into Myth 1 and the problems it creates today.

Industrial Age Myth: The best way to run a mine is to focus on cost certainty and manage people as if they are parts of a machine.  

The Industrial Age was a golden period of growth, expansion and productivity increase. The big idea in the early 20th century was Frederick Taylor’s Scientific Management principles of productivity.

Two quotes from Taylor illustrate the managerial thinking at the time.


Order, structure, and discipline emanated from Taylor’s beliefs. Industrial giants like Henry Ford implemented the machine assembly line and production flow concepts into manufacturing. In line with this thinking was Ford’s “You can have any colour of car as long as it is black.” Certainty meant dealing with “known knowns” and working with proven cause & effect relationships.

The Industrial Age birthed statistics and statistical theory. The first control chart appeared in 1924. People schooled in Scientific Management developed the new method of statistical process control (SPC). However, it wasn’t successfully implemented in a business setting until the 1950s. Other cost certainty methods that followed included cost accounting, activity-based costing, inventory management, zero-based budgeting, material requirements planning (MRP).

Academic professors turned consultants chimed in with business research applying a case study approach. It didn’t take long before project managers were writing a business case complete with a benefit-cost analysis.

In conjunction with improving assembly line operations was the formal organisation of people. Academics and big consulting firms introduced an idea dating as far back as Plato – Division of Labour. A managerial class would separate decision making from the doing of work, a strategy visible in the institutions of church and military at the time. The schema took root and easily spread in a relatively stable, repeatable, and predictable work environment.[2]

An early adopter was General Motors who implemented the divisional organisation in response to the car market demanding greater variety and choice. Cost accounting was used to calculate transfer pricing and keep the system coherent. This made sense because 85-90% of the value of an item sold could be attributed to variable costs (direct labour and raw material).[3]  As engineering, financial and marketing functions grew to satisfy the evolving market, by the late 1990s only 30-40% of costs were truly variable. However, management thinking stayed the same and fixed overhead costs were allocated by various means. This started to skew decision making, but few noticed.

To keep the assembly line running smoothly, engineers, accountants, and process analysts closely tracked what went wrong. Control was about minimalising deviations and stoppages like machine breakdowns, equipment failures, supply shortages. Failure analysis extended to the treatment of front-line workers. Processes were designed with humans performing “perfectly” without errors. Mistakes and absenteeism were not tolerated and often led to loss of pay punishment or outright dismissal.

In 1936 Charlie Chaplin wrote and directed the film “Modern Times.” While billed as a comedy, the film captured the painful working conditions shaped by the efficiencies of modern industrialisation.

The rise of unions

Counterbalancing the heavy-handed treatment of workers was the rise of labour unions. Work stoppage was the economic weapon. Not all strikes were confined to internal struggles between workers and management; politicians and even military troops were drawn into the picture. In Australia the 1949 coal miners strike saw 23,000 workers withdraw their labour between June 27 and August 15 of that year[4]. The dispute dominated Australian politics at the time and saw elements of revolution and counter-revolution which had been a rarity on Australian soil. Labour unrest shook the once stable work environment. The assumption that humans behaved in a predictable manner like machines was thrown into doubt.

The non-union managerial class was also subjected to command & control. HR produced job descriptions which included new terms such as roles & responsibilities, accountability, transparency, blameworthiness. Management by Objectives (MBO) was popularised by Peter Drucker in his 1954 book The Practice of Management. It surfaced as a system to measure managerial performance. Pressure was applied by setting annual KPI targets and stretch objectives for individuals aspiring to climb the corporate ladder.

TQM and PM

During this crisis period in the Industrial Age humans strengthened by union solidarity reacted to being poorly treated as cogs of a cost-driven industrial machine and demanded changes in working conditions.

Total Quality Management emerged as one “yellow bubble” solution. Pioneers Edwards Deming, Joe Juran, and Phil Crosby led the advancement of TQM. They are also credited for developing Project Management as a discipline. Progressive companies adopted TQM as their way of overseeing all activities and tasks needed to maintain a desired level of excellence. Instead of mainly looking inward for efficiency improvements, TQM promoted the idea of looking outward and achieving customer satisfaction.

Themes in Deming’ s PDCA cycle were continuous improvement, waste reduction, and customer loyalty. Quality was measured in financial terms. Improvements in waste management, production control, and increased sales from happy customers were calculated in terms of budgetary impact.

Juran applied the 80/20 Pareto Principle to prioritise quality issues. A major contribution was highlighting the human side of TQM. He stressed the importance of education, training, and understanding resistance to change.

Crosby’s philosophy was “do it right the first time”. He coined the term Zero Defects. Eliminate errors. Avoid time-consuming and costly failure fixes.

Many organisations did not get excited about TQM and saw it as a passing fad. They chose to remain entrenched in cost certainty mode and placed attention on finding more ways to reduce expenses.  Consultants were more than willing to help and offered innovations such as unbundling, outsourcing,  replacing labour with automation, and optimising supply chains.

Not everyone was in favour of Zero Defects. Detractors deemed the assumption human error is avoidable as unrealistic and unattainable. In the safety industry a similar assumption is that all injuries are preventable. The worry is putting a strain on worker performance and morale.

Not everyone was in favour of focusing on the customer. In 1976 a controversial idea that shareholders owned the firm and the true purpose of management was to maximise shareholder value. SVA[5] became the rallying cry for CEOs and financial markets who would benefit most from the paradigm. A major player was Jack Welch while CEO at General Electric. Not quite calling it a myth, upon reflection in 2011 he called SVA “the dumbest idea in the world.” [6] He questioned why do CEOs and their top managers receive massive incentives to focus most of their attention on the expectations market, rather than the real job of running the company producing real products and services.

Lessons learned from the Industrial Age

Behind all ideas are good intentions. But so are unintended negative consequences. What results have been accomplished? What have we discovered and learned from the Industrial Age?

Mining Productivity

Australian mining experienced a resource boom in the Industrial Age. In the early 1960s, discoveries of new metals led to a resurgence of interest in Australia’s mineral resources. Production also increased and Australia became a major raw materials exporter, especially to Japan and Europe.

Today Australia is one of the world’s leading mineral resources nations. It is the world’s largest refiner of bauxite, producer of gem and industrial diamonds, lead and tantalum, and the mineral sands ilmenite, rutile and zircon. Other world rankings in production are: zinc (2nd); gold, iron ore and manganese ore (3rd); nickel, aluminium (4th); copper, silver, black coal (5th). [7]

It seems odd that Australia’s enviable position has been accomplished with productivity levels that have been trending downwards. According to Ernst & Young[8] capital productivity in Australia has fallen 45% since 2000. Perhaps it’s because Australia hasn’t been alone in the worldwide decline. E&Y reported labour productivity in the South African gold sector dropping by 35% since 2007.


These sobering findings are corroborated by McKinsey [9] which found that global mining productivity overall has decreased by 29% over the last decade. From 2014 to 2016 McKinsey’s Mine Lens shows a 2.8% per annum uptick in productivity, but productivity is still far below the level 15 years ago.[10]

Employee engagement

Organisations consider employee engagement an important indicator of company health. Engaged employees offer their talents and energy to work efficiently and effectively. Actively disengaged workers, on the other hand, look around for ways to ignore or damage the best interests of the organisation. Galluphas been measuring employee engagement across the world for many decades.

