Demystifying and rationalizing the ‘new view’ safety theories

In the late 1980s, HRO theory emerged with the belief that organizations operating complex and high-risk systems (e.g. nuclear power and aviation) seem to be able to operate more reliably and safely than other organizations. This theory was in contrast to another of the time, Normal Accident Theory, which suggested that the complexity of systems and technologies we create makes it impossible to predict and prevent all possible accidents. HRO was the first theory to propose a set of organizational capacities that create safety: pre-occupation with failure, reluctance to simplify, sensitivity to failure, commitment to resilience and deference to expertise.

Around 2008, Erik Hollnagel proposed his Safety II theory, pointing out that we have traditionally focused on what goes wrong in safety – the accident or the non-compliance – and only investigated situations to identify what needs to be fixed. He suggested that if we want to learn about safety, we should be studying things that are safe, i.e. work that goes well, to understand why that is the case. Safety II is often incorrectly characterized as the opposite of Safety I due to the language, however the theory is very clear that Safety II is an expansion of Safety I and a way of looking at work in the same organization with a different perspective. Hollnagel, David Woods and Nancy Leveson also expounded on the existing research in the field of Resilience Engineering to discover that organizations need to build the following capacities for resilient performance:

·??????monitor normal work and what goes well

·??????learn about the gap between Work-As-Imaged and Work-As-Done

·??????anticipate performance variability

·??????respond to variability and local adaptations in a way that will ensure work goes well?

In 2012, Sidney Dekker proposed Safety Differently as an extension of the ideas within Safety II, but also to address some of the issues with the way safety culture was being used in industry. Safety Differently suggests three key changes organizations should make in relation to how they conceptualize and approach safety management. This theory called for people as the solution not a problem to control, safety as an ethical responsibility not a bureaucratic accountability, and the presence of positive capacities not the absence of negative events.

These and other influential new view safety theories are summarized, aligned and rationalized in the following table:

The inaccessibility of the scientific literature (which is not written with the practitioner in mind) that describes the theories in the table above led to the creation of the Forge Works Map?, which unpacks the last 100 years of organizational theory and safety science into the key milestones of the journey towards resilience. The key principles derived from this meta-research revealed that resilient organizations are those that:

·??????Develop leaders with a safety motivation who care for every person

·??????Understand their own organizational logics and how they drive local action

·??????Set workers up for success in all operational objectives

·??????Understand the variation and complexity of work performance

·??????Closely monitor operations and reflect deeply on insights garnered

·??????Anticipate future operational scenarios and update their models of work and risk

·??????Establish a priority for learning and support it with diverse practices

·??????Make continuous adjustments to goals, structures and resources.

Application of the Forge Works Map? within a variety of industries that do not typically fit within the description of High Reliability Organizations (e.g. mining, manufacturing, automotive, energy, transportation, construction and technology), revealed, despite the differing nature and complexity of these organizations, a clear trend of common challenges:

·??????The persistence of safety work with no measurable impact on the safety of work

·??????Focus on human error, the need to assign blame and punitive outcomes

·??????Covert goal conflicts and the unintended prioritization of production over safety goals

·??????Insufficient allocation of resources for risk reduction

·??????Under-specified critical risk management processes

·??????Underinvestment in developing frontline workers’ non-technical skills

·??????A lack of capacity and capability within the safety organization to support adaptive practice.

Due to a general lack of understanding or guidance, past efforts to resolve these challenges typically focused on minimizing variability through robust systems of work and enforcement of compliance to those systems, with the benefits of contemporary safety management practices going unrecognized.

Collectively, the contemporary ‘new view’ theory describes that:

·??????Error is normal, therefore organizations need to anticipate performance variability as a normal part of executing work in complex settings, by ensuring free flow of information and ideation of future operating scenarios

·??????Context drives behavior, therefore organizations need to monitor normal work and what goes well, by exploring everyday work

·??????Blame fixes nothing and learning is vital, therefore organizations need to learn about the gap between Work-As-Imaged and Work-As-Done, by facilitating learning from surprises and normal work

·??????Management response matters; therefore, organizations need to respond to variability and local adaptations in the performance of work in a way that will ensure work goes well, by supporting local practices, balancing frontline demand and reducing goal conflict through sacrifice judgements.

By viewing the new view theories collectively in this way, we reveal that organizations must learn to accept the truths/realities described by Human & Organizational Performance and establish the objectives described by Safety II, before they can start to grow the capacities described by Resilience Engineering to achieve the objectives.

However, in most organizations, the dominance of compliance-focused safety management approaches requires a concerted effort to deploy the insights from a holistic view of both traditional and contemporary theories to build the foundations for growing resilient capacities. Industry must first implement and embed a strong foundation using the traditional safety management approaches. Indeed, scientific management led to documentation of operating practices, safety culture focused attention on the importance of organizational learning from incidents, and advances in risk-based decision making in the major hazard sector created a demand for the control of dynamic critical risk in other high-risk industries. These are essential foundations on which to build complementary or evolutionary ‘new view’ approaches towards building capacities for resilience, e.g. critical steps, learning from normal work, and creating risk foresight (to anticipate future operating scenarios, respond to weak signals of the changing shape of risk, and revise our model of risk), respectively.