- 1 What is the difference between safety 1 and safety 2 white paper?
- 2 What is the safety 2 approach?
- 3 What is the difference between safety and security on board?
- 4 What is the new view of safety?
- 5 What is the difference between work as imagined and work as done safety?
- 6 What is safety 3?
What is the difference between safety 1 and safety 2 in aviation?
What is Safety-II? – Let’s first see what it’s all about. Summing up quickly, Safety-I is the traditional way of safety management, taking accidents/incidents as the point of departure and trying to prevent bad things from happening. Safety-II is taking another point of view, focusing on things that go right and ensuring that as much possible goes right.
- To quote Andy Evans: “Safety-I is minimising the bad and Safety-II is maximising the good”.
- Important is that Safety-II sees variation in human performance as an essential factor for success because reaction to variability is necessary, while Safety-I rather tends to restrict variability and focuses on error, or what is perceived as error.
Ideas like this are not necessarily new, and indeed we find a synthesis of ideas and practices of things that have been around for a while. The reader may recall things discussed in the Resilience Movement (of which Hollnagel is an important thinker, of course), Dekker and Perrow are other names that pop up.
What is the difference between safety 1 and safety 2 white paper?
From Safety-I to Safety-II: A White Paper. | PSNet Citation Text: Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015. To enhance patient safety, researchers must consider complexity in health care settings. This white paper describes the difference between to improving safety, the first focuses on identifying causes and contributing factors to adverse events without considering human performance while the second considers variations in everyday performance to understand how things usually go right.
The authors suggest that a combination of the approaches is necessary to achieve to enhance safety. Citation Text: Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015. Patient Safety Innovations Patient Safety Innovations : From Safety-I to Safety-II: A White Paper.
What is the safety 2 approach?
How is Safety-II connected with agility in organizations? – Committed employees make your organization stronger. Not only because they are more agile, but also because they are more likely to report incidents when things do go wrong. Download our eBook ‘Staff Commitment’ about increasing the motivation of healthcare professionals.
Safety-II recognize that in modern systems, causes of errors or incidents are often multifactoral and adjustments can lead to both desired and unintended/undesired outcomes. As a result, agility and resilience are desired qualities, both for organizations and their employees. Flexibility and resilience equate to a state of readiness to adapt to any situation instead of rigidly adhering to work processes and protocols (i.e., work as imagined).
The FRAM method provides insight into how professionals work together all day, under complex circumstances, and the ways in which they must adapt again and again. Analyzing how people and systems respond to unexpected and ever-changing circumstances helps us to create more adaptable organizations and aid individuals in becoming more resilient.
What are the principles of safety 2?
The past decades have seen a shift in safety thinking, which has been inspired by reflections on incidents, accidents, and safety efforts in various industries. The present summary seeks to briefly outline the underlying thoughts and assumptions of the traditional view of safety, commonly referred to as Safety-I, and aspirations to think about and do safety differently (Safety-II).
- Download PDF version from That Which Goes Right Safety-I Safety has traditionally been defined as the absence of unwanted outcomes, such as incidents, accidents, or injuries.
- Today, freedom from unacceptable risk is often equated with high levels of safety.
- Operation is deemed safe when the number of things that go wrong is acceptably low.
Safety is defined as the absence of negatives and seen as a condition where the number of adverse outcomes (near misses, incidents, accidents) is as low as possible. This definition is largely in accordance with the original meaning of ‘safety’: to be uninjured, unharmed, and not exposed to danger.
In Safety-I, efforts to improve safety mainly focus on what goes wrong or could go wrong. Safety is measured indirectly by the absence of negatives: safety is high when the number of negative events is low and vice versa. Focusing on negatives is assumed to allow blocking the transition of an organisation from a normal (functioning) to an abnormal (non-functioning) state, using barriers, automation, redundancy etc.
Safety efforts thus largely pursue a mission zero: to reduce the number of incidents, accidents, and all sorts of frequency rates to zero (e.g. LTIFR, TRIFR). Lower numbers are equated with progress on safety. Assumptions of Safety-I are partly mirrored in efforts to improve work processes, efficiency, and productivity.
- An early example is Scientific Management Theory by Frederick Taylor.
- In 1911, Taylor suggested a set of steps to increase the performance of an organisation: 1) Work analysis: Analyse the best way of doing work.
- Workers’ tasks are broken down into elementary steps and movements.
