When the purpose of safety is to ensure that everything goes right, safety, quality and productivity go hand in hand. Craig Donaldson speaks with Erik Hollnagel about why safety management should move to ensuring that “as many things as possible go right”
Safety management should move from ensuring that “as few things as possible go wrong” to ensuring that “as many things as possible go right”, according to international expert on resilience engineering, Erik Hollnagel, who serves as professor at the department of regional health research, University of Southern Denmark.
This perspective on safety, termed “Safety-II”, relates to a system’s ability to succeed under varying conditions, so that the number of intended and acceptable outcomes (in other words, everyday activities) is as high as possible, said Hollnagel.
Most people think of safety as the absence of accidents and incidents (or as an acceptable level of risk, a perspective termed "Safety-I"), which is defined as a state where as few things as possible go wrong.
Shifting to a Safety-II Perspective
A main challenge for an organisation in shifting to a Safety-II perspective is changing its mindset to accept that it is important to understand everyday performance, said Hollnagel.
“Things do not go right because everything and everyone work as imagined. Things go right because people, individually and collectively,are able to adjust smoothly to what they do, to the conditions - both at the sharp end and at the blunt end,” he said. “This is rarely a surprise to people at the sharp end, but it is sometimes a surprise to management.”
Safety-II does not see safety as an isolated phenomenon, separate from quality and productivity, he added. “On the contrary, when the purpose of safety is to ensure that everything goes right, safety, quality, and productivity go hand in hand,” he said.
“Studying the variability of everyday performance is important for the wellbeing of the organization – in addition to being a prerequisite for understanding why things that go right sometimes go wrong.”
The Role of FRAM
The FRAM (Functional Resonance Analysis Method) methodology is a practical way to develop an overall understanding of how a socio-technical system works – should work, Hollnagel said.
Instead of decomposing a system into components and component characteristics, the FRAM describes the functions (activities) that take place, how they depend on each other, and how they can vary. “The FRAM does not start from a predefined model of the system, but helps to build a functional model of the system, which then may be used to analyse events and to consider possible future scenarios – both risks and improvements,” he said.
Hollnagel noted that the FRAM has been used with good results in the aviation, ATM, nuclear power, construction, health care, and maritime domains – initially as an accident analysis method, but increasingly as a way to understand how complex sociotechnical systems function.
Is CREAM Obsolete?
Hollnagel says the purpose of CREAM (Cognitive Reliability and Error Assessment Method) was to offer a method that would avoid the “human error” fallacy and instead describe human performance failures in terms of the performance conditions.
“It tried to provide sensible answers to questions about human reliability,” he said. “There is still a thirst for probabilities in some camps, but on the whole I think that this need is more limited today than in the 90s, and I hope that it eventually will wither and die. Since I no longer accept the legitimacy of this need, I personally consider CREAM as obsolete, although a number of the sensible ideas proposed by CREAM can be found in a different form in the FRAM.”
Steps for OHS Professionals
In shifting to a Safety-II perspective, Hollnagel recommended OHS professionals to look at what they themselves do at work – and for that matter in any kind of activity. “Try to recognise the usefulness of the ubiquitous performance adjustments that everyone makes all the time, try to understand why they happen and how we can become better at monitoring and managing them, in ourselves and in others,” he said.
“And then, of course, point out that whatever is spent to improve Safety-II is not a cost but an investment that improves the organization’s ability to succeed.”