Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Each week join Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips.
Ep.88 Why do organisations sometimes make bad decisions?
52:09While this paper was written over half a century ago, it is still relevant to us today - particularly in the Safety management industry where we are often responsible for offering solutions to problems, and implementing those solutions, requires decisions to be made by top management. This is another fascinating piece of work that will broaden your understanding of why organisations often struggle with solving problems that involve making decisions. Topics:Introduction to the research paper: A Garbage Can Model of Organisational ChoiceOrganised anarchies Phenomena explained by this paperExamples of the garbage can modelsStandards CommitteesEnforceable undertakings processHow to influence the processDeciding on who makes decisionsConclusion - most problems will get solvedPractical takeawaysNot to get discouraged when your problem isn’t solved in a particular meetingBeing mindful of where your decision-making energy is spentProblems vs Solutions vs Decision-making Have multiple solutions ready for problems that may come up - but don’t force them all the time. Quotes:“Decisions aren’t made inside people’s heads, decisions are made in meetings, so we’ve got to understand the interplay between people in looking at how decisions are made.” - Dr. Drew Rae“Incident investigations are a great example of choice opportunities.” - Dr. Drew Rae“It’s probably a good reflection point for people to just think about how many decisions certain roles in the organization are being asked to be involved in.” - Dr. David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work PodcastThe Safety of Work [email protected] Garbage Can Model of Organizational Choice (Wikipedia Page)Administrative Science Quarterly
Ep.87 What exactly is Systems Thinking?
55:34We will review each section of Leveson’s paper and discuss how she sets each section up by stating a general assumption and then proceeds to break that assumption down.We will discuss her analysis of:Safety vs. ReliabilityRetrospective vs. Prospective AnalysisThree Levels of Accident Causes:Proximal event chainConditions that allowed the eventSystemic factors that contributed to both the conditions and the event Discussion Points:Unlike some others, Leveson makes her work openly available on her websiteLeveson’s books, SafeWare: System Safety and Computers (1995) and Engineering a Safer World: Systems Thinking Applied to Safety (2011)Drew describes Leveson as a “prickly character” and once worked for her, and was eventually fired by herLeveson came to engineering with a psychology backgroundMany safety professionals express concern regarding how major accidents keep happening and bemoaning - ‘why we can’t learn enough to prevent them?’The first section of Leveson’s paper: Safety vs. Reliability - sometimes these concepts are at odds, sometimes they are the same thingHow cybernetics used to be ‘the thing’ but the theory of simple feedback loops fell apartSumming up this section: safety is not the sum of reliability componentsThe second section of the paper: Retrospective vs. Prospective Accident AnalysisMost safety experts rely on and agree that retrospective accident analysis is still the best way to learnExample - where technology changes slowly, ie airplanes, it’s acceptable to run a two-year investigation into accident causesExample - where technology changes quickly, ie the 1999 Mars Climate Orbiter crash vs. Polar Lander crash, there is no way to use retrospective analysis to change the next iteration in timeThe third section of the paper: Three Levels of AnalysisIts easiest to find the causes that led to the proximal event chain and the conditions that allowed the event, but identifying the systemic factors is more difficult because it’s not as easy to draw a causal link, it’s too indirectThe “5 Whys” method to analyzing an event or failurePractical takeaways from Leveson’s paper–STAMP (System-Theoretic Accident Model and Processes) using the accident causality model based on systems theoryInvestigations should focus on fixing the part of the system that changes slowestThe exact front line events of the accident often don’t matter that much in improving safetyClosing question: “What exactly is systems thinking?” It is the adoption of the Rasmussian causation model– that accidents arise from a change in risk over time, and analyzing what causes that change in risk Quotes:“Leveson says, ‘If we can get it right some of the time, why can’t we get it right all of the time?’” - Dr. David Provan“Leveson says, ‘the more complex your system gets, that sort of local autonomy becomes dangerous because the accidents don’t happen at that local level.’” - Dr. Drew Rae“In linear systems, if you try to model things as chains of events, you just end up in circles.’” - Dr. Drew Rae“‘Never buy the first model of a new series [of new cars], wait for the subsequent models where the engineers had a chance to iron out all the bugs of that first model!” - Dr. David Provan“Leveson says the reason systemic factors don’t show up in accident reports is just because its so hard to draw a causal link.’” - Dr. Drew Rae“A lot of what Leveson is doing is drawing on a deep well of cybernetics theory.” - Dr. Drew Rae Resources:Applying Systems Thinking Paper by LevesonNancy Leveson– Full List of PublicationsNancy Leveson of MITThe Safety of Work PodcastThe Safety of Work on [email protected]
Ep.86 Do we have adequate models of accident causation?
