Systemic Safety

and

Human and Organizational Factors

Patrik Lundell

and

Kim Hafström E-mail pll.lwr@icloud.com

Mars 2016

1

MODERN SAFETY THINKING

• Modern views complement and do not cancel

traditional models and approaches.

• Modern safety thinking recognises the value of

standardized procedures but goes beyond

compliance behaviour.

• The ultimate goal is to build a mature and

proactive organizational culture, which does not

merely react to unwanted events.

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• Human error seen as symptom and not as cause. This does

not cancel responsibility and accountability of workers and

managers.

• Avoidance of hindsight bias. We try to understand the

course of events from the place of the actors and not as

external observers.

• Shared responsibility. Both good and adverse outcomes

result from interdependencies and interactions of all

organizational functions.

• Focus on success rather than solely on failures. We need to

understand how employees perform well under constantly

changing conditions and conflicting goals.

3

MODERN SAFETY THINKING

• Feedback mechanisms. System processes in addition to

their planning and operation must be constantly monitored

in order to allow adjustments.

• Avoidance of folk models. The use of abstract statements

without further explanations (e.g., lack of motivation,

boredom, loss of awareness) does not support our

understanding of why things go wrong.

• Non-counterfactual approach. In addition to comparing

performance with standards, we must explore the

underlying reasons for non-adherence to procedures.

• Non-judgmental attitude. We need to both question

established “norms” and explain why people do not act as

expected.

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MODERN SAFETY THINKING

5

Systemic view. Good and unwanted events

result from continuous interaction among

systems elements under variable conditions

and multiple objectives.

MODERN SAFETY THINKING

Bad apple theory

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The Theory of Bad Apples approach is popular, because blaming

and removing individuals from the system seems like a quick-fix

and is attractive in its simplicity…

But… we need to move

beyond the simplicity. We need

to understand the accidents

and the context to improve our

safety work. We need to think

more creatively and differently

about the safety issues we as

humans and our organizations

face…

Exampels of influencing factors

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Stress Distraction

Complacency

Communication

Team

Work/Group

think

Fatigue

Personal

issues

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Management

commitment and

leadership

Clear

responsibilities and

accountabilities of

all management

areas towards

safety

Safety department

visibly responsible and

accountable for safety

planning

Employees’

involvement

Non‐reliance on

past success

Risk management

policy

Planning for

buffers

Rewarding safety

initiatives

Internal and external

communication

Organizational

Prerequisites

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Organizational safety components

Reason´s Subcultures Definition

Just culture Defined acceptable and unacceptable behaviour. A culture in which

types of acceptable and unacceptable behaviour are communicated

and understood.

Flexible culture A culture that accepts variability whenever procedures do not suffice

to deal with conflicting goals, and which enables reconfiguration of

the organizational structure in the face of a dynamic environment.

Reporting culture A culture where staff, both in the sharp end and blunt end, are

prepared to voluntarily report their own hazards, errors, violations,

and deviations.

Informative culture A culture that enables information sharing across the organization.

Such information is derived from the safety information system. The

system must collect, analyse and spread event data (e.g., incidents,

accidents, near misses) and data obtained from proactive checks.

Learning culture A culture that draws valuable conclusions from its safety information

system, and drives changes in the organization based on the lessons

learned.

The implementation

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Just

Flexible

Reporting

Informative

Learning

The enviroment in wich

accountability is well

understood by all

employees.

The boundaries of

accepted human

performance have been

established and agreed.

All staff is knowledgeable

about potential implications

of unaccepted behaviour.

A fair operational

enviroment is the basis for

the operation of the rest of

the components.

Flexibility must be recognised as

valuable and accepted whenever

current procedures do not suffice

to deal with conflicting goals,

working conditions deviate from

the ones designed or unplanned

events emerge.

Increase of the amount of hazard

reports, also a boost of the quality

and traceability of such reports. In

addition to hazards, staff will share

with the organisaztion lessons and

experiences sourcing from

confrontation with competing

objectives and poor working

conditions.

When reporting becomes

systematic, a broad range of

additional local safety

information will be obtained,

and can be shared across the

organization.

The sharing of

safety related

information,

including

conclusions

drawn from

volontary reports,

increases the

possibility that

the organization

will learn and

plan for change.

Just Culture

Flexibel Culture

Reporting Culture

Informativ Culture

Learning Culture

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Documented definition of ‘’acceptable’’ and

‘’unacceptable’’ safety behaviour, accompanied

by assumptions, examples, indications etc. The

decision for attributing unacceptable behaviour

is made and agreed by peers. Practitioners

know their rights and duties regarding

occurrences. Prevention of practitioners’

stigmatisation. Organizational support in legal

disputes.

Recognize the inevitable gap between

standard procedurs and working practices.

Control of variability. Emergency response

and crisis management exercises.

Clear policy about reporting. Characteristics for

maximum potential of a reporting system.

Learning from success. Learning from failures.

Safety training. Internal and external benchmark.

Safety information used to initiate changes

A user‐friendly safety information system in

place with free access for all employees.

Content of safety information. Planning for

access to safety information. Information

sharing across teams, units and

departments.

The operationalization

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Understanding

Flexibility

the Blunt end

”Work as imagine”

the Sharp end

”Work as done”

GAP

Resilient organizations - four components

In accordance to the relevant literature, a resilient organization is characterised by the

following four abilities:

1. Anticipation: the ability to anticipate potential disturbances and their

consequences at medium and long terms. This ability promotes the organizational

preparedness to deal with unplanned, unexpected and unwanted events, instead of

trying to predict and preventing them.

2. Monitoring: the ability to monitor and trace performance variability, enabling thus

an organization to deal with uncontrolled deviations before these being aggregated to

critical events.

3. Responding: the ability to act and adapt to both planned

and unforeseen situations.

4. Learning: the ability to learn from responses and drive

organizational changes.

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Organizational safety components Resilience components

Common organizational prerequisites

Anticipate, monitor, response, learn Just culture

Flexible culture Response

Reporting culture Monitor

Informative culture Learn

Learning culture

A reporting culture ensures that information stemming from a wide range of

safety‐related activities can be obtained, and therefore relates to the monitoring property

of resilience. Both informative, and learning cultures allow the organization to learn

from experience, hence, are associated with the learning property of resilience.

Just culture, is the basis for operationalizing the rest of the organizational

safety components. As flexible culture enables an adaptive reaction to

changing environments, it corresponds to the ability to response

Organizational safety maturity model

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Promote readiness,

safety is how we do

business around here

Calculative, having

systems in place to

manage hazards

Safety is not our concern

Anticipate

problems before

they arise

We do safety

only when we

have accidents

HTO

HTO = The interaction between human,

technology and organization

In a given situation, humans and

organizations have different types of

resources available to perform a task

successfully.

It's how the humans and organizations

utilizing these resources, through the

interplay and interaction, which constitutes

the principle of HTO.

Organization

Instructions

Procedures

Regulators

Managment systems

Culture

HUP Tools

Money

Training

Human

Competence

Communication

Motivation

Leadership

Abilities

Experiences

Employees

Technic

Instrument

Tools

Computers

Technical systems

Controls

Fire extinguisher

Ladder

Spare parts

H T

O

What is a resource?

The systemic view

Good and unwanted events result from continuous

interaction among systems elements under variable

conditions and multiple objectives.

Humans and organizations acting and thinking are constantly

influenced by it´s context. Therefor,

a systemic view is vital!

Thank you for your attention

…Questions and comments? 21