“Worldwide, the percentage of adults who work full time for an employer and are engaged at work — they are highly involved in and enthusiastic about their work and workplace — is just 15%.

“They imply a stunning amount of wasted potential, given that business units in the top quartile of Gallup’s global employee engagement database are 17% more productive and 21% more profitable than those in the bottom quartile”.

For Australia/New Zealand the 2013 report identifies 24% or workers as highly engaged and 16% actively disengaged.[11] In the 2017 survey the highly engaged number dropped to 19%.[12] 

Compounding the employee engagement problem is anecdotal evidence that millennials do not see mining as a promising career. Jake Klein, CEO of Evolution Mining stunned many attending the 2019 Future of Mining Conference in Sydney by informing there are only 25 mining engineers enrolled in Australian Universities[13]. He sees the biggest challenge is making mining an attractive industry for young people.

Klein’s concern reinforces a view expressed by the World Economic Forum (WEF).[14]Business leaders say that attracting, managing and retaining a skilled workforce is their number one business challenge in the next five years. WEF research showed better benefits, more accessible savings plans, and guidance and technology tailored to individual needs would have a very positive impact on a workforce.

Despite the clear message, Myth 1 continues to be played out today. Permanent employee levels are contained or shrunk by using contracted labour and outsourcing (parts of a machine). Financial actions such as switching employer-employee shared pension plans from defined benefits to market-based enhance cost-certainty and shift the risk of retirements fund sufficiency from the company to the individual. When workers opt out on corporate buy-out and early retirement programs, the labour cost savings are highlighted but neglected are the non-monetary losses in tacit knowledge and experience.

Implications of running mines according to Myth 1

History has taught us that Myth 1 has created “wicked” problems for the mining industry. Wicked problems are difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognise. [15] 

Some industry pundits believe that poor productivity and employee engagement are two sides of the same coin. Measuring systemic productivity while enforcing individual accountability injects disharmony into the organisation and reaps diminishing returns.  How does this happen? Boston Consulting group partner Yves Morieux[16] explains: 

“…this drive for clarity and accountability triggers a counterproductive multiplication of interfaces, middle offices, coordinators that do not only mobilise people and resources, but that also add obstacles. And the more complicated the organisation, the more difficult it is to understand what is really happening. So we need summaries, proxies, reports, key performance indicators, metrics. So people put their energy in what can get measured, at the expense of cooperation. And as performance deteriorates, we add even more structure, process, systems. People spend their time in meetings, writing reports they have to do, undo and redo. Based on our analysis, teams in these organisations spend between 40 and 80 percent of their time wasting their time, but working harder and harder, longer and longer, on less and less value-adding activities. This is what is killing productivity, what makes people suffer at work. 

We need employees to cooperate, to trust their coworkers and managers. It is to take a risk, because you sacrifice the ultimate protection granted by objectively measurable individual performance. It is to make a super difference in the performance of others, with whom we are compared. It takes being stupid to cooperate, then. And people are not stupid; they don’t cooperate.” 

Safety in the Industrial Age

Ever wonder why Safety is a cost item in a budget? We hear platitudes that an organisation’s greatest asset is its employees. Yet instead of an investment, they are entered as expenses on the Profit & Loss statement. No different than a replaceable part in a machine.

“Safety-I” was coined by Erik Hollnagel[17] to reflect the mechanistic treatment of humans in the Industrial Age. Safety is defined as the absence of negative events. Humans are error prone, focus on what goes wrong, and the ideal target is Zero Harm, a logical extension of Zero Defects thinking.

Surrounded by scientific management principles, the beginnings of Safety as a practice intuitively mirrored the patterns of business and the avoidance of human failure. In 1931 Herbert Heinrich published his book “Industrial Accident Prevention, a Scientific Approach.” [18]  The book cited 88 percent of all workplace accidents and injuries/illnesses are caused by “man-failure.” More famous is Heinrich’s Law: that in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. Alas, Fred Manuele disclosed in his 2011 review, it’s a myth.[19]

Learning to let go

The Y-axis of the Life-cycle diagram is labelled “Utility of the Paradigm” for a good reason. A subsequent age doesn’t start from zero but is elevated by the previous age. That means we carry forward the valuable lessons and practices and adapt them to the next emerging Age. And just as important, we let go of the myths and fallacies of the old Age.

In the next article we examine the radical thinking in the Information Age. Scientific Management yields to Systems Thinking. An Engineering paradigm emerges. And a new myth is born.

Thank you for the feedback and enthusiastic show of support. In response to the interest, we are conducting 1-day Radical Innovation in Mining Management workshops on October 31 (Sydney) and November 8 (Brisbane). To be added to our invitation list, please contact Hendrik Lourens at .

Written by Gary Wong and Hendrik Lourens


[1]       The Real Lessons From Kodak’s Decline, MITSloan Management Review Magazine: Summer 2016.

[2]       Freedom from command and control, John Seddon, Productivity Press, Kindle, 2005.

[3]       Profitability with no boundaries, Reza M. Pirashteh and Robert Fox, American Society for

Quality, 2011.

[4]       Australian Coal Strike

[5]       Theory of the Firm: Managerial Behavior, Agency Cost and Ownership Structure, Michael Jensen and William Meckling, Journal of Financial Economics, 1976.

[6]       The Dumbest Idea In The World: Maximising Shareholder Value, Steve Deming, Forbes, Nov 2011.

[7]       History of Australia’s Minerals Industry.

[8]       Productivity in Mining: Now comes the hard part, Ernst & Young, 2016.

[9]       Productivity in Mining Operations: Reversing the downward trend, McKinsey, 2015.

[10]   Behind the mining productivity upswing: Technology enabled transformation, McKinsey, 2018.

[11]   State of the Global Workplace, Gallup, 2017.

[12]   State of the Global Workplace, Gallup, 2013.

[13]   Future of Mining Australia 2019, Jake Klein.

[14]   Is this the secret to happy and engaged employees? WEF 2018.

[15]   Wicked Problem, Wikipedia.

[16]   Smart Rules: Six ways to get people to solve problems without you, Yves Morieux, Harvard Business Review, September 2011.

[17]   Safety I and Safety II: The Past and Future of Safety Management, Erik Hollnagel, 2014.

[18]   Industrial accident prevention, H.W. Heinrich, McGraw Hill, 1931

[19]   Reviewing Heinrich: Dislodging Two Myths From the Practice of Safety, Fred Manuele, Oct 2011, Professional Safety,

Radical Innovation in Mining Management – Introduction

The following article was published on 2019 May 06 at  Austmine is the leading industry body for the Australian Mining, Equipment, Technology and Services (METS) sector. 


Social license, Digital transformation, Safety, and Profitability – four issues that seem to be caught in a perpetual trade-off. Spend more time on one, and it reduces the attention given to the others. It’s a problem that impacts everyone in the organisation:

  • As an executive, you’re frustrated with events that unexpectedly emerge to disrupt production.
  • As a manager, you’re angry when corporate performance statistics don’t reflect the tireless effort required to keep things running locally.
  • As a supervisor, you’re frustrated with fault finding in people and blaming individuals for mediocre results that are beyond their control.
  • As an engineer, you’re disillusioned by past innovative programs that started with a bang and then either withered away or had the budget pulled. 
  • As a tradesperson, you can sense worsening mine conditions but feel powerless in voicing your concerns.