1:00:04We will discuss how other safety science researchers have designed theories that use Rasmussen’s concepts, the major takeaways from Rasmussen’s article, and how safety professionals can use these theories to analyze and improve systems in their own organizations today. Discussion Points:Rasmussen’s history of influence, and the parallels to (Paul) Erdős numbers in research paper publishingHow Rasmussen is the “grandfather” of safety scienceRasmussen’s impact across disciplines and organizational categories through the yearsThe basics of this paperWhy risk management models must never be staticHow other theorists and scientists take Rasmussen’s concepts and translate them into their own models and diagramsThe paper’s summary of the evolution of theoretical approaches up until ‘now’ (1997)Why accident models must use a holistic approach including technology AND peopleHow organizations are always going to have pressures of resources vs. required resultsEmployees vs. Management– both push for results with minimal acceptable effort, creating accident riskRasmussen identified we need different models that reflect the real worldTakeaways for our listeners from Rasmussen’s work Quotes:“That’s the forever challenge in safety, is people have great ideas, but what do you do with them? Eventually, you’ve got to turn it into a method.” - Drew Rae“These accidental events are shaped by the activity of people. Safety, therefore, depends on the control of people’s work processes.” - David Provan“There’s always going to be this natural migration of activity towards the boundaries of acceptable performance.” - David Provan“This is like the most honest look at work I think I’ve seen in any safety paper.” - Drew Rae“If you’re a safety professional, just how much time are you spending understanding all of these ins and outs and nuances of work, and people’s experience of work? …You actually need to find out from the insiders inside the system. ” - David Provan“‘You can’t just keep swatting at mosquitos, you actually have to drain the swamp.’ I think that’s the overarching conceptual framework that Rasmussen wanted us to have.” - David Provan Resources:Compute your Erdos NumberJens Rasmussen’s 1997 PaperDavid Woods LinkedInSidney Dekker WebsiteNancy Leveson of MITBlack Line/Blue Line ModelThe Safety of Work PodcastThe Safety of Work on [email protected]
Ep.85 Why does safety get harder as systems get safer?
55:20Find out our thoughts on this paper and our key takeaways for the ever-changing world of workplace safety. Topics:Introduction to the paper & the Author“Adding more rules is not going to make your system safer.”The principles of safety in the paperTypes of safety systems as broken down by the paperProblems in these “Ultrasafe systems”The Summary of developments of human errorThe psychology of making mistakesThe Efficiency trade-off element in safetySuggestions in Amalberti’s conclusionTakeaway messagesAnswering the question: Why does safety get harder as systems get safer? Quotes:“Systems are good - but they are bad because humans make mistakes” - Dr. Drew Rae“He doesn’t believe that zero is the optimal number of human errors” - Dr. Drew Rae“You can’t look at mistakes in isolation of the context” - Dr. Drew Rae“The context and the system drive the behavior. - Dr. David Provan“It’s part of the human condition to accept mistakes. It is actually an important part of the way we learn and develop our understanding of things. - Dr. David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work PodcastThe Safety of Work [email protected] Paradoxes of Almost Totally Safe Transportation Systems by R. AmalbertiRisk Management in a Dynamic society: a Modeling problem - Jens RasmussenThe ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong - Book by Erik HollnagelEp.81 How does simulation training develop Safety II capabilities?Navigating safety: Necessary Compromises and Trade-Offs - Theory and Practice - Book by R. Amalberti
Ep.84 How do orgasnisations balance reliable performance and spontaneous innovation?