- The most effective performance is determined.2) Select people to perform the tasks: A best match is sought between workers’ capabilities and the requirements to successfully complete a task.
Workers should neither be under- nor overqualified.3) Training: Workers are instructed to exactly apply and follow the specified process deemed best in the analysis. People are trained to ensure specific performance and remain within the set boundaries of their tasks and activities.4) Compliance: Line supervisors constantly monitor workers’ performance and compliance.
- Incentives and awards are used to increase productivity.
- Scientific Management Theory has influenced and shaped the role of organisations and humans.
- An organisation or system (e.g.
- The collaboration of various organisations to achieve a certain goal, such as air transport) is basically safe because it can be thoroughly designed and described.
Technologies and processes are well established and controlled. Procedures are correct, complete and applicable to any work situation. System developers are capable of anticipating and designing for all contingencies. For work to succeed, people only have to follow the specified rules and procedures.
They are not supposed to improvise. Variability of human performance is harmful and has to be prevented as good as possible. Yet workers not always meticulously execute work as planned or imagined by management but sometimes divert from the specified processes (work as done). This makes people a liability, a problem to control, or even a threat to safety.
To avoid negative events, humans thus have to be controlled. The replacement of humans with automation is regarded a valuable approach to reducing and eliminating human error. In Safety-I, the principle of safety management is reactive: Changes are necessary when a negative event has occurred or when something is deemed an unacceptable risk.
Accidents are caused by malfunction and failure. All causes have an effect, and all effects have a cause. Things go wrong due to differences between work as imagined by management and work as done by the workforce. The relationship between cause (e.g. an operator’s inadequate decisions) and effect (e.g.
an accident) are deemed linear and unproblematic. Investigations have to reveal the causes and contributing factors, reasoning backwards from the negative event. This often means to identify the components, both technical and human, that have failed. The sequence of events leading up to the accident is traced back in time until a (plausible) root cause is found (or constructed).
Reflections on Safety-I The world has continuously changed since the industrial revolution. During the Age of Technology from around 1760 to the late 1970s numerous technologies were invented, such as the steam engine and railway lines. It was of course important to ensure that the new technologies worked reliably and without causing harm to humans and the environment.
In case of a malfunction, the faulty machine was taken apart until the broken parts were found and replaced, since the functioning of the machine results from the functioning of all of its parts. Large accidents in the 70s and 80s (i.e. Three Mile Island, Chernobyl) have pointed out that the Human Factor had initially been left out of the equation.
In the Age of Human Factors it thus made sense to apply the same methods and methodologies to deal with the human element as those that had been successfully applied to technologies (e.g. root cause analysis, reductionism). Like technologies, humans are either successful or unsuccessful ( bimodality principle ).
Somebody must have failed when something went wrong. The larger the accident and the higher the number of injuries and fatalities, the more severe someone’s mistakes must have been. Large and serious outcomes have equally large and serious causes ( belief in the proportionality between cause and effect ).
The more serious an event, the more can be learnt. To prevent accidents from occurring and reoccurring, the faulty human operators—equal to the broken technical components—have to be identified, retrained, or replaced ( Bad Apple Theory ). The period from the late 70s onward is characterised by production that increasingly had to be faster, better, and cheaper.
Yet accidents, such as the explosion of the Challenger Space Shuttle in the late 80s, tragically pointed out the potential consequences of such an aggressive strategy and the need to account for organisational factors. During the Age of Safety Management, the development and use of Safety Management Systems has become a central and typical HSE effort in many organisations and industries.
- As such, the focus of safety efforts has been expanded from technologies to human, organisational, and systems factors.
- Yet the underlying assumptions about the functioning of technologies, humans, organisations, and systems seem to have hardly changed.
- In order to improve safety and the performance of humans and organisations, the “broken” human and organisational components need to be identified and resolved.
Accident investigations largely apply complex linear models (e.g. Swiss Cheese Model) to identify the broken parts, equal to holes in the layers of defence. Human and organisational factors are dealt with in the same way as technologies, following the assumption that success and failure have different underlying mechanisms,
- Safety-I assumptions may apply to very simple work processes and systems that are well understood, tested, and relatively uncomplicated.
- Yet compared to the beginning of the 20th century when Taylor proposed Scientific Management Theory, today’s work environment has dramatically changed.