Have we reached a plateau in our ability to improve on each of these issues individually as well as collectively? Peter Senge claimed: “Today’s problems come from yesterday’s solutions”. In this first article, we introduce how yesterday’s solutions have led to three myths that control current mining thinking. In the following months, we will delve deeper into each myth and the problems they create today.

Based on 15 years of consulting experience we believe that radical innovation is essential to disrupt myth domination. “Radical” does not necessarily mean painful and agonising. It means being enlightened that the world has radically changed and the Mining industry needs to catch up.

Three myths that destroy mining innovation

Myth 1: The best way to run a mine is to focus on cost certainty and manage people as if they are parts of a machine.

Myth 2: Mine operations should be optimised from start to finish to produce the best results.

Myth 3: We can achieve social licence acceptance and safety aims within our current management paradigm by pursuing effective culture change.

Each myth began as a solution for a specific era of time. Besides introducing new thinking, an Age carries the best of the previous ages forward while dispensing myths and fallacies with facts and evidence.

The evolution and implications of different Ages

The Industrial and Information Ages

The Industrial Age growth mindset in the early 20th century was fuelled by Scientific Management principles of productivity. The work environment was stable, certain, and predictable. However, it couldn’t last forever when humans revolted over their treatment as mere cogs in a machine. A crisis point was reached resulting in declines in capital, labour, and material productivity.

Systems thinking and Human Factors boosted by computer technology offered new and improved alternatives. A popular solution called Business Process Reengineering succinctly captures the dominant engineering paradigm. This is the Information Age with people, process, and technology as parts of a system. “The whole is equal to the sum of its parts.” Industry rally behind “Faster, better, cheaper” in the pursuit of optimised efficiency. However, all is not well. We observe promising Information Age digital tools yielding negative impacts and making operations extremely complicated. As consultants, we have seen many attempts to optimise across the entire system to achieve efficiency. Some software packages are coded on this premise. However, systems thinkers like Russell Ackoff argue that system capability decreases. Eli Goldratt in his Theory of Constraints mathematically supports Ackoff’s claim.

Figure 1: The development of the Industrial, Information and Ecological Ages.

Figure 1: The development of the Industrial, Information and Ecological Ages.

Implementation of new technologies has not been easy. In 2016 strategic business & technology advisor and internationally best-selling author Bernard Marr wrote in that 25% of technology projects fail outright; 20-25% don’t show any Return on Investment, and 50% need massive re-working by the time they’re finished. From his experience, many projects failed not due to tech problems.  In fact, 54 % of IT project failures were attributed to poor management.

Change Management programs are often deployed as the lever to execute implementation because they focus on changing culture. The belief is cause & effect relationships will apply to people as they do for mechanistic processes and technologies. Great, if valid. However, consulting firms (McKinsey, Connor, Kotter) have reported a dismal 70% failure rate of change management programs. Once again we’ve reached a crisis period and the decline of an Age.

The Ecological Age

In the Ecology Age, confusing dilemmas, ambiguous paradoxes, diverse conflicts are natural occurrences. Mining has become a complex adaptive system. The unexpected emergence of new things means “the whole is greater than the sum of its parts”. For example, when “hot water is poured over dry coffee grinds, aroma as a new thing emerges”. The interaction of two ingredients creates something new. A deeper example happens inside our heads. “Billions of neurons in our brain interact in ways that we cannot fully understand to create a stream of consciousness.” People are no longer viewed as predictable cause & effect machines but are illogical, emotional decision makers. Culture is not a lever but emerges as an outcome of people, process, and technology interacting.

The evolution of Safety through the Ages

Safety has gone through similar paradigm changes. In the Industrial Age, safety was defined as the absence of negative events. Humans are error prone, focus on what goes wrong, and the ideal target is zero harm. The term “Safety-I” was coined by Erik Hollnagel to describe this thinking, one which many organisations still follow.

In the Information Age, new schools of safety sprung to life. One posed humans as problems in a system that could be managed using safety policies, standards, rules and compliance inspections. In the “Safety-II” view, humans are solutions, able to adapt performance due to varying conditions in the work environment.

In the Ecology Age, we accept it’s human nature to be fallible; mistakes will be made.  Less emphasis is given to changing the behaviours of illogical, emotional decision-makers. Instead, emphasis is placed on influencing relationships and interactions and designing systems for imperfect humans. Like culture, safety is an emergent property of a complex adaptive system. Workers don’t create safety. They create the conditions that enable safety to emerge; they can also create the conditions that enable danger to emerge.

Social Licence as an Ecological problem

We can add Social Licence to Operate as another emergent property of a complex adaptive system. SLO involves not just the community in which the mine is situated, it also involves employees, government (through regulation) and societal attitudes at large. In our conversations with mining managers, we hear the lament they cannot free up the time to deal with ecological issues. They are also aware in the Ecology Age the Internet with fast feedback loops empowers people to socially connect and voice their concerns. Failure to place sufficient attention may lead to a tense issue “going viral”. What do we do?

Dealing with Ecological problems

We need to create the conditions where we are able to free up time and high-level manpower to embark on new ways of doing to deal with these ecological issues. To do this we need to understand the myths holding us back, to stop doing much of what is considered best practice and start doing differently. Management’s role in this endeavour is critical.

Based on 15 years of experience and more than 85 mining interventions we believe this is possible.

We look forward to offering our Information and Ecology Age ideas and thoughts in the series of upcoming articles. We shall put Einstein’s quote to the challenge: “We cannot solve our problems at the level of thinking that caused them in the first place.”

Written by:

Gary Wong and Hendrik Lourens – Stratflow

Evolution of Safety

Yesterday I was pleased to speak at the Canadian Society of Safety Engineering (CSSE)  Fraser Valley branch dinner.  I chose to change the title from the Future of to the Evolution of Safety.  Slides are available in the Downloads or click here.  The key messages in the four takeaways are listed below.

1. Treat workers not as problems to be managed but solutions to be harnessed.

Many systems have been designed with the expectation  humans will perform perfectly like machines. It’s a consequence of the Systems Thinking era based on an Engineering paradigm. Because humans are error prone, we must be managed so that we don’t mess up the ideal flow of processes using technologies we are trained to operate.

Human & Organizational Performance (HOP) Principle #1 acknowledges people are fallible. Even the best will make mistakes. Despite the perception humans are the “weakest link in the chain”,  harnessing our human intelligence will be critical for system resilience, the capacity to either detect or quickly recover from negative surprises.

As noted in the MIT Technology Review, “we’re seeing the rise of machines with agency, machines that are actors making decisions and taking actions autonomously…” That means things are going to get a lot more complex with machines driven by artificial intelligence algorithms. Smart devices behaving in isolation will create conflicting conditions that enable danger to emerge. Failure will occur when a tipping point is passed.

