Safety Management:
Avoid or Approach

Erik Hollnagel, Ph.D.

Senior Professor, Jönköping Academy, Sweden
Visiting Professorial Fellow, AIHI, Macquarie University, Sydney
Email: sensei@safetysynthesis.com© Erik Hollnagel, 2020

Purposes of safety management
Safety-I

Purpose: To avoid something you don’t want.
Safety management is managing business activities andapplying principles, framework, processes to help prevent
accidents, injuries and to minimise other risk.

Safety-II

Purpose: To approach something you want
Safety management is managing business activities andapplying principles, framework, processes to help ensurethat work goes well under expected and unexpectedconditions alike.

© Erik Hollnagel, 2020

Safety Management Systems
A safety management system is asystematic approach to managing
safety, including organisational
structures, accountabilities, policies
and procedures.

© Erik Hollnagel, 2020

What is management?
Management is a process of planning, decision
making, organising, leading, and controlling theresources (human, financial, physical, andinformation) of an organisation to ensure that it
can reach its goals efficiently and safely

The purpose of management is either to maintain the current state, to approach a new
and desirable state, or to avoid or evade an unwanted state.
To maintain ...
To approach …
To avoid …

requires the ability to change in order to compensate for external(and internal) influences, degradation, and variability.
requires the ability to change, in order to move from the current to a
new position or state in an orderly manner.
requires the ability to change, in order to steer clear of a temporary
or permanent hazard or risk.
Management is the purposeful control of change.
© Erik Hollnagel, 2020

Management is like travelling
GOALS or TARGETS:

Where do we want to be?
When should we arrive?
POSITION:

Where are we now?
How well are we doing?

MEANS or PROCESS:

How can we change
position (“speed” and“direction”)?
© Erik Hollnagel, 2020

Management requires knowledge (1)Position:

Goal:

Means:

A need to know where you are: the current position / condition(s) /state.
Indicators (KPI)? Measurements? Dashboards? Benchmarks?
Predictions about how the current situation will develop in the shortterm.
A need to know where you want to be: the new or future position /condition / state.
Criteria for success – approach or avoidance? Stakeholders, consensus
or conflict? Costs and benefits?
A need to know how to get there where you want to be: how to move thesystem from the current position to the resulting position.
What are the effective means for change? How long will it take? Are
there any side-effects? Will outcomes be temporary or permanent?

© Erik Hollnagel, 2020

Managing something tangible

DRIVINGPRODUCTION

FLYING

Goal: Well defined
Position: Known
Means / Process:Well known, transparent

Goal: Well defined
Position: Known
Means / Process:Well known, transparent

Goal: well defined
Position: Known
Means / Process:Well known, transparent© Erik Hollnagel, 2020

Managing something intangible

MANAGING SAFETY

Goal: Defined bynegation(no accidents)

Position: Vaguelyknown or unknown

Means / Process:Partly unknown, basedon tradition rather
than knowledge.

© Erik Hollnagel, 2020

Safety: What is the position?

Most,
Most,ififnot
notall,all,safety
safetymeasures
measuresrefer
refer
totonegative
outcomes(accidents,etc.)
negative outcomes (accidents, etc.)© Erik Hollnagel, 2020

Safety: What is the goal?

Safety goals are rarely described
explicitly© Erik Hollnagel, 2020

Roadmap versus sea-chart

Position: Easy to establish
Direction: Clearly indicatedRoutes: Well marked
Conditions: Stable

Position: ?
Direction: ?
Routes: ?
Conditions: ?

Position: Can be uncertain
Direction: Must be worked out
Routes: Course must be set
Conditions: Unpredictable© Erik Hollnagel, 2020

How to change an organisation?
Managers should monitor andregulate how efficiently and effectively
an organization and its members are
performing the activities necessary toachieve organizational goals.

We know how tochange the direction
and speed of a vehicle.

But how can we change the“direction” and “speed” ofan organisation?

Establish standards ofperformance, goals & targets.
Measure actual performance(output, behaviour, culture).

Why is it necessary to change?

To approach ... To maintain ...

To avoid ...

Compare actual performanceagainst standards.
Evaluate results and takecorrective action if needed.

© Erik Hollnagel, 2020

Management requires knowledge (2)Position:How (well) do you know the current position?
Are there any delays?
What happens around the organisation?

Goal:

How have goals been defined and targets set?
Are there priorities or conflicting interests?
What is the time window / time horizon?

Means:

Are the means appropriate for the goals?
How much effort will be required and by whom?
Is there any “noise” that may drown the “signals”?

