Better Learning From Accidents & Near Misses – Part 02

Hello, I am Ian Pemberton managing director of Human Focus.

I'm a chartered ergonomist or human factors specialist and I've got a free CPD live online webinar, coming up on the 16th of February at 2 p.m. titled: How Better Learning from Accidents and Near Misses Can Transform Your Safety Culture.

Register Now

Now, ahead of this event I have put together a number of short videos to explain

what this event is going to cover and also to set in place, some of the foundational concepts that I'm going to explore, just to give you a flavour.?So, if you are attending, this will give you some insights as to what this event is.

This is a foundational element that I'll be using throughout these videos and actually the webinar itself and it's called the Cynefin Framework.?And Cynefin in is all about helping us to understand complicated, complex and the relationships between them.?And Cynefin works like this.

It's actually got five quadrants to it. It's a framework which helps us to figure out what we're dealing with. And these are the four main quadrants the fifth being those grey areas in the, in the middle, which is basically, you're not certain which of those for your in.

So there's basically five sectors top-left complex. Top right, complicated, clear and chaotic. So in the clear sector, basically, from the left to the right, it gets very unpredictable, very complex on the left.?As we move over to the right it becomes more predictable.

So, starting in the bottom, right. The clear zone is where you have known knowns. You know what's going on. You might have a production line. They're highly regimented and, you know, you can figure that out.

Then we move into the known unknowns. You perhaps need an expert to look at it, But it's still possible to predict what is going on.

And then we go over into the complex zone. This is where we get what's called socio-technical systems, where lots of people are interacting doing different things and it becomes a lot of unknown unknowns. You know, healthcare environments, construction sites, people out and about in the real world doing things. This is all very complex.

And then finally, the chaotic zone is when something goes wrong. This is when an accident happens. So there again, it's it's unknown unknowns, but it becomes unstable. And complex the unknown unknowns are stable. Your people are dealing with it.

So that is Cynefin, and I'm going to be referring back to the Cynefin framework. When I first came across this, it was a massive, aha moment. It really was, because it gave a whole new way of looking at how we manage health and safety are how we investigate accidents and how we learn from them.

So let me begin that process now. So let's just make this real for you. First of all, you have best practices which are entirely appropriate down in that clear sector.

It's like, this is how you start this machine. There's only one way to do it. You define those steps and there's no argument. There's no discussion about that. You have to follow that because it's a clearly defined process.

Complicated starts to get much more difficult to have clear steps, but you can have good practice that lays out how to do it.

Once we go over to complex, it's much more about emergent practices. These will change and vary according to context, conditions and you have to be adaptable, you have to go with it.

And then, as we're going to see in chaotic, it's really about highly novel practices on the day. When something goes wrong, you have to be able to respond to that.

And these four quadrants, from a management perspective require very different approaches.?So, Let's just say, make this real. Let's look at one accident to see how this happens in practice.

So, the chaotic zone, by the way, those lines are supposed to be a cliff edge. So when you get to those what are called liminal lines, when you get to that liminal line, it's?literally a very sudden transition from clear, complicated, complex, and you literally fall off the edge.

So once you get to that boundary, there's it's literally black and white and that's when accidents happen.

So let's think about?he Miracle on the Hudson as an example. Sullenberger, who landed the American Airlines flight on the Hudson, double bird strike into his engines, just after take-off. Let's place various things that happened there on this Cynefin framework.

So first of all, best practice, well, the engines stalled. They had to figure out how to restart them. So, the first thing they did is pull out checklists. How do we restart the engines? That is clear, there is best practice. There are certain steps that you have to go through to get that to work.

Then we have, how do we configure the plane for water landing? This is a pretty rare event. And there's lots of things to consider lots of complicated systems to all align and configure. Mmm, not so clear. But we can have, we can have, you know, good practice.

Then in complex, Sullenberger was, where do I land? Highly dynamic, highly complex. He had his own crew to think about his own airplane. He had other aeroplanes. He had Air Traffic Control. He had to think about various airports where he could land even have to think about the local, the local urban makeup.?Did he did, he was he going to crash-land into a into a densely packed area or into waste ground?

And these were decisions, he was having to make, and seconds count.

They had never trained for that. There was nothing in the guidance manual to show them what to do. And literally in seconds, minutes, they were able to deal with that. And as you probably know, successfully land on the, on the river Hudson.

But the Cynefin framework doesn't end there. It's, ‘okay we've landed, how can we now safely recover from this chaotic situation’?

And as you may recall, the Hudson ferries all came in the New York Police Department. The divers, the helicopters, they all immediately converged on to the site and basically pull these people off.??It was a highly novel, highly chaotic, but very novel set of practices that were brilliant.?Saved everybody's lives. Highly successful outcome.

So there you go. There's Cyenefin framework. There's one accident, you can see how you've got lots of elements in one accident on this framework. And the message here is, you are going to need different ways of analysing these different elements, in an accident investigation.?Very different techniques, very different approaches. This is one of the first things we are going to be looking at in this forthcoming event.

If you're already registered, your already got an insight. We can hit the ground running. If you haven't yet registered, there's the date 16th of February, wherever you're watching this. You'll see there is a link below.

Hope you found that helpful. Look out for the next video. Thank you very much for watching.

Register Now