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

2. 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

3. Introduction

4. "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

5. How did we get here?

7. Signs of strategic weakness?

8. 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?

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

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

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

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

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

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

15. Safety I vs Resilience

16. 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

17. 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

18. 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)

19. 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.

20. The Four Cornerstones of Resilience

21. 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.

22. BOTTOM LINE

23. 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.

24. “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

25. Are you ready to think about
“safety differently”?