Tag Archives: Utilities

Safety-I + Safety-II

At a July 03 hosted conference Dave Snowden and Erik Hollnagel shared their thoughts about safety. Dave’s retrospects of their meeting are captured in his blog posting. Over the next few blogs I’ll be adding my reflections as a co-developer of Cognitive-Edge’s Creating and Leading a Resilient Safety Culture course.

Erik introduced Safety-II to the audience, a concept based on an understanding of what work actually is, rather than what it is imagined to be. It involves placing more focus on the everyday events when things go right rather than on errors, incidents, accidents when things go wrong. Today’s dominating safety paradigm is based on the “Theory of Error”. While Safety-I thinking has advanced safety tremendously, its effectiveness is waning and is now on the downside of the S-curve. Erik’s message is that we need to escape and move to a different view based on the “Theory of Action”.

Erik isn’t alone. Sidney Dekker’s latest presentation on the history of safety reinforces how little safety thinking has changed and how we are plateauing. Current programs such as Hearts & Minds continue to assume people have physical, mental, and moral shortcomings as was done way back in the early 1900s.

Dave spoke about Resilience and why the is critical as its the outliers where you find threat and opportunity. In our CE safety course, we refer to the Safety-I events that help prevent things from going wrong as Robustness. This isn’t an Either/Or situation but a Both/And. You need both Robustness + Resilience.

As a young electrical utility engineer, the creator of work-as-imagined, I really wanted feedback but struggled obtaining it. It wasn’t until I developed a rapport with the workers was I able to close the feedback loop to make me a better designer. Looking back I realize how fortunate I was since the crews were in proximity and exchanges were eye-to-eye.

During these debriefs I probably learned more from the “work-as-done” stories. I was told changes were necessary due to something that I had initially missed or overlooked. But more often it was due to an unforeseen situation in the field such as a sudden shift in weather or unexpected interference from other workers at the job site. Crews would make multiple small adjustments to accommodate varying conditions without fuss, bother, and okay, the occasional swear word.

I didn’t know it then but I know now: these were adjustments one learns to anticipate in a complex adaptive system. It was also experiencing Safety-II and Resilience in action in the form of narratives (aka stories).

When a disaster happens, look for the positive

In last month’s blog I discussed Fast Recovery and Swarming as 2 strategies to exit the Chaotic Domain. These are appropriate when looking for a “fast answer”. A 3rd strategy is asking a “slow question.”

Resilience as Cynefin DynamicsWhile the process flow through the Cynefin Framework is similar to Swarming (Strategy B), the key difference is not looking for a quick solution but attempting to understand the behaviour of agents (humans, machines, events, ideas). The focus is on identifying something positive emerging from the disaster, a serendipitous opportunity worth exploiting.

By conducting safe-to-fail experiments, we can probe the system, monitor agent behaviour, and discover emerging patterns that may lead to improvements in culture, system, process, structure.

Occasions can arise when abductive thinking could yield a positive result. In this type of reasoning, we begin with some commonly well known facts that are already accepted and then works towards an explanation. The vernacular would be playing a hunch.

Snowstorm Repairs

In the electric utility business when the “lights go out”, a trouble crew  is mobilized and the emergency restoration process begins. Smart crews are also on the lookout for serendipitous opportunities. One case involved a winter windstorm causing  a tree branch to fall across the live wires. Upon restoration, the crew leader took it upon himself to contact customers affected by the outage to discuss removal of other potentially hazardous branches. The customers were very willing and approved the trimming. The serendipity arose because these very same customers vehemently resisted in the Fall to have their trees trimmed as part of the routine vegetation maintenance program.  The perception held then was that the trees were in full bloom and aesthetically pleasing; the clearance issues were of no concern. Being out of power for a period of time in the cold winter can shift paradigms.