44:11This paper by Daniel Katz was published in 1964 and, scarily still has some very relevant takeaways for today’s safety procedures in organisations. We delve into this research and discover the ideas that Katz initiated all those years ago. The problem is that an organization cannot promote one of these concepts without negatively affecting the other. So how are organizations meant to manage this? We share some personal thoughts on whether or not the world of safety research has since found an answer to dealing with these two contradictory concepts. Topics:Introduction to the paperIntroduction to the Author Daniel KatzThe history of the safety research industryThree basic behaviors required from employees in all organizationsPeople’s willingness to stay in an organizationManaging dependable role performanceSpontanious initiativeFavourable attitudeCreating this motivation in employees to follow rulesCultivating innovative behaviourHow this paper remains relevant in current safety researchNo answer to this question of balancing these two behaviours Quotes:Katz is really one of the founding fathers in the field of organizational psychology. - Dr. Drew RaeIt’s not just that you’re physically getting people to stay but getting them to stay and still be willing to be productive. Dr. Drew Rae“When we promote autonomy, we need to think about what that does to reliable role performance.” - Dr. Drew RaeComplex situations, clearly need complex solutions. - Dr. David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] 2The motivational basis of organizational behavior (Paper)
Ep.83 Does the language used in investigations influence the recommendations?
37:34This paper reveals some really interesting findings and it would be valuable for companies to take notice and possibly change the way they implement incident report recoMmendations. Topics:Introduction to the paperThe general process of an investigationThe Hypothesis The differences between the reports and their languageThe results of the three reportsDifferences in the recommendations on each of the reportsThe different ways of interpreting the resultsPractical TakeawaysNot sharing lessons learned from incidents - let others learn it for themselves by sharing the report.Summary and answer to the question Quotes:“All of the information in every report is factual, all of the information is about the same real incident that happened.” Drew Rae“These are plausibly three different reports that are written for that same incident but they’re in very different styles, they highlight different facts and they emphasize different things.” Drew Rae“Incident reports could be doing so much more for us in terms of broader safety in the organization.” David Provan“From the same basic facts, what you select to highlight in the report and what story you use to tell seems to be leading us toward a particular recommendation.” - Drew Rae Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] Report Interpretation PaperEpisode 18 - Do Powerpoint Slides count as a safety hazard?
Ep.82 Why do we audit so much?
57:09It's Modelling the Micro-Foundations of the Audit Society: Organizations and the Logic of the Audit Trail by Michael Power. This paper gets us thinking about why organizations do audits in the first place seeing as it has been proven to often decrease the efficiency of the actual process being audited. We discuss the negatives as well as the positives of audits - which both help explain why audits continue to be such a big part of safety management in organizations. Topics:What kinds of audits are happeningWhy is the number of audits increasing?Why do we keep doing audits when they seemingly do not help productivity.Academia and publication metricsThe audit societyThe foundations of an audit trailThe process model of an audit trailThe problem with audit trails.Going from push to pull when audits are initiatedWhy is it easier for some organizations to adopt auditing processes than others?Displacement from goals to methodsAudits help different organizations line up their way of thinkingPractical takeaways Quotes:“We see that even though audits are supposed to increase efficiency, that in fact, they decrease efficiency through increased bureaucracy. - Drew Rae“The audit process needs to aggregate multiple pieces of data, and then it has to produce a performance account, so the audit actually needs to deliver a result.” - David Provan“We become less reflexive about what’s going on in terms of this value subversion - so we stop worrying about are we genuinely creating a safety culture in our business and we worry more about what’s the rating coming out of these audits in terms of the safety culture.” - Drew Rae“Audits themselves are not improving underlying performance.” - David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] paper: Modelling the Microfoundations of the Audit Society
Ep.81 How does simulation training develop Safety II capabilities?
