The current focus of safety is on negative consequences, that is, after something has gone wrong we try to look for an explanation, usually involving allocating blame to varying social considerations;
Yet none of these factors really explain what happened to cause the accident or why. To help us look beyond the current social thinking Dr Erik Hollnagel refers to the phrase “complex system” a new, yet-to-be-defined concept to explain that every task is influenced by many other factors.
This method of safety is where we find and fix problems after an accident, there is a focus on events where safety is absent, not where safety is present. What we are really doing is studying a lack of safety and not the presence of safety.
Many organisations have slogans such as ‘ZERO HARM’ and claim that we may prevent these negative events and injuries by eliminating unsafe acts and hazards. This assumes failures are based on deviation from work-as-imagined, and that this deviation is wrong.
This method of safety understands that individuals and organisations must constantly adjust and change the way they work (work-as-done) to achieve successful outcomes.
How can we prevent unsafe acts if we don’t know what safety done right is?
Management often has an imaginary view of how work is actually done in practice. Workers know that they cannot always strictly follow written procedures and need to vary their actions in accordance with varying conditions (such as variable weather). In most cases these variations still result in a successful job i.e. when nothing goes wrong. But sometimes a combination of adjustments causes things to go wrong.
A model for looking at the relationship between workers and factors which impact on them is “The sharp end and the blunt end”.
The sharp end refers to the people who are exposed to the hazardous processes e.g. the plant operators, drivers, people that are working at the time and in the place where the accident takes place. This diagram helps us to understand the factors influencing work-as-done, and what can cause adjustments.
If we get better at understanding how work-as-done is completed successfully, and the various ways it is done successfully e.g. what adjustments lead to success without failure, then we can reduce the number of times things go wrong.
To close the gap between work-as-imagined and work-as-done we need to:
- Think of safety as a positive (good) state and not the lack of a negative state.
- Acknowledge the gap between work-as-done and work-as-imagined.
- Study the sharp end and the blunt end and look for what goes right (What happens every day when no incident occurs).
- Understand that work-as-done requires constant adjustment to achieve success.
- Study what combination of adjustments lead to unsafe conditions and determine how we can compensate for unacceptable conditions.