- Traffic volume has increased (e.g.
in the air and on the road). Computerisation and automation seem unstoppable. Engines have become stronger. Transport takes place at higher speed and greater distances. Production is still expected to become even faster, better, and cheaper. At the same time, the world is becoming increasingly complex, and so is operation in various socio-technical systems, such as aviation.
- Multiple diverse parts (e.g.
- People, operators, technologies, organisations) are interdependently connected and adapt to the surrounding conditions.
- New technologies, tools and equipment are constantly developed and introduced.
- Organisations face harsh competition and are largely dependent on the financial market (e.g.
oil price changes), which often requires company-internal adaptations, such as restructures and redundancies. The result is a complex interplay of different actors and components that potentially gives rise to outcomes that are difficult or impossible to foresee.
As a consequence of increased complexity, social-technical systems are becoming more difficult—if not impossible—to tract: by the time a system has been thoroughly described and modelled, it may already have changed and adapted. The system is interdependent of other systems and difficult to control. Elaborate descriptions are necessary with many details.
The principles of the system’s functioning are only partly known. Examples of intractable systems are aviation, emergency medical treatment, or military operation. Many of today’s intractable systems stand in sharp contrast to the work environment at the beginning of the 20th century.
- Back then, work processes were relatively simple and could be described with few details.
- The principles of the functioning of work were largely known.
- The system was mostly independent of other systems, rather easy to control, and did hardly change while being described.
- Rapidly developing technologies, such as new aircraft, are produced, delivered and used across the continents.
In the hangar, professionals are able to understand the functioning of complicated airliners in detail (despite with considerable effort). Yet released into operation all over the world, factors may come into play that are difficult to account for during the planning and design phase.
- Examples are differences in culture, training, use, or design assumptions (e.g.
- Meaning of the colour red).
- This is when complexity increases.
- There is no doubt that Safety-I thinking has helped many industries become highly safe (such as commercial aviation or nuclear power generation).
- Accident rates have gradually decreased in ultra-safe systems (with probabilities of an accident being 10-6).
Yet rates have also mostly become asymptotic, in the sense that they have reached a plateau: many systems are very safe, but they are hardly getting any safer. A small number of accidents continue to occur. This raises the question about the limits of traditional safety thinking as a means to further improve safety in complex systems.
- Whereas Safety-I assumptions may have well applied to work processes at the beginning of the last century, they might be limited or no longer unequivocally applicable to some of today’s increasingly complex systems and work environments.
- Safety-II Safety-II offers an alternative, complementary view of safety, questioning widely held assumptions.
As outlined above, Safety-I regards a system as safe when negative events are absent. Safety-II challenges this assumption as a valid and logical conclusion. Referring to safety as the absence of negatives implies to focus on the lack of safety, on unsafety.
- Consequently, Safety-II defines safety as the presence of positives, such as people’s capabilities, capacities, and competencies that make things go right.
- Hence, safety is present when as many things as possible go right.
- The need to define safety as the presence of positives is reflected in the regulator paradox: the safer the system, the less there is to measure.
At a perfect level of safety, there is nothing to measure at all (until the next accident occurs). At this stage, it becomes impossible to demonstrate that safety efforts have any positive result. Low counts of things that go wrong make expenses on safety difficult to justify.
- Reductions in safety efforts likely follow.
- Focusing on diminishing numbers is thus a highly questionable measurement of safety, and the absence of negatives an utterly poor predictor for safe operation in the future.
- For instance, managers had celebrated the seven-year-absence of a lost-time accident on Deepwater Horizon just days before the rig exploded on 20 April 2010, killing 11 people.
Today, various concepts and models are available to measure and determine what goes wrong (e.g. loss of situational awareness; slips, trips and falls; inadequate knowledge; poor decision making; distraction; fatigue). On the contrary, few methods exist to identify the presence of positives and why things usually go right.
Safety-II challenges the prevailing attitude towards humans and organisations. Systems and organisations are no longer deemed basically safe and undermined by unreliable workers. Instead, humans are seen as a valuable and necessary resource for the flexibility and resilience of an organisation to succeed.
Workers are a solution to harness because they know the messy details of how to get the work done. Only the people know how to deal with time pressure, inadequate tools, incomplete system design, and trade-offs, such as being thorough and efficient at the same time.
- Rules and procedures are no longer regarded as entirely complete and applicable to any work situation.
- For work to succeed, people have to constantly adapt and adjust their performance to the local circumstances.
