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

The safety focus should be accidents
Safety is the state in which the possibility of harm to persons or property damage isreduced to, and maintained at or below, an acceptable level through a continuing processof hazard identification and risk management.

Safety is the state of being "safe", the conditionof being protected from harm or other nondesirable outcomes.
© Erik Hollnagel, 2020

A need to be safe and to feel safe ...
At first, whatever happened was attributed to higher powers (gods, nature)“Act of god?”

Liber de ludo aleae(Cardano, ca. 1564)© Erik Hollnagel, 2020

A need to be safe and to feel safe ...
Gradually adverse outcomes were seen as having causes – usually astechnological failures.

Technicalfailure!

Vasa (1628)

Meudon (F), May 8,1849 (55 dead)© Erik Hollnagel, 2020

A need to be safe and to feel safe ...
In the 1970s – especially after the TMI accident – accidents became linked to“human error” and human factors issues.

Human error!

© Erik Hollnagel, 2020

A need to be safe and to feel safe ...
In the late 1980s – following Chernobyl and Challenger – the search forcauses turned to organisations and culture.

Organisationalculture?

© Erik Hollnagel, 2020

What You Look For Is What You Find
Looking backWhat hasgone wrong
before, may gowrong again!

Look at all the things thatwent wrong in the past.
Deviations and violations
Non-compliance to guidelines
Errors and miscalculationsNoisy or confusing measurements
Inadequate ergonomic design
Organizational underspecification

When we look back, we tend to notice accidents and incidents – events that conflictwith our intentions and expectations.
These events “prove” that our understanding was incomplete or incorrect. We
therefore have to improve our understanding.
© Erik Hollnagel, 2020

Preference for monolithic explanations
Humans prefer monolithic explanations that rely ona single concept or factor.
As social constructs, monolithic explanations areefficient (easily found and accepted) but lack inthoroughness and precision.
Monolithic explanations reinforce a linear, causal
understanding of the world.
Monolithic causes:
Technical failures
Human error(Lack of) safety culture
Deviations from norms
Brittleness…
Captain HindsightMonolithic solutions:
Design, construction, maintenanceTrain, automate, redesign, simplify
Improved safety culture
Compliance
Resilience...
The Silver Bullet© Erik Hollnagel, 2020

Problems and solutions must match
Simpleproblems

Complexproblems

may possibly (?) have

Simplesolutionsalways require

Complexsolutions

Disguising complex problems as simple problems by offering apparently“simple” solutions does not make the problems any simpler.
It only makes it more likely that the solution will not work.
© Erik Hollnagel, 2020

Safety-I – when nothing goes wrong
Safety is a condition where the number ofadverse outcomes (accidents / incidents /near misses) is as low as possible.

TheThepremise
premisefor
forSafety-I
Safety-Iisisthetheneedtounderstandwhyaccidents
need to understand why accidents
happen.
happen.

Safety-I
Safety-Iisisdefined
definedby
byits
itsopposite
opposite– –bybythethelacklackofofsafety
safety(accidents,(accidents,incidents,risks).
incidents, risks).

How
Howcancanwe
weimprove
improvesafety
safetyby
bystudying
studyingsituations
situationswhere
wherethere
thereisis
aalacklackofofsafety?
safety?

© Erik Hollnagel, 2020

AVOID

DAV
OI

AV
OI

AVOID

D

AVOID

OI
AV

Find and eliminate causes ofaccidents and incidents

AVOID

D

Negative outcomes are caused by
failures and malfunctions.

OI
AV

Safety is the condition of being
without harm or other nondesirable outcomes.

D

Safety-I: Avoid unwanted outcomesIf you want to avoid or get away fromsomething, then any direction you takewill work!
© Erik Hollnagel, 2020

Positive

Safety is managed by snapshots

NegativeTime

Harmful events attract
attention. But they arerare and isolated.

Limiunac t ofperf ceptableorman ce

Events are analysed step-by-step.
Prevention/responses are developedfor each problem found.
© Erik Hollnagel, 2020

How can we learn about safety?
*Is it possible to understand what a
happy marriage is by analysing andlearning from divorces alone?

*Analogy suggested by Marit de Vos

Is it possible to understand whatsafety is by analysing and learningfrom accidents and incidents alone?

