From counting errors to creating organisational resilience in managing safety Matita Tshabalala

Signs of strategic weakness Introduction Signs of strategic weakness Safety Currently - Safety Differently Presentation outline Safety I vs Resilience The Four Cornerstones of Resilience The bottom line

Introduction

"As far as the laws of mathematics refer to reality, they are not certain; and as far as they are certain, they do not refer to reality.“ Albert Einstein

How did we get here?

Signs of strategic weakness?

Signs of strategic weakness? Demonstrated vulnerability to unanticipated events Do we need to do better, and more intensively, what we already do… ‘Try harder…’ Or is the current safety paradigm itself challenged?

Safety Currently People are a problem to control Tell them what to do Count success by the absence of negatives

Safety Currently - Effects Growing safety bureaucracy No measurable improvements Measuring and managing wrong risk Numbers game Disengagement

Safety Management Sticks Carrots Compliance demands, surveillance, sanctions Carrots Rewards for showing low numbers

Safety Management “There’s a mismatch between what science knows and what business does.” Dan Pink

Safety Differently People are the solution Ask them what they need Count positive capacities

Safety Leadership Autonomy Mastery Purpose Task, timing, technique, team Mastery Ever better at something that matters Purpose Part of something larger than self

Safety I vs Resilience

Safety I vs Resilience Traditional safety management (Safety I) Resilience Engineering Definition of safety Freedom from unacceptable risk Ability to succeed under varying conditions Understanding of safety Systems are tractable and performance conditions can be completely specified Systems are intractable, and performance conditions are always underspecified Explanations of accidents/incidents Accidents/incidents are caused by failures and malfunctions Things basically happen in the same way, regardless of the outcome View of the human factor Liability Resource Safety management principle Reactive, respond when something happens Proactive, try to anticipate developments and events Aim for safety management Learn from mistakes and calculate the probability of future failure Improve the capability to cope with the complexity of the present and the future

What is Resilience? “Resilience is the intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations even after a major mishap or in the presence of continuous stress”. Hollnagel, 2008

Organisations good at resilient performance do the following: 1. They do not take past results as guarantee for future success 2. They keep the discussion about risk alive even when nothing wrong has happened 3. They bring in different and fresh perspectives around safety (listen to minority view points) 4. They have the function or the resource to put the foot down (around safety)

From the Negative to the Positive Negative outcomes are caused by failures and malfunctions. All outcomes (positive and negative) are due to performance variability.. Safety = Reduced number of adverse events. Safety = Ability to respond when something fails. Safety = Ability to succeed under varying conditions. Eliminate failures and malfunctions as far as possible. Improve ability to respond to adverse events. Improve resilience.

The Four Cornerstones of Resilience

The Four Cornerstones of Resilience Responding: Knowing what to do, being capable of doing it. Anticipating: Finding out and knowing what to expect Actual Factual Critical Potential Learning: Knowing what has happened Monitoring: Knowing what to look for (attention) An increased availability and reliability of functioning on all levels will not only improve safety but also enhance control, hence the ability to predict, plan, and produce.

BOTTOM LINE

Bottom Line It is possible to summarise the arguments of this presentation by the following simple statements: (1) When something goes wrong, then there is no safety (safety is missing or not there). (2) When nothing goes wrong, when things just work as they should, then there is safety. Therefore: (3) The scientific study of safety should focus on situations where nothing goes wrong, i.e., where there is safety, rather than on situations where something goes wrong – where there is no safety.

“Every body perseveres in its state of being at rest or of moving uniformly straight forward, except insofar as it is compelled to change its state by forces impressed”. Isaac Newton

Are you ready to think about “safety differently”?