- According to Scientific Management Theory, work processes have to be developed and specified by management, following assumptions about the working conditions at the sharp, operational end.
In contrast, Safety-II underlines the importance of involving workers into the planning and improvement of work processes. Management needs to identify where and why workers divert from specified procedures to get the job done. Differences between work as planed and work as done have to be identified and resolved.
In Safety-II, the principle of safety management is proactive: to continuously try to anticipate developments and events in an uncertain future. Yet safety efforts reach far beyond the assessment of visible risks and calculations of probability. Paths towards unlikely, unthinkable outcomes are explored and discussed.
Voices of minorities are heard, no matter how small or seemingly irrelevant people’s concerns appear at the time. Safety efforts are made and maintained even when adverse events are absent. Discussions about safety and risks are kept alive even when everything looks safe.
- Safety-II questions whether humans and technologies succeed and fail in the same way.
- For instance, the stopping of an elevator is performed by a technological mechanism that takes place in a stable environment (e.g.
- The floors do not move up or down; the weight of the elevator cannot exceed a certain limit).
Technologies are unable to adapt performance unless programmed to do so. In contrast, humans are capable of adjusting their actions to the situation encountered, where conditions and outcomes might be unknown or only partly known. A situation might differ from what was expected or previously experienced by the worker, the organisation, colleagues, or management.
In order to create safety, humans have to adapt performance to the local conditions and circumstances. Safety-II challenges the bimodality principle of human work and the assumption that human success and failure have different origins ( hypothesis of different causes ). It is questioned whether success (acceptable outcomes) is solely the result of compliance (in the sense that work as done matches work as planned), whereas failure (unacceptable outcomes) is caused by error, malfunction, and non-compliance (work as done diverts from work as planned).
Instead, success and failure, function and malfunction, are thought of as the result of everyday work. Both result from identical processes. The things that go right and wrong have the same mechanism and basically happen in the same way, regardless of the outcome.
The same performance that usually leads to success sometimes leads to failure. Procedures provide valuable guidance on how to successfully perform specific tasks. Yet rules and procedures might not always be complete and specify work in every possible situation. For instance, no procedure existed on how to land a DC-10 aircraft after a complete loss of all flight controls due to an engine failure of United Airlines Flight 232 on 19 July 1989.
Yet the crew managed to perform an emergency landing at Sioux City airport, saving 185 out of 296 people on board. The survivors of the Piper Alpha rig explosion in 1988 were largely those who risked a 35m-leap into the ocean—against the procedure of remaining on the platform in case of a fire.
In fact, many of today’s socio-technical systems have become so intractable that work situations are often underspecified in terms of procedures. Work can only be specified in detail for situations that can be entirely understood. Taylorist ideas may apply to simple work situations and processes. Yet a growing number of negative events are impossible to be explained by means of linear cause-effect relationships.
An example is the friendly fire shutdown of two U.S. Blackhawk helicopters on 14 April 1994 over Northern Iraq. The more complex and less tractable a socio-technical system becomes, the greater the uncertainty about the details of how to perform the work.
- Hence, the more is left to humans, and the less to technology and automation.
- In a world that is becoming increasingly complex, the Human Factor is the most valuable asset for system safety.
- Most of today’s systems and organisations do not succeed because they have been perfectly thought out and designed.
They are successful and reliable because their people are flexible and able to adjust, at all levels of the organisation. In contrast to technologies, people have the ability to adapt performance, adjust work to the existing conditions and local circumstances (e.g.
- Resources and requirements), improvise when necessary, and create safety in a challenging environment.
- People can detect and intervene when something is about to go wrong.
- They come up with new ideas and improvements.
- Workers can apply and interpret the procedures to match the conditions at work.
- They can identify and overcome problems.
People are able to recognise present demands and adjust their performance accordingly. They can make trade-offs between multiple, competing goals (e.g. economic efficiency, timeliness, and safety). Humans do the tasks that machines cannot do. They keep organisations and systems working in a complex, rapidly developing, and partly unpredictable world.
Download PDF version from That Which Goes Right This summary largely builds on the following publications: Amalberti, R. (2001). The paradoxes of almost totally safe transportation systems. Safety Science, 37 (3), 109-126. Dekker, S.W.A. (2011). Drift into Failure: From Hunting Broken Components to Understanding Complex Systems,
Farnham, UK: Ashgate. Dekker, S.W.A. (2014). Safety Differently: Human Factors for a New Era. Boca Raton, FL: CRC Press. Hollnagel, E. (2010). Safer Complex Industrial Environments: A Human Factors Approach, Boca Raton, FL: CRC Press. Hollnagel, E. (2014). Safety-I and Safety-II: The Past and Future of Safety Management,
What is Safety-II in aviation?