© Erik Hollnagel, 2020

The focus should NOT be accidents!
Safety is defined and measured more by its absence than by its presence.

Reason, J. (2000). Safety paradoxes and safety culture. Injury Control & Safety Promotion, 7(1), 3-14.

Reliability is a dynamic non-event … it is an ongoing condition in which problems
are momentarily under control due to compensating changes …
Weick, K. E. 1987. Organizational culture as a source of high reliability. California Management Review 29(2), 112-128.

Non-events are “invisible” because they happen all the time. People get used tosomething that happens all the time and therefore stop paying attention to it.
© Erik Hollnagel, 2020

Explaining what happens and how
When “nothing”
happens
A need to understand
why the unexpectedhappened.

No need to understand
why the expectedhappened.

Expected,
invisible

When something
happensd,
etcpexe
Un isiblev© Erik Hollnagel, 2020

Habituation
When you get so used to something that you no longer notice it.
“ … a form of learning in which an organism decreases
or ceases its responses to a stimulus after repeated orprolonged presentations.”

The chair you sit in now.
The clothes that you wear.
Background noises (ventilation,traffic, office sounds, waves, etc.)
Things on the route that you drive
every day.
Things that happen regularly.
Work that goes well – as expected.
© Erik Hollnagel, 2020

Life is full of expected events
Every day, frommorning to night,

practically everything
we doworks just as itshould …

… and we take it forgranted© Erik Hollnagel, 2020

Why does work usually go well?
Availability of resources (time,manpower, materials,information, etc.) may belimited and uncertain.

People adjust what they doto match the situation.
Performance adjustments are inevitable, ubiquitous, and necessary.
Because of resource limitations, performanceadjustments will always be approximate.
Performance adjustments
are the reason why things
usually go well.

Same process Different outcomes

Performance adjustments
are the reason why things
sometimes go wrong.
© Erik Hollnagel, 2020

The four systemic potentials
To respond in a flexibleway

To learn what works
and what doesn’t

To monitor whatgoes onTo anticipate looking ahead© Erik Hollnagel, 2020

What You Look For Is What You Find
Looking backLooking ahead

Look at all the things thatwent well in the past.

How can make sure they
go well in the future?

When we look back we should look at
everything that happens, andespecially look at what went well.
The future is NOT a “mirror” image of the past.
The future has never happened before. It involves a combination of known performancevariability that usually is seen as irrelevant for safety.
© Erik Hollnagel, 2020

Can we explain why things go well?

Positive

Outcomevalue

We have few ways of explaining how and why things go well!
To manage safety we must know what happens when “nothing” happens.

TimeNegativeLimi
unac t ofperf ceptableorman ce

We have many ways ofexplaining how and why things go wrong.
© Erik Hollnagel, 2020

Safety II – when things go well
Safety is a condition where the number of successful
outcomes (meaning everyday work) is as high as possible.
It is the ability to succeed under varying conditions.
Safety concerns should be directed at everyday
events, at that which happens when “nothing” happens,when work just goes as it should.

© Erik Hollnagel, 2020

Managing Safety-I
Safety-I is a condition where the number of adverse outcomes (accidents / incidents/ near misses) is as low as possible.
The belief in causality(Causality Credo)(1) Adverse outcomes happen because
something has gone wrong (causeeffect thinking + value congruence
between cause and effect).
(2) Causes can be found and treated(rational deduction).
(3) All accidents are therefore
preventable (zero harm principle).

We are safe if
there is as little
as possible of
thisPrevent, eliminate, constrain.
Safety, quality, etc. are different
and require different measuresand methods.
© Erik Hollnagel, 2020

Managing Safety-II
Safety-II is a condition where as much as possible goes well.

We are safe if
there is as
much aspossible of thisSupport, augment, facilitate.
Safety, quality, etc. areinseparable and need matchingmeasures and methods.

1. Care about what happens all the time rather
than what happens rarely. We always count the
number of times something fails, but rarely the
number of times it just works.
2. Look for ‘work-as-done’ - the habitualadjustments and why they are made. Whensomething is done, as a part of work, it has
usually been done before and gone well before.
3. Learning should be based on the frequency ofevents rather than their severity. Small
improvements of everyday performance may be
more important than large improvements ofrare performance.

© 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