MIT Professor Nancy Leveson believes technology has advanced to such a point that the routine problem-solving methods engineers had long relied upon no longer suffice.  As complexity increases within a system, linear root cause analysis approaches lose their effectiveness. Things can go catastrophically wrong even when every individual component is working precisely as its designers imagined. “It’s a matter of unsafe interactions among components,” she says. “We need stronger tools to keep up with the amount of complexity we want to build into our systems.” Leveson developed her insights into an approach called system theoretic process analysis (STPA), which has rapidly spread through private industries and the military. It would be prudent for Boeing to apply STPA in its 737 Max 8 investigation. 

So why is it imperative that workers be seen as resourceful solutions?  Because complex systems will require controls that use the  immense power of the human brain to quickly recognize hazard patterns, make sense of bad situations created by ill-behaving machines, and  swiftly apply heuristics to prevent plunging into the Cynefin Chaotic domain.

2. When investigating, focus on the learning gap between normal deviation / hazard and avoid the blaming counterfactual.

If you read or hear someone say:
“they shouldn’t have…”
“they could have…”
“they failed to…”
“if only they had…”
it’s a counterfactual. In safety, counterfactuals are huge distractions because they focus what didn’t happen. As Todd Conklin explains, it’s the gap between the  black line (work-as-imagined) and the blue line (work-as-done). The wavy blue line indicates that a worker must adapt performance in response to varying conditions. The changes hopefully enable safety to emerge so that the job can successfully completed. In the Safety-II view, this is deemed normal deviation. Our attention should not be on “what if” but “what” did.

The counterfactual provides an easy path for assigning blame. “If only Jose had done it this way, then the accident wouldn’t have happened.”  Note to safety professionals engaged in accident investigations: Don’t give decision makers bullets to blame but information to learn. The learning from failure lessons are in the gap between the blue line and the hazard line.

3. Be a storylistener and ask storytellers:
How can we get more safety stories like these, fewer stories like those?

I described the ability to generate 2D contour maps from safety stories told by the workforce.  The WOW factor is we now can visually see safety culture as an attitudinal map. We can plot a direction towards a safety vision and monitor our progress.  Click here for more details.

Stories are powerful. Giving the worker a voice to be heard is an effective form of employee engagement. How safety professionals use the map to solve safety issues is another matter. Will it be Ego or Eco? It depends. Ego says I must find the answer. Eco says we can find the answer.

Ego thrives in hierarchy, an organizational  structure adopted from the Church and Military. It works in the Order system, the Obvious and Complicated domains of the Cynefin Framework. Just do it. Or get a bunch of experts together and direct them to come up with viable options. Then make your choice.

Safety culture resides in the Cynefin Complex domain. No one person is in charge. Culture emerges from the relationships and interactions between people, ideas, events, and as noted above, machines driven by AI algorithms. Eco thrives on diversity, collaboration, and co-evolution of the system.

An emerging role for safety professionals is helping Ego-driven decision makers understand they cannot control human behaviour in a complex adaptive system. What they control are the system constraints imposed as safety policies, standards, rules. They also set direction when expressing they want to hear “more safety stories like these, fewer stories like those.”

And less we forget, it’s not all about the workers at the front line. Decision makers and safety professionals are also storytellers. What safety stories are you willing to share? Where would your stories appear as dots on the safety culture map?

Better to be a chef and not a recipe follower.

If Safety had a cookbook, it would be full of Safety Science recipes and an accumulation of hints and tips gathered over a century of practice. It would be a mix of still useful, questionable (pseudoscience), emerging, and recipes given myth status by Carsten Busch.

In the Cynefin Complex and Chaotic domains, there are no recipes to follow. So we rely on heuristics to make decisions. Some are intuitive and based on past successes – “It’s worked before so I’ll do it again.” Until they don’t because conditions that existed in the past no longer hold true. More resilient heuristics are backed by natural science laws and principles so they withstand the test of time.

By knowing  the art and principles of cooking, a chef accepts the challenge of ambiguity and can adapt to unanticipated conditions such as missing ingredients, wrong equipment, last-minute diet restrictions, and so on.

It seems logical that safety professionals would want to be chefs. That’s why I’m curious in the study An ethnography of the safety professional’s dilemma: Safety work or the safety of work?  a highlight is “Safety professionals do not leverage safety science to inform their practice.”
Is it worth having a conversation about, even collecting a few stories? Or are safety professionals too time-strapped doing safety work?

Designing for Emergence

Last year Naomi Stanford posted a LinkedIn article questioning whether we can design for emergence or just set up the conditions to enable emergence.  To answer her posed question, I replied the business change function I like to use involves Cynefin Dynamics.

You start in the Disorder domain and collect stories to understand the present situation. The stories may lead you to the Cynefin Complicated domain where traditional Change Management practices and tools are useful. We can call on experts to analyze and develop idealistic future state solutions. Targets, milestones as governing system constraints work well because behaviour is consistent, repeatable, predictable.

However, if the stories are full of uncertainty, confusion, ambiguity in the form of dilemmas and paradoxes, then we move into the Cynefin Complex domain. Here, we design for emergence by probing the system with safe-to-fail experiments and monitoring behaviour. Experiments are designed with the conditions of emergence in mind – diversity, feedback loops, self-organization. Coherence and Obliquity are two enabling constraints (think of container in Glenda Eoyang’s CDE model) that allow patterns of different behaviour to emerge.

Continual dynamic flow around the Cynefin Framework essentially means staying in beta. Our propensity is to begin with reductionism (Complicated and Obvious domains) due to the many years of formal schooling and training drilled into us. Thankfully, complexity science helps us to think holistically and signals us to change our methods and tools to engage people differently.

Cynefin Complicated domain work is diagnostic. Complex domain work is dialogic. This is the new Dialogic OD perspective that folks like Peggy Holman are exploring and why stories are preferred over surveys and interviews.

Design for Emergence was given a deeper focus at a Cynefin Retreat held at Whistler BC in June 2018. Ann Pendleton-Jullian introduced “scaffold, not structure” to enable emergent thinking. She has co-authored a book Pragmatic Imagination. This book is the last chapter of a larger work in a soon to be published five-book system of books called Design Unbound: Designing for Emergence in a White Water World. 

Her concept and framework is based on six principles: 

  1. The imagination serves diverse cognitive processes as an entire spectrum of activity.
  2. The imagination both resolves and widens the gap between what is unfamiliar – new/novel/strange – and what is known. This gap increases along the spectrum from left to right. Within the range of abductive reasoning, there is a shift from using the imagination for sense-making to sense-breaking, where one first widens the gap and then resolves it with the imagination (see diagram below).
  3. The Pragmatic Imagination pro-actively imagines the actual in light of meaningful purposeful possibilities. It sees opportunity in everything.
  4. The Pragmatic Imagination sees thought and action as indivisible and reciprocal. Therefore it is part of all cognitive activity that serves thought and action for anticipating, and thought and action for follow-through.
  5. The imagination must be instrumentalized to turn ideas into action – the entire spectrum of the imagination. And the generative/poïetic/sometimes-disruptive side of the spectrum is especially critical in a world that requires radically new visions and actions.
  6. Because the imagination is not under conscious control, we need to understand, find, and design ways to set it in motion and scaffold it for play and purpose.

The last principle on scaffolding really resonates with me, especially as a professional engineer. It was cool to make the connection between using scaffolding to build skyscrapers and using scaffolding to mentally enable imaginative ideas to play with each other and build something entirely new. I’ll be adding scaffolding into my 21st century toolkit.