Safety management should therefore move from ensuring that ‘as few things as possible go wrong’ to ensuring that ‘as many things as possible go right’. This perspective is termed Safety-II and relates to the system’s ability to succeed under varying conditions.
What is P1 vs P2 aviation?
Terminology – “Monitored approach” is the most commonly used term for a specific allocation of pilot tasks during approach (task sharing). It involves a different distribution of workload to the traditional one in which a single individual is assigned all the aircraft handling tasks for instrument approach, visual landing and instrument go-around phases, as well as decision-making and overall management of the flight.
- The other individual is assigned the Pilot Monitoring tasks throughout.
- In a “monitored approach”, pilot duties are divided differently.
- One individual is responsible for overall management, decision-making, monitoring of all instrument flight during approach and go-around, and handling during the visual landing phase.
The other’s responsibilities are aircraft handling during instrument flight (approach and go-around), and monitoring during visual flight. Thus, the “co-pilot” controls the aircraft on approach exclusively ‘head down’ by reference to the flight instruments, whilst the “pilot” monitors and oversees the flight prior to either (a) assuming control for landing, or (b) continuing to monitor and manage in the event of a go-around being necessary.
- This basic duty allocation has also been known by other terminology including but not limited to “delegated”, “pilot monitored” “split”, “shared”, or “control handover” approach.
- A significant reason for these terminology variants is to accommodate concerns that limiting the application of the term “monitored approach” exclusively to this duty allocation implies that other duty allocations do not require the approach to be monitored, when there are clear obligations to do so.
Consequently there has been ambiguity in the flight operations community about what is meant when the term “monitored approach” is used ( George Mason University study for FAA, 2004, page 7: “Ambiguity of the term” ). For clarity, in the description and arguments sections here the term “Pilot-in-charge Monitored Approach” will be used for this purpose under the acronym “PicMA”, as it specifies that the pilot in charge of the flight is performing the Pilot Monitoring tasks during the approach.
This will encompass all known specific implementations of the procedure. In the “history” section the term “monitored approach” in quotes will be used as it represents the terminology used in most references. The abbreviation “P1” will be used for the “Pilot in charge”, who is normally the pilot who has made the takeoff and is anticipating making the landing.
“P2” means the other, second pilot or co-pilot.
What is the difference between safety and security on board?
Table Summarising the Difference between Safety and Security –
|Meaning||The word safety is used to refer to a condition where someone or a thing is protected from causes that are likely to cause harm to them.||The word security means protecting organisations/people against threats/danger.|
|Usage||It is used as a Noun.||It is used as a Noun.|
|Example||Miners have to take various precautions before they go into the mines for their own safety,||The Queen’s security is of the utmost importance.|
As you can see, the words ‘safety’ and ‘security’ are not the same. The following in-depth explanations of the words will help students understand these a bit more clearly. Let’s take a look.
What is the new view of safety?
6 – It is more useful to know how an accident happened than knowing why it happened. Doing safety differently shifts attention from “why” an incident occurred to “how” it happened. Learning is a fundamental tenet of the new view, and gaining insight and understanding to prevent incidents requires close study of how work actually gets done – in reality – not work as imagined or drawn up in a playbook.
How do workers successfully adapt to changing conditions? How do they get the job right 99.99% of the time? How are successful outcomes achieved? “Researchers or scientists typically avoid ‘why’ questions, and focus on ‘how’,” says Dr. Scott Geller, psychology professor at Virginia Tech. “How” uncovers the environmental factors, past or present, that enabled or motivated the occurrence of an event, behavior or attitude, says Geller.
“In my view, clinicians and spiritual leaders deal with answers to the ‘whys’ of life and death.” Many pros, while no longer so wedded to the old “5 Whys” line of root cause analysis, are pragmatic. “We need to know both ‘how’ and ‘why’ equally,” says Hansen.
Knowing one without knowing the other leaves pieces of the puzzle missing, he says. This is an example of how the new view or doing safety differently have no intent of tossing traditional safety practices in the dust bin. Advocates are quick to point out new philosophies and models complement tried-and-true staples – not supercede or eliminate them.
