Commentary from William F. Maloney on "Complexity and safety" by Rosa Antonia Carrillo.

During the past 50 years, safety improvement efforts have progressed through three identifiable approaches. The first, based upon the hierarchy of control, focused on eliminating hazards or designing procedures to mitigate risk, educating workers in those procedures, and enforcing their utilization. Interest then moved to systems thinking whereby the various systems within an organization (selection, training, reward, work, etc.) were developed and coordinated to achieve desired objectives. Both approaches reflect an engineering culture (Schein, 1996) and an assumption that the perfect procedure or system can be designed. History provides many examples to refute this assumption. In the past 20 years, interest has turned to organizational approaches, including safety climate, safety culture, and the reciprocal influence process between the individual and the organization. Carrillo's paper (doi: 10.1016/j.jsr.2011.06.003), by synthesizing complexity theory and sensemaking, has created a framework for improving safety performance that reflects reality and the role of operatives. Given the dynamic nature of organizations and workforces today, the complexity of developing shared understandings of objectives and the means to achieve them cannot be underestimated. Simply agreeing on the meaning of safety can be difficult. An understanding of complexity, sensemaking, practical drift, and polarity is crucial to safety improvement. By using conversation and dialogue to develop a shared understanding with the workforce of the situation, the need to improve safety, and the predictability of safety, it should be possible to develop trust between management and operatives that will allow the workforce to develop the processes and procedures to achieve safe performance, thus eliminating the resistance to top-down imposition. To ignore Practical Drift is to be ignorant of the nature of operatives. Regardless of the procedure, operatives are going to adapt it to meet their needs. Operatives must understand the reason for the procedure. The initial procedure establishes a base method to achieve the goal. The procedure will then evolve as operatives use it and modify it to fit their needs. Management must understand that and utilize the dialogue with operatives to continue to emphasize goal achievement rather than rote reliance on the means. Polarity management requires management to understand the mechanisms by which values are embedded in an organization (Schein, 2010). Critically important is what managers pay attention to. Management in any organization tends to focus on the one issue that is paramount at the moment (e.g., production, safety, cost, quality, absenteeism). Operatives become accustomed to continually changing emphases: “What is it this week?” Management cannot use a dichotomous framework of production versus safety. People respond to what they see their managers focusing on. All members of an organization need to understand the multidimensional nature of performance and the importance of each dimension. Absent concerted effort to use dialogue to make sense and create shared understandings, safety performance will continue to suffer. What is needed, to use Carrillo's ladder analogy, is to move organizational members from a view of the safety system from No Sense to Nonsense to Common Sense. Language: en