Safety Differently: Recipe Follower and/or Chef?

Over at, Sidney Dekker provides some enlightening background how he coined the term “Safety Differently”  in 2012.  While many pertinent thoughts are expressed, the key message for me is below:

So people ask about Safety Differently ‘How do I do this.’ But what they really want an answer to is the question ‘What do I do now?’ What they really want is someone to tell them, because they haven’t taken the time to think it through, to study the ideas further, to show curiosity and discover the difficulties and adaptive triumphs of frontline work for themselves. They just want other people to tell them what to do. That is literally taking a Safety I mindset to a Safety II world. Of course, the ‘how’-to-get-to-Safety-Differently question is increasingly getting answered in the expanding menu of method options—from embedded discovery to micro-experiments, collective improvements, appreciative inquiry and more. But not the ‘what’ question.

Giving you, or anyone, the ‘what’of the procedural steps, milestones and content for the implementation of anything (including Safety II or Safety Differently) would fundamentally negate what Safety Differently is. There is no intellectual shortcut into a simple procedure for the application of Safety Differently. If there was, it wouldn’t be Safety Differently. It would be Safety I. In Safety I, after all, you have to be willing to hand over your brain, your expertise, your experience, to someone else who has already written the solution for you. You don’t have to think, you just receive and apply. Follow the procedure, stick with the rule, do the checklist that someone else has filled with things they believe are important, so that you can see whether you’re on track according to their definition of that ‘track.’

It’s an important distinction but not an easy one to grasp especially when dominant paradigms are deeply entrenched or as we  say “Fish discover water last.”

To help people flip the switch, I sometimes will use cooking as an analogy. I’ll ask: Do you want to be a Recipe Follower or a Chef? Recipes are written to be easily repeated. Anyone can follow. Practice and expertise increase success. And you get a standardized result. There are lots of recipes in Safety-I.
What happens though if you don’t have all the recipe ingredients at hand? Or someone above demands you must cut the baking time in half? As a Recipe Follower you would be confused, stymied, even paralyzed. A Chef, however, would accept the challenge and adapt to the unexpected conditions. A Chef doesn’t follow a cookbook but knows the art and principles of cooking.

Samin Nosrat in “Salt Fat, Acid, Heat” explains how salt enhances flavour, fat amplifies flavour and makes appealing textures possible, acid brightens and balances, and heat determines the texture of food.

Safety Differently isn’t a cookbook but a new view of perceiving people as resources, the capacity to change and the margin of manoeuvre to make adjustments.
I believe we want workers to be both Recipe Followers and Chefs. The key is understanding when the current situation calls for abandoning the recipe and putting on the chef’s hat.

The Future of Change Management

At the Organizational Change Network on LinkedIn, Ron Leeman posted an article on the continuing argument about traditional Change Management being “old skool” and that it needs a re-think, an overhaul, some fresh ideas etc. He researched CM methods currently being offered by a handful of leading consulting organizations. His conclusion was apart from how new digital tools can help with some aspects of Change Management, he didn’t think there is a lot of new thinking out there. Rather it looked like just a regurgitation and/or re-naming of previous approaches.
I replied what if there was an emerging change practice that wasn’t a regurgitation but quite different as per the following:
  • What if a change practice emerged that treated all organizations as complex adaptive systems? It would mean escaping the dominant human-imposed Engineering paradigm (faster, better, cheaper)  and setting aside age-old tools such as reductionism, benchmarking, future state visioning, cause & effect analysis, linear road mapping, surveys, and yes, even metrics to a certain degree.
  • The change practice would be built on an Ecological paradigm applying ideas and words such as Anthro-complexity, Cynefin, Liminality, Morphogenesis, enabling constraints, managing the evolutionary potential of the Present.
  • The change practice would be informed by Natural science – what we have learned from observing Nature in action: Messy coherence, Homeostasis, Natural Resilience, Mutating containers, Exaptation, Biomimicry.
  • The change practice would leverage real world Complexity phenomena: Emergence, Diversity, Viral Butterfly Effect, Non-linear Tipping Point, Self-organization, Stigmergy, Pareto Power Law Risk (fat tail).
  • The change practice would recognize people are Homo Narrans: Dialogic sense-making, Distributed ethnography, narrative fragments, Thick Data, Disintermediation.
  • The change practice would understand the concept of Homo Faber – use of tools to shape a complex environment: Distributed cognition, Chaordic teaming, Safe-to-fail experiments, Weak signal detection, Obliquity, Asymmetric co-evolution, Scaffolding, Nudging, Fractal management.
  • The change practice would recognize humans like to play creative games (Homo Luden): Pattern recognition, Strange attractors, Non-hypothesis abduction, Wicked problems, Serendipity.
  • The change practice would be pragmatic: Conceptual blending, Adjacent Possible, Satisficing, Heuristics, Phronesis, Praxis.
As many of you know, what I outlined was the complexity-based approach to implement change during unpredictable, constantly changing times.
As Dave Snowden explained, you can view the real world in terms of 3 basic systems: Order, Complex, Chaotic. The 20th century was dominated by Order system thinking. Many change practices are  designed for a work environment that is stable, consistent, and where cause & effect relationships exist. The future is deemed predictable and possibly extends from past history. The popular image of jigsaw puzzle parts being put together is apropos. If a change project fits in this environment, one can confidently carry on using a linear step-by-step command and control mindset.
In a complex system the puzzle parts are constantly moving or even missing. Furthermore, a complex adaptive system will see humans adapting by evolving relationships and adjusting emotional interactions. If your change project faces uncertainty, unpredictability, ambiguity, think twice about using Order system CM tools. They really aren’t built for uncontrollable turbulence and volatility.
In 2000, Stephen Hawking stated the new century is the Age of Complexity. It’s getting close to two decades. The time is ripe, perhaps overdue, to update the Future of Change Management.

The Future of Safety

Today I had the privilege and pleasure of speaking at the BCCGA AGM.  A copy of the slides presented can be downloaded here. In my conclusion I posed 4 questions for the BCCGA and its member organizations to consider.

1. What paradigm(s) should our safety vision be based upon?

The evolution of safety thinking can be viewed through 4 Ages.

The recurring theme is about how Humans were treated as new technologies were implemented into business practices. It’s logical that the changes in safety thinking mirror the evolution of Business Practices. The Ages of Technology, Human Factors, and Safety Management are rooted in an Engineering paradigm.

It’s Systems Thinking with distinct parts: People, Process, Technology. Treat them separately and then put them together to deliver a Strategy.  Reductionism works well when the system is stable, consistent, and relatively fixed by constraints imposed by humans (e.g., regulations, policies, standards, rules). However, in addition to ORDER, there are 2 other systems: COMPLEX and CHAOTIC in the real world. These two are constantly changing so a reductionistic approach is not appropriate. One must work holistically with an Ecological paradigm.

This diagram from the Cynefin Centre shows the relative sizing of the 3 systems. Complexity by far is the largest and continues to grow.  All organizations are complex adaptive system. A worthy safety vision must include the Age of Cognitive Complexity and view Safety as an emergent property of a complex adaptive system. The different thinking means rules don’t create safety but create the conditions that enable safety to emerge. Now we can understand why piling on more and more rules can lead to cognitive overload in workers and enable danger, not safety, to emerge.