Continue to write rules and enforce procedures. Just don’t write tomes. Continue to audit, find and fix hazards, train employers and analyze incidents. But don’t put it all on the safety department. The new view holds that safety is a system of interactions involving leadership, culture, processes, training, supervision, design and more.
- Safety is not housed in one department.
- It’s integrated into almost all areas of the business – procurement, contractors, maintenance, operations, engineering, human resources, legal and senior leadership.
- Some pros see this as a threatening diffusion of their power.
- For others, integration, alignment and making safety invisible has been their thinking all along.
And they will tell you, in essence, that they have been doing safety differently for years. “An idea whose time has come” ISHN interviewed by email Dr. Sidney Dekker, professor, Safety Science Innovation Lab, Griffith University, Brisbane, Australia, and author of “The Safety Anarchist” among other books.
Dr. Dekker posts regularly at and is one of the founding fathers of the new view of safety. “Over the past two decades, we have not seen any progress in reducing fatalities across many industries. Yet during those same two decades the amount of safety bureaucracy (petty rules, a growing clutter of procedures and checklists and invasive surveillance of frontline work through technologies everywhere) has doubled or even tripled.
The problem is not going away. It is staying stubbornly the same. “All these new ideas are pointing to us interfering less with how work is actually accomplished, and instead asking operational frontline people what they need to get it done safely (rather than safety professionals telling them what to do through all kinds of compliance).
Safety professionals can actually feel a bit threatened by all this. It might have consequences for the relevance and importance of their role, after all. “There is a groundswell of adoptions of these kinds of approaches. You can see this in incident reports, for instance, where it is increasingly illegitimate to say that ‘human error’ was the cause: people are demanding more explanation than that.
How did the organization set the worker up for failure? Not many organizations have figured out yet how to learn from things going right, but we do see progress there.
“The greatest obstacles to progressing to Safety Differently include a fear of regulatory authorities that demand compliance (like OSHA), the opposition from safety professionals themselves who might see their influence diminished, and the fears of boards and managers of losing control over ‘accountability’ in their organization.””Nothing much foundational has changed”ISHN interviewed by email Corrie Pitzer, CEO of SAFEMap International.
“Safety has been at a dead end before, or so claimed Dan Petersen, way back in 1975, when he stated that the ‘human era’ is (was) upon us. Yet, for the past few decades, maybe even since the 1970s, nothing much foundational has changed in safety management.
- We still set up a manual of policies and rules of work, set performance standards and require compliance – all with the same focus: to control and or modify behavior, especially that of the front-line workers.
- The way we define and measure safety has NOT changed.
- That executives and management are still rewarded for safety, as measured by accident rates, and we still show trendy graphs on injury rates, even at board meetings! I have not yet seen a business, any business, that defines safety in any other way.
“Safety is killing business. We are the millstone around the operation’s neck because it goes against everything we want the business to be: To be more efficient, smarter, leaner, more profitable. We want an agile production system that allows risk-taking and experimentation, in order to innovate, to prosper, to change and improve.
We need people to be adaptable, operational systems to be flexible and performance goals to be stretched to the limit. “Henry Ford famously said: “If I asked people what they wanted, they would have said, a faster horse.” If he asked the safety directors what they wanted, the answer would have been: ‘A slower horse.’ “Sadly, we are not part of the success, reach or stretch of the business, we are part of its restraint, its containment, its failures.” “The OSHA stuff does not help small organizations” ISHN interviewed by email Dr.
Todd Conklin, author of “Better Questions,” among other books. He is a retired senior advisor at Los Alamos National Laboratory and one of the foremost authorities on human factors and human performance. “If you ask bad questions you get bad answers. So one way to be better (that is more effective and meaningful) is by pulsing, validating, asking, looking at the right stuff.
Our questions traditionally have been very focused on worker behavior – because we believed that worker behavior was the problem. Those questions always lead us to the same damn stuff. And that damn stuff does not make for long-term, sustainable improvement. “The push is to get industry off the outcome bias.
Safety is never (nor never will be) an outcome to be achieved. Safety is never over – you know that. Every day the clock starts again, so to speak. “Shift the question from ‘who failed’ to ‘what failed’? Don’t look down and in but look up and out. You will find new stuff to fix, and that is really refreshing.
What is the difference between work as imagined and work as done safety?
