Balancing Safety I and Safety II: Learning to manage performance variability at sea using simulator-based training

[This is an update & repost of an older summary but now in article format]

An interesting study exploring how simulator training of maritime deck officers can improve the management of Performance Variability (PV) & safety in critical operations at sea. Learning & PV was framed through the lens of Safety-I (SI) / Safety-II (S-II) & Resilience Engineering (RE).

Too much to unpack so I’ll cover just a few points.?

It’s noted maritime features a high degree of PV with frequent & irregular operational changes & other challenges, eg weather. Officers must be prepared to handle known and unknown conditions – with PV & performance adjustments characterised, in part, by the S-II / RE lens. Simulator training allows a safe way to respond to PV & reflect with others on decisions & techniques, thereby allowing double-loop learning.

Importantly, it’s emphasised that S-I & S-II are not mutually exclusive but complimentary ways to manage PV; with maritime characterising components of both. E.g. a shuttle tanker’s approach is regulated by rules, but the operator must adapt to keep things going right in a balance of compliance & resilience (p4).

They provide nice balance to the topic of S-II, noting that a S-I perspective fills an essential role of identifying or imagining what can go wrong and implementing measures to counteract unwanted performance.

S-II, in this perspective, explores how work succeeds under normal and/or varying conditions [* although there are inconsistencies with what it entails.] The authors argue that "Few advocates of safety II would disagree that it is important to keep trying to identify predictable ways a system can fail" (p4), but rather focusing on failures isn't enough to deal with complex and variable work.

Taken together therefore, “Safety II plays out within a context of Safety?I” (p4).

A brief overview of definitions are below:

Results

A lot was covered in this paper. Overall, the authors said that their data suggests that simulator training offers a realistic setting for experiential learning and joint reflection, where officers can improve performance variability (PV) through:?

1. preventing adverse events by noticing anomalies & problem solving,?
2. defining limits of action via shared knowledge,?
3. operating a system with confidence.

The focus on simulating unforeseen events during regular activities was seen as an advantage to focusing exclusively on extreme emergency events, given that responding to variable conditions is the more common skillset needed.?

Simulator instructors emphasised the use of ‘hot debriefs’ and time-outs, where they sometimes stopped the simulation to guide operators and unpack certain critical decisions, procedures etc. This period of joint reflection between operators and instructors was said to improve the process of double-loop learning.

Despite rules & checklists guiding offloading activities, there was, expectedly, a multitude of ways operators used to achieve requirements. Thus, simulations allowed people to jointly learn about performance and different ways to achieve outcomes and recover from deviations.

Discussing S-I / S-II in this context, it’s said it’s not a matter of choosing between either, as both highlight different capabilities needed to maintain safety.?Indeed, "This was underlined early by Hollnagel [7, p.178] who emphasised that Safety II is ‘intended as a complement to Safety I rather than a replacement of it" (p8).

Instead, the contrast between the perspectives are "pedagogical", highlighting different capabilities needed to maintain safety.

Further, it’s said that in empirical work the “boundaries between the two concepts become far more blurred” (p8) – also seen in this study. E.g. the simulator training is based on scenarios constructed from previous accidents (S-I), but are used to develop skills related to S-II.

That is, previous failure “works as a repository for highlighting and improving the skills and confidence needed to deal with situational complexity” (p8).

The authors highlight that a balance with S-I / S-II perspectives are needed.

For instance if operational complexity is low then more focus on a S-I approach may be sufficient, whereas high Op. complexity involving marked adaptations to unknowns should focus more on RE/S-II skills. Both, however, involve a mixture of technical and non-technical skills.

They highlight how they balanced the S-I/S-II perspectives in developing simulator training:

For improving simulator training, it’s said:

• Training should be realistic by combining unexpected events and normal op (rather than just emergencies)
• Focus on experiential learning & joint reflection
• Persistent use of debriefings and post simulator debriefings

Link in comments.

Authors: Wahl, A., Kongsvik, T., & Antonsen, S. (2020).?Reliability Engineering & System Safety,?195, 106698.