2. How should we treat workers – as problems to be managed or solutions to be harnessed?

The Age of Technology and Age of Human Factors treated workers as problems – as cogs in a machine and as hazards to be controlled. The Age of Safety Management view recognizes that rules cannot cover every situation. Variability isn’t a threat but a necessity. We need to trust that humans always try to do what they think is right in the situation. The Age of Cognitive Complexity appreciates that humans think differently than logical information-processing machines in an Engineering paradigm. Humans are not rational thinkers; decisions are based on emotional reactions & heuristic shortcuts. As storytellers, people can articulate thick data that a typical report is unable to provide.  As solution providers, workers can call upon tacit knowledge – difficult to transfer to another person by means of writing it down or verbalizing it. Workers who feel like cogs or hazards tend to stay within themselves for fear of punishment. Knowledge is volunteered; never conscripted.

3. What safety heuristics can we share?

While Best Practices manuals are beneficial,  heuristics are on a  bigger stage when dealing with decisions. Humans make 95% of their decisions using heuristics. Heuristics are mental shortcuts to help people make quick, satisfactory but not perfect decisions.

They are the rules of thumb that Masters pass on to their Apprentices. Organizations ought to have a means to collect Safety-II success stories and use pattern recognition tools. Heuristics that emerge can be distributed to Masters for accuracy scrutiny.

4. How can we get more safety stories like these, fewer stories like those?

This question pertains to a new way of shaping a safety vision through the use of narratives (stories, pictures, voice recordings, drawings, sketches, etc.)

Narratives are converted into data points to generate a 2D contour map or fitness landscape
Each dot is a story and seen together they form patterns. The map shows the general direction we want to head – top right corner (High compliance with rules & High level of getting the job done). Clearly we want more safety stories in the Green area.  We also want fewer in the Red and Brown areas. Here’s the rub: If we try to go directly for the top right corner, we won’t get there.  This is ATTITUDE mapping at a level way deeper than observable BEHAVIOUR. Instead we head for an Adjacent Possible.
We get people to tell more stories here, fewer there  by changing a human constraint. It might be loosening a controlling constraint like a rule or practice. It could also be introducing an enabling constraint like a new tool or process.
We gather more stories and monitor how the clusters are changing in real-time. The evolving landscape maps a new Present state – a new starting point. We then change another constraint. Since we can’t predict outcomes both positive and unintended negative consequences might emerge. We accelerate the positives and dampen the negatives. In essence we co-evolve our way to the top right corner of the map. This is how we shape our Safety Culture.

7 Implications of Complexity for Safety

One of my favourite articles is The Complexity of Failure written by Sidney Dekker, Paul Cilliers, and Jan-Hendrik Hofmeyr.  In this posting I’d like to shed more light on the contributions of Paul Cillliers.

Professor Cilliers was a pioneering thinker on complexity working across both the humanities and the sciences. In 1998 he published Complexity and Postmodernism: Understanding Complex Systems which offered implications of complexity theory for our understanding of biological and social systems. Sadly he suddenly passed away in 2011 at the much too early age of 55 due to a massive brain hemorrhage.

My spark for writing comes from a blog recently penned by a complexity colleague Sonja Bilgnaut.  I am following her spade work by exploring  the implications of complexity for safety. Cilliers’ original text is in italics.

  1. Since the nature of a complex organization is determined by the interaction between its members, relationships are fundamental. This does not mean that everybody must be nice to each other; on the contrary. For example, for self-organization to take place, some form of competition is a requirement (Cilliers, 1998: 94-5). The point is merely that things happen during interaction, not in isolation.
  • Because humans are natural storytellers, stories are a widely used  interaction between fellow workers, supervisors, management, and executives. We need to pay attention to  stories told about daily experiences since they provide a strong signal of the present safety culture.
  • We should devote less time trying to change people and their behaviour and more time building relationships.  Despite what psychometric profiling offers, humans are too emotional and unpredictable to accurately figure out. In my case, I am not a trained psychologist so my dabbling trying to change how people tick might be dangerous, on the edge of practising pseudoscience.  I prefer to stay with the natural sciences (viz., physics, biology), the understanding of phenomena in Nature which have evolved over thousands of years.
  • If two workers are in conflict, don’t demand that they both smarten up. Instead, change the nature of relationship so that their interactions are different or even extinguished. Simple examples are changing the task or moving one to another crew.
  • Interactions go beyond people. Non-human agents include machines, ideas (rules, policies, regs) and events (meeting, incident). A worker following a safety rule can create a condition to enable safety to emerge. Too many safety rules can overwhelm and frustrate a worker enabling danger to emerge.

2. Complex organizations are open systems. This means that a great deal of energy and information flows through them, and that a stable state is not desirable.

  • A company’s safety management system (SMS) is a closed system.  In the idealistic SMS world,  stability, certainty, and predictability are the norms. If a deviation occurs, it needs to be controlled and managed. Within the fixed boundaries, we apply reductionistic thinking and place information into a number of safety categories, typically ranging from 4 to 10. An organizational metaphor is sorting solid LEGO bricks under different labels.
    In an open system, it’s different. Think of boundary-less fog and irreducible mayonnaise. If you outsource to a contractor or partner with an external supplier, how open is your SMS? Will you insist on their compliance or draw borders between firms? Do their SMS safety categories blend with yours?
  • All organisations are complex adaptive systems. Adaptation means not lagging behind and plunging into chaotic fire-fighting. It means looking ahead and not only trying to avoid things going wrong, but also trying to ensure that they go right. In the field, workers when confronted by unexpected varying conditions will adjust/adapt their performance to enable success (and safety) to emerge.
  • When field adjustments occasionally fail, it results in a new learning to be shared as a story. This is also why a stable state is not desirable. In a stable state, very little learning is necessary. You just repeat doing what you know.

3. Being open more importantly also means that the boundaries of the organization are not clearly defined. Statements of “mission” and “vision” are often attempts to define the borders, and may work to the detriment of the organization if taken too literally. A vital organization interacts with the environment and other organizations. This may (or may not) lead to big changes in the way the organization understands itself. In short, no organization can be understood independently of its context.

  • Mission and Vision statements are helpful in setting direction. A vector, North Arrow, if you like. They become detrimental if communicated as some idealistic future end state the organization must achieve.
  • Being open is different than “thinking out of the box” because there really is no box to start with. It’s a contextual connection of relationships with other organizations. It’s also a foggy because some organizations are hidden. You can impact organizations that you don’t even know  about and conversely, their unbeknownst actions can constrain you.
    The smart play is to be mindful by staying focused on the Present and monitor desirable and undesirable outcomes as they emerge.

4. Along with the context, the history of an organization co-determines its nature. Two similar-looking organizations with different histories are not the same. Such histories do not consist of the recounting of a number of specific, significant events. The history of an organization is contained in all the individual little interactions that take place all the time, distributed throughout the system.