In human factors there is a set of terminology that is used to describe our work. The terms used are work-as-imagined, work-as-done, work-as-prescribed and work-as-disclosed. Work-as-done is the work that takes place every day. What we actually do. Work-as-imagined is the work people think we should be doing or imagine we are doing.
Work-as-prescribed is the work as set out in rules, policies, procedures, standards and guidelines. Work-as-disclosed is the way people work if they are prepared to share, if they feel safe to share with you what they actually do. To improve safety and apply safety-II what we need to do in healthcare is take a close look at the work as it and in all the different situations.
Not the work that people think should be done, not the work that people will tell you about, but the actual way in which people work. In any normal day – a work-as-done day – people:
Adapt and adjust to actually demand and change their performance accordingly Deal with unintended consequences and unexpected situations Interpret policies and procedures and apply them to match the conditions and patients Detect and correct when something is about to go wrong and intervene to prevent it from happening
However, conventionally we assume that people will work as they are supposed to. This is the gap between work-as-imagined and work-as-done. The term work-as-imagined can often refer to as the work of policymakers, standard writers, regulators and inspectors.
That they imagine what the work is like and set policy or design interventions for frontline staff to implement. However, there may be a considerable difference between what people are assumed or expected to do and what they actually do. If people who are responsible for developing guidelines or standards or policies and procedures are relying on what they imagine someone does rather than what the frontline workers actually do then the policy could turn out to be unworkable, incomplete or fundamentally wrong.
It can also be a gap between work-as-prescribed and work-as-done. There are some specialties such as radiotherapy, chemotherapy, medication administration when the gap between work-as-prescribed and work-as-done needs to be as narrow as it possibly could be.
- This is where it is vital that the prescribed practice matches reality and is constantly reviewed to ensure that it remains so.
- However, most work-as-done is carried out in areas of healthcare that are constantly adapting (ultra-adaptive) and consequently impossible to prescribe exactly.
- Work-as-done in these areas is a combination of experience, expertise, clinical judgement and know-how.
Not everything we do in ultra-adaptive environments can be written down in detail. In this case, the prescribed guidance is more likely to work if it is written in general terms rather than the fine detail. It is important to ensure that the guidance is constantly reviewed to ensure that it is up to date and workable.
In respect of safety solutions, if the safety experts don’t understand, consult and engage the frontline then they can develop the wrong solutions that won’t work. If they think they have come up with something that ‘will solve the problems at the frontline’ and those who are at the frontline are left with the feeling that ‘this doesn’t solve our problems’, it feels clumsy.
The incongruence makes it hard for frontline staff to implement things they are being told to do, resulting in frustration and workarounds. The unintended consequence of this is that it triggers a degree of fatigue in relation to initiatives that seem misaligned with the goals of their day-to-day work (work-as-done) creating a chasm between the leadership and frontline of organisations.
- When we fix the wrong thing for the wrong reason, the same problems continue to surface.
- It is costly and demoralising.
- Finally, work-as-disclosed is how people describe what they do, either in writing or when they talk to each other.
- However, this may not always be what is actually done.
- For many reasons, it may be the partial truth.
This may be because:
explaining every little detail would be too tedious we do things automatically and we may forget some of the details when we come to explain it depending upon who we trust, we may tailor it to the audience and when we come to explain what we do we simply we say what we want people to hear or what we think they want to hear
Work-as-disclosed is a particular issue for healthcare. In a culture of fear and when we are being scrutinised or investigated, we may ‘just tell people what should or did happen not what does or did happen’. People often do not report workarounds and conceal the actual practices they do in order to keep patients safe because they are not what the policy says they should do.
- In that respect those designing safety interventions may think that the interventions are working when they are not because no one is disclosing that they are not.
- In order to learn from staff about their work-as-done and work-as-disclosed there is a need for both a psychologically safe environment and a restorative just culture,
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What are the two dimensions of safety?
TWO DIMENSIONS OF SAFETY – A key point of the WHO’s definition of safety is that it has two dimensions: an objective dimension, which can be seen as behavioural and environmental factors measured against external criteria, and a subjective dimension, which can be variously defined as the individual’s internal feelings or perceptions of being safe (which can be aggregated to the macrolevel, to represent the community’s subjective safety perception).