Three
Three assumptions:assumptions:
Everything
Everything will
will gogoaccordingaccording toto plans.
plans.
Conditions
Conditions will
will bebestablestable during
during thethechange.
change.
Nothing
Nothing else
else willwillhappen.
happen.

© Erik Hollnagel, 2020

Means: Understanding systems
Tractable system(technical)

Intractable system(socio-technical)

A

B

Entangled system(synergistic and selfregulating)© Erik Hollnagel, 2020

Understanding how something is done
Task networks

The connectors(arrows) represent
temporal (orlogical) order.
© Erik Hollnagel, 2020

From HTA to FRAM

© Erik Hollnagel, 2020

Tasks and activities
Tasks - describe work as designed oras imagined, e.g., by managers.

Activities – describe work as it isactually performed or done.

Tasks represent Work-as-Imagined(WAI)

Tasks represent Work-as-Done(WAD)The Functional Resonance Analysis Method can describe both tasks and activities
but is especially useful for the latter.
© Erik Hollnagel, 2019

Safety is about WAD, not about WAI
Design (tools, roles,environment)

Work & production planning(“lean” - optimisation)

Safety management,investigations & auditing

Work-As-ImaginedWork-As-ImaginedWork-As-ImaginedWork-As-Done

Work-As-Done

Work-As-Done© Erik Hollnagel, 2020

What is FRAM and what does it do?
THE DESIGN, management, and analysis of work tacitly assumes that we know how
things are done or should be done.
IN REALITY work is never completely regular or orderly. Work-as-done (WAD) will
always be different from work-as-imagined (WAI) because it is impossible to know inadvance what the actual conditions of work will be, not least what the demands andthe resources will be.
THE FRAM is a method to analyse how work activities take place either
retrospectively or prospectively. This is done by analysing work activities in order toproduce a model or representation of how work is done.
the equivalence of failures and successes,
THE FRAM is based the necessity of approximate adjustments,
the reality of emergence, andon four principles:
functional resonance as an alternative tocausality.
The FRAM focuses on describing what happens in terms of the functions involved.
© Erik Hollnagel, 2020

FRAM analysis (model building) steps
1

Define the scope of the model, i.e., the purpose and duration of the activity
that is being analysed. The defined duration of the activity being studied –when it begins and when it ends – helps to distinguish foreground functionsfrom background functions..

2

Make a list of the essential functions that are needed for the activity/event.
Possible sources are event report, procedures/instructions, designspecifications, story-telling, field observations & interviews, experience, etc.

3

Describe each function using the FMV. Describe the relevant aspects of eachfunction using breadth-before-depth. Define additional functions needed;
designate foreground and background functions.

4

Refine the model through discussions and iterations. When finished, calibrate
the model using subject matter experts.

© Erik Hollnagel, 2020

A linear description of work

Readinstructions

Secure tiltback frame

Clear areaaroundLower theplatform

Lower tiltback frame

Tilt platform*Move
platform

Return tostandingposition*Use the appropriate number ofpeople and proper lifting techniques.

Manual is 35 pages long
Diagrams are small and complicatedDifferent steps for DC, AC, and air (pneumatic)
Rental company drops lift early outside and leaves.
Rainy season© Erik Hollnagel, 2020

A non-linear description of work

© Erik Hollnagel, 2020

Safety-II: With wanted outcomes

Safety is the condition of being
with intended and wantedoutcomes.

All outcomes involve someperformance variability.

APPROACH

Study everyday performance inorder to support what goes well.
If you want to approach or get close tosomething, you need to move in theright direction!
© Erik Hollnagel, 2020

Different ways to manage safety
Safety-I
Goal:
Prevent accidents, injuries and minimise
other risk.
Means:
Understand why things go wrong, findcauses of failures.
Eliminate causes, reduce hazards,
remove variability by standardisationand norms

Safety-II
Goal:
Ensure that work goes well under bothexpected and unexpected conditions.
Means:
Understand why things go well, manage
and sustain the systemic potentials:© Erik Hollnagel, 2020

Different ways of looking
A Safety-I perspective:

A Safety-II perspective:

What went wrong?

What happened? Has it happened before?

What was the cause?

Why did it work the other times?

How can it be prevented?

How can we make sure it works next time?

What else can go wrong?

What else happens in the same way?
© Erik Hollnagel, 2020

Different ways of looking
A mature perspective:

What happens here? How often?
How did this pattern arise?
What are the pros and cons?

What else happens in the same way?

© Erik Hollnagel, 2020

Thank you for your attention

どうもありがとうございました© Erik Hollnagel, 2020