  • Don’t think about creating a new safety mission or vision by starting with a blank page, a clean sheet, a greenfield.  The organization has history that cannot be erased. The Past should be honoured, not forgotten.
  • Conduct an ongoing challenge of best practices and Life-saving rules. Remember the historical reasons why these were first installed. Then question if these reasons remain valid.
  • Be aware of the part History plays when rolling out a safety initiative across an organization.
    • If it’s something that everyone genuinely agrees to and wants, then just clone & replicate. Aggregation is the corollary of reductionism and it is the common approach to both scaling and integration. Liken it to putting things into org boxes and then fitting them together like a jigsaw. The whole is equal to the sum of its parts.
    • But what if the initiative is controversial? Concerns are voiced, pushback is felt, resistance is real. Then we’re facing complexity where the properties of the safety system as a whole is not the sum of the parts but are unique to the system as a whole.
      If we want to scale capabilities we can’t just add them together. We need to pay attention to history and understand reactions like “It won’t work here”, “We tried that before”, “Oh no! Not again!”
      The change method is not to clone & replicate.  Start by honouring local context. Then decompose into stories to make sense of the culture. Discover what attracts people to do what they do. Recombine to create a mutually coherent solution.

5. Unpredictable and novel characteristics may emerge from an organization. These may or may not be desirable, but they are not by definition an indication of malfunctioning. For example, a totally unexpected loss of interest in a well-established product may emerge. Management may not understand what caused it, but it should not be surprising that such things are possible. Novel features can, on the other hand, be extremely beneficial. They should not be suppressed because they were not anticipated.

  • In the world of safety, failures are unpredictable and undesirable. They emerge when a hidden tipping point is reached.
    As part of an Emergency Preparedness plan, recovery crews with well-defined roles are designated. Their job is to fix the system as quickly as possible and safely restore it to its previous stable state.
  • Serendipity is an unintended but highly desirable consequence. This implies an organization should have an Opportunity crew ready to activate. Their job is to explore the safety opportunity, discover new patterns which may lead to a new solution, and exploit their benefits.
    At a tactical level, the new solution may be a better way of achieving the Mission and Vision. In the same direction but a different path or route.
    At a strategic level, the huge implication is that new opportunity may lead to a better future state than the existing carefully crafted, well-intentioned one. Decision-makers are faced with a dilemma: do we stay the course or will we adapt and change our vector?
  • Avoid introducing novel safety initiatives as big events kicked off with a major announcement. These tend to breed cynicism especially if the company history includes past blemished efforts. Novelty means you honestly don’t know what the outcomes will be since it will be a new experience to those you know (identified stakeholders) and those you don’t know in the foggy network.
    Launch as a small experiment.
    If desirable consequences are observed, accelerate the impact by widening the scope.
    If unintended negative consequences emerge, quickly dampen the impact or even shut it down.
    As noted in (2), constructively de-stabilize the system in order to learn.

6. Because of the nonlinearity of the interactions, small causes can have large effects. The reverse is, of course, also true. The point is that the magnitude of the outcome is not only determined by the size of the cause, but also by the context and by the history of the system. This is another way of saying that we should be prepared for the unexpected. It also implies that we have to be very careful. Something we may think to be insignificant (a casual remark, a joke, a tone of voice) may change everything. Conversely, the grand five-year plan, the result of huge effort, may retrospectively turn out to be meaningless. This is not an argument against proper planning; we have to plan. The point is just that we cannot predict the outcome of a certain cause with absolute clarity.

  • The Butterfly effect is a phenomenon of a complex adaptive system. I’m sure many blog writers like myself are hoping that our safetydifferently cause will go viral, “cross the chasm”, and be adopted by the majority. Sonja in her blog refers to a small rudder that determines the direction of even the largest ship. Perhaps that’s what we are: trimtabs!
  • On the negative side, think of a time when an elected official or CEO made a casual remark about a safety disaster only to have it go viral and backfire. In 2010 Deep Horizon disaster then CEO Tony Hayward called the amount of oil and dispersant “relatively tiny” in comparison with the “very big ocean”.  Hayward’s involvement has left him a highly controversial public figure.
  • Question: Could a long-term safety plan to progress through the linear stages of a Safety Culture Maturity model be a candidate as a meaningless five-year plan?
    If a company conducts an employee early retirement or buy-out program, does it regress and fall down a stage or two?
    If a company deploys external contractors with high turnover, does it ever get off the bottom rung?
    Instead of a linear progression model, stay in the Present and listen to the stories internal and external workers are telling. With the safety Vision in mind, ask what can we do to hear more stories like these, fewer stories like those.
    As the stories change, so will the safety culture.  Proper planning is launching small experiments to shape the culture.

7. Complex organizations cannot thrive when there is too much central control. This certainly does not imply that there should be no control, but rather that control should be distributed throughout the system. One should not go overboard with the notions of self-organization and distributed control. This can be an excuse not to accept the responsibility for decisions when firm decisions are demanded by the context. A good example here is the fact that managers are often keen to “distribute” the responsibility when there are unpopular decisions to be made—like retrenchments—but keen to centralize decisions when they are popular.

  • I’ve noticed safety professionals are frequent candidates for organization pendulum swings. One day you’re in Corporate Safety. Then an accident occurs and in the ensuing investigation a recommendation is made to move you into the field to be closer to the action. Later a new Director of Safety is appointed and she chooses to centralize Safety.
    Pendulum swings are what Robert Fritz calls Corporate Tides, the natural ebb and flow of org structure evolution.
  • Central v distributed control changes are more about governance/audit rather than workflow purposes. No matter what control mechanism is in vogue, it should enable stigmergic behaviour, the natural forming of network clusters to share knowledge, processes, and practices.
  • In a complex adaptive system, each worker is an autonomous decision-maker, a solution not a problem. Decisions made are based on information at hand (aka tacit knowledge) and if not available, knowing who, where, how to access it. Every worker has a knowledge cluster in the network. A safety professional positioned in the field can mean quicker access but more importantly, stronger in-person interactions. This doesn’t discount a person in Head Office who has a trusting relationship from being a “go to” guy. Today’s video conferencing tools can place the Corp Safety person virtually on site in a matter of minutes.
Thanks, Sonja. Thanks, Paul.
Note: If you have any comments, I would appreciate if you would post them at
















Safety Differently

My thanks to Peter Caulfield for interviewing me and writing an article in the Journal of Commerce on a different view of safety.

Veteran Vancouver engineer and consultant Gary Wong says the safety industry needs to reexamine its goals and how to accomplish them if it wants to keep workers safe and at the same time make them productive.

Wong’s approach, called Safety Differently, is based on what he says is a more realistic take on what goes on in the workplace.

“Industry standards and practices typically evolve based on what we learn from failures,” says Wong. “But evolution in the safety industry has been slow and continues to follow the old idea that safety is only the absence of people getting hurt.”

That approach, says Wong, is based on the belief that humans must be controlled with compliance rules and procedures.

“If an accident occurs, we automatically look for the people to blame and then punish them through discipline or termination,” Wong says. “Experts today promote the idealistic goal of zero harm, so it isn’t surprising workers are confused if a safety dilemma arises.”

Safety Differently on the other hand credits workers for getting things right, which he says they do most of the time.

“Safety Differently sees people as the solution and safety as an ethical responsibility,” says Wong. “It recognizes that safety is not something that is created, but emerges out of a complex adaptive system.”