Hence, for the researchers who contributed to the WHO report, safety is more than merely “non-injury”. In the injury prevention domain, safety is rarely, if ever, operationalised in a manner that is consistent with WHO’s broad definition of the concept. Indeed, most injury prevention interventions and programs are designed and implemented with the overall objective to reduce injury rates; injury incidence is seen as the primary focus of program interest and success is overwhelmingly defined as a reduction in injuries.4– 6 Thus, safety is typically defined and measured more by its absence than its presence.
The reduction of objective injury related measures, such as fewer falls or assaults, does not necessarily lead to a proportional increase in subjective safety, and vice versa.3 Studies have demonstrated a lack of correlation between subjective and objective safety—for example, between citizens’ perceptions of crime versus official crime statistics from police departments, 7 between public anxiety about the wellbeing of children versus the statistical likelihood of their being kidnapped by non-custodial adults, 8 or between risk perceptions versus involvement in accidents in the offshore oil industry.9 The approaches that community safety researchers and program personnel use to define and operationalise safety concepts can be illustrated by a figure depicting four quadrants (fig 1).
Quadrant 1 is the optimal state, where both subjective and objective aspects of safety are taken into account when designing and implementing injury prevention interventions. Traditional injury prevention programs are “located” in quadrant 2. Such programs focus on objective macrolevel parameters (that is, injury rates), with little or no regard of the subjective dimension.
Quadrant 3 denotes a situation in which objective surveillance and epidemiological injury data are ignored in favour of reliance on subjective safety assessments. Quadrant 4, meanwhile, is characterised by uninformed guesses regarding subjective and objective safety goals, which result in ad hoc safety initiatives.
Figure 1 Approaches to defining and operationalising safety concepts. To date, most community based injury prevention programs can be defined as operating primarily in quadrant 2: they are predominantly based on assessments of objective safety and demonstrate success through injury rate reductions. What is often lacking in these types of programs are data that demonstrate an increase in subjective safety that can be linked to the programs or interventions, as measured within the target population.
The goal of community based safety promotion should be to move intervention and research efforts towards quadrant 1, which requires an increased emphasis on providing services that affect not only the elimination of injuries, but also increase individual and group perceptions of feeling safe.
Is a safety worth 2 points?
In gridiron football, the safety (American football) or safety touch (Canadian football) is a scoring play that results in two points being awarded to the scoring team.
What is Step 2 of risk assessment?
Step 2. Decide who might be harmed and how. For each hazard you need to be clear about who might be harmed; it will help you identify the best way of managing the risk. That doesn’t mean listing everyone by name, but rather identifying groups of people (eg ‘people working in the storeroom’ or ‘passers-by’).
What is safety principle?
Core safety principles are set to control the main risks in the workplace and prevent serious incidents. Principles are expected behaviors that apply to all workers and partners. Physical & mental well-being. Take care of your personal well-being and make sure you are fit for work.
What is a Category 1 and 2 hazard?
Assessments are carried out on the property – A full inspection of a property will be completed by the council using a risk based assessment to consider the effect of any hazards in the property. The hazards are rated according to how serious they are and the effect they are having, or could have, on the occupants.
Class 1 – Extreme (death from any cause, permanent loss of consciousness, regular severe pneumonia, 80% burn injuries)Class 2 – Severe (cardio-respiratory disease, asthma, loss of a hand or foot, serious factures, severe burns)Class 3 – Serious (chronic severe stress, mild heart attack, loss of finger, fractured skull and severe concussion)Class 4 – Moderate (occasional severe discomfort, mild pneumonia, broken finger, severe bruising, regular serious coughs and colds)
Please see the document below for a detailed list of the 29 hazards and the four harm outcomes. HHSRS Hazards and Harm Outcomes (PDF) It must be remembered that all properties contain hazards and it is not possible to remove all of these. The emphasis is to minimise the risk to health and safety as far as possible either by removing the hazard completely or minimising the effect. If you have a complaint about poor housing conditions, please send a message to the Housing Standards team,
What is Safety-II in aviation?
Safety management should therefore move from ensuring that ‘as few things as possible go wrong’ to ensuring that ‘as many things as possible go right’. This perspective is termed Safety-II and relates to the system’s ability to succeed under varying conditions.
What is safety 3?
He points out that, although many regulations exist to attempt to protect workers, ‘Just because you are in compliance doesn’t mean you’re safe.’ Mike and his crew started using the phrase ‘Safety Third’ to remind each other that safety was ultimately their individual responsibility, and was more complex than an