When facing an unexpected change, people will adjust their actions accordingly, he says. In most cases, their adjustment will keep them stay safe.

But an unexpected change can also be dangerous, and, if a tipping point is reached, an incident can happen.

“Safety Differently focuses on hidden non-linear tipping point signals and how humans sense impending danger,” Wong says.

“It boosts the capacity of people to handle their activities safely and successfully under different conditions.”

Ron Gantt, vice-president of SCM Safety Inc. in San Ramon, Calif., says there is a big difference between Safety Differently and the old way of doing safety.

“The old safety model focuses on regulations and takes an adversarial approach,” Gantt says. “Safety Differently, on the other hand, is more collaborative, with more worker participation in finding solutions that prevent accidents.”

Safety Differently is based on three principles, Gantt says.

“First, it is a forward-looking, predictive tool,” he says.

“It looks ahead to prevent accidents in the future, not backward at accidents that happened in the past. Its purpose is to build the capacity to be successful from now on and as conditions change.”

Safety Differently’s second operating principle is that people are the solution, not the problem.

“People are instinctive risk managers and they have an innate ability for creative problem-solving,” Gantt says. “Let’s trust them to do the right thing. Unfortunately, there’s not a lot of trust in the old safety model.”

Third, the people at the top of an organization should view safety as an ethical responsibility.

“They need to be curious about what their employees want and make an effort to satisfy them,” Gantt says.
Safety Differently is needed, he says, because the world is becoming more interdependent and complex and small changes can have huge effects.

Support for Safety Differently is growing, he adds.

“Many safety professionals are frustrated with the old way of doing things,” Gantt says.

At the same time, there is resistance from people and groups with a vested interest in maintaining the status quo.

“They are likely to say that the way to reduce the number of workplace injuries and deaths is to keep things the old way but to try harder,” he says.

Erik Hollnagel, a Danish academic and expert in system safety and human reliability analysis, advocates the application of “synesis to safety.” The term means the same thing as synthesis, or bringing together.

“The effort to ensure that work goes well and that the number of acceptable outcomes is as high as possible requires a unification of priorities, perspectives and practices,” says Hollnagel.

“Synesis brings together all these practices to produce outcomes that satisfy more than one priority and even reconciles multiple priorities.”

Many sectors of the economy conflate safety and quality or safety and productivity, Hollnagel says.

“We can look at a process or work situation from a safety point of view, from a quality point of view or from a productivity point of view,” Hollnagel says.

“But we should keep in mind that any individual point of view reveals only part of what is going on and that it is necessary to understand what is going on as a whole.”

Using Cynefin to publish a book

It’s been some time since I last blogged on my website. It’s not because I’ve grown tired of complexity and safety; it’s mainly due to my  involvement with friends to publish a book about an amazing man who dedicated over 50 years on the University of British Columbia campus. The target was achieved: The Age of Walter Gage: How One Canadian Shaped the Lives of Thousands.  This particular blog is not about the book  but  how Cynefin  dynamics  & cadence was put to good use.

When the book idea took hold in early 2016, it wasn’t a surprise that we started in the Cynefin Complicated domain. We certainly did not qualify as experts in producing a book but as “expert” engineers schooled in systems thinking, we all had a propensity to set a desired future state target and build a project plan by linearly working backwards. We at least were cognizant we needed the right set of talent and skills – writing, photo compilation , book editing, publication, distribution. The first milestone on the roadmap was a book publishing firm that would assume these activities in their entirety. Then we could manage the project in the Complicated domain using a “waterfall” approach.

I volunteered to build a companion website (open network platform) to collect stories (narrative research). My blogging efforts would focus on engaging storytellers and spreading the news about our Walter Gage book project. We literally had no clue who had stories and how many there were. All that we knew was that time was not on our side so there was an urgency to contact storytellers before life took its natural toll.

The prompt question for stories was simple: “a personal or professional experience that sheds light on how Walter Gage impacted you.” While written stories were requested, we did receive other narrative fragments – a voice recording, photos and letters.

Could I have signified the stories with triads and dyads to later search for patterns? Yes, but  it would have required team education and, of course, more work (probably unappreciated) by storytellers. Instead, we chose to rely on the hired author’s vast experience to read the stories and extract themes worth highlighting in the book.

While I was busy gathering stories and narrative fragments, other team members were approaching several publishers with our book idea.  While we were told our pitch was for a noble cause and commendable, nobody signed on.  We learned that our  “business case” did not provide sufficient ROI as a money-making opportunity.

Drat. Our path was broken. The roadmap led us to a dead end. Being resilient, we shifted into the above diagram’s “Yellow loop” to reset our thinking.  We decided to deploy a self-publishing strategy and search for resources who could help us make our book a reality. It also meant more work on our part.  It was intriguing to observe the team’s need to “self-organize.” We were divided into 2 sub teams- Book Creation and Marketing. Was there a concern for the silo effect? Yes, but like physical silos on a farm which are ventilated, we continued to meet often as an overall team to enable venting to take place.

Due to our lack of knowledge and practical experience, I knew our cadence would be between Cynefin Complicated and Complex domains (the “Blue loop”). Whenever a totally unexpected unintended consequence emerged, we would move into the Complex domain. With the Engineer’s disposition to immediately “fix” a problem, patience was necessary to make sense of outcomes and explore options. BTW, not all consequences were negative. One UBC grad came forth and surprised us with a major donation. Serendipity at its finest!

I introduced different software tools to the team. Some worked, some didn’t. I opened a Trello board to track our progress under the 2 sub teams. It was great for storing documents and having them available at a meeting with a couple of clicks. However,  I ran into objections regarding too many email notifications being received. I also learned that not all team members wanted the full picture, just happy to do their tasks. I eventually deleted half the team with the balance remaining on the app to stay abreast. Chalk it up as a safe-to-fail experiment.

Our primary online communication mode was Email, with all its pros and cons. “Reply to All” messages became problematic. One time we had a thread with over 72 responses. Talk about being on the Obvious/Chaotic boundary with a failure looking for a place to happen! Attachments were easily lost in the long threads. Fortunately with Trello I was able to access quickly and send them to members, as a separate new email of course.

“Email tag” had me thinking of introducing Slack to simplify communication but my Trello discovery led me to a “Don’t even think about it” conclusion. When navigating complexity, we can’t control human behaviour but can only influence the relationships and interactions amongst team members. In this case, I chose not to drop in Slack as a catalyst which would have certainly disrupted communication patterns but, who knows, maybe enable worse patterns to emerge.

We held two “by invitation only” project celebration events.  Planning was autonomic: Let’s issue invitations via email. After all, if you’re good with a hammer, everything looks like a nail. Hmm, if there’s a “best practice” in the Obvious domain, email tops the list.

Thankfully I was able to influence the team to go with Its messaging features enabled us to leverage feedback loops, a key phenomenon of complex systems. One attendee even went a step further by posting photos of the event on for everyone to enjoy. (Note to self: Use to manage the next class reunion instead of personal email account.)

We have our official book launch tomorrow, Feb 15th.  The beginning of the end. Or perhaps the end of the beginning since book promotion and marketing now ramps up. Either way, I plan to invest more time pushing the boundaries on complexity and safety, from a natural sciences perspective.