53:10The specific paper found some interesting results from these simulated situations - including that it was found that the debriefing, post-simulation, had a large impact on the amount of learning the participants felt they made. The doctors chat about whether the research was done properly and whether the findings could have been tested against alternative scenarios to better prove the theorized results. Topics:Individual and team skills needed to maintain safety.Safety-I vs Safety-IIIntroduction to the research paperMaritime Safety and human errorSingle-loop vs Double-loop learningSimulator programs help people learn and reflectResearch methodsResults discussionRecognizing errors and anomaliesShared knowledge to define limits of actionOperating the system with confidenceImportance of learning by doing and reflecting back afterwardComplexity and uncertainty as a factor in safety strategy.Practical Takeaways Work simulation is an effective learning processHalf of the learning comes from the debriefRead this paper if doing simulation training Quotes:“Very few advocates of Safety-II would disagree that it’s important to keep trying to identify those predictable ways that a system can fail and put in place barriers and controls and responses to those predictable ways that a system can fail.” - Dr. David Provan“It limits claims that you can make about just how effective the program is. Unless you’ve got a comparison, you can’t really draw a conclusion that it’s effective.” - Dr. Drew Rae“A lot of these scenarios are just things like minor sensor failures or errors in the display which you can imagine in an automated system, those are the things that need human intervention.” - Dr. Drew Rae“Safety-I is necessary but not sufficient - you need to move on to the resilient solution ” - Dr. Drew Rae“I don’t really think that situational complexity is what should guide your safety strategy. - Dr. Drew Rae Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] paperNorwegian University of Science and TechnologyEpisode 79 - How do new employees learn about safety?Episode 19 - Virtual Reality and Safety training
Ep.80 What is safety clutter?
1:00:50The paper we reference today is our own research paper published in 2018 named; Safety clutter: the accumulation and persistence of ‘safety’ work that does not contribute to operational safety. So we have done ample research when it comes to this particular topic and we’re excited to share this knowledge with you. Hopefully you will take away from this episode a better understanding of where to start looking for (and clear out) clutter in your own workplace. Topics:What is safety clutter?The three C’s ContributionConfidenceConsensusThe paper - Safety clutter: the accumulation and persistence of ‘safety’ work that does not contribute to operational safetyTypes of duplication in safety tasksGeneralization of safety tasksSymbolic application of safety tasksAttempted simplificationLeast common denominatorOverspecificationThe causes of safety clutterWhy reduce safety clutter?Ways to deal with safety clutter Quotes:“Clutter by duplication - when you literally have two activities that perform the same function, then you know that at least one out of the two is going to be unnecessary. - Drew Rae“They ended up having to create a hazard on the work site for the manager who was doing the critical controls inspection to check that they had properly managed the hazard.” Drew Rae“I found a 28 page work page work instruction on how to spray weeds on a concrete pathway with a weedspray that was biodegradable and commercially available at any supermarket.” - David Provan“It’s harder to remove anything that is there for safety than it is to add something that’s there for safety.” - Drew Rae“Did you know that some of the things we do in this organization, specifically for safety, may make our organization less safe. - David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] paper
Ep. 79 How do new employees learn about safety?
44:05While there may be many reasons for this - this particular research paper looks at how younger workers are inducted into the workplace and how they learn about the safety practices and requirements that are expected. The findings are pretty fascinating - especially for people responsible for hiring new employees. TopicsIntroduction to the research paperTypes of questions researchers asked research subjectsLiterature reviewHow people learnLearning safe practicesIndustries researchedMetalworkElderly careRetailGeneral inferencesCommunity of practiceGradient towards unsafety Practical TakeawaysThere’s a direct link between employment practices and safetyTemporary workers are less likely to follow safety precautionsAwareness of safety and how it relates to labor-hireReflective practiceLook at what happens during a new employee’s first weekAre your formal and informal induction and onboarding processes aligned to your safety risk profile of the different roles within your organization Quotes:“Learning isn’t about uploading knowledge, it’s about creating a sequence of experiences, and each person in the experience, they reflect on that experience, they learn from that, it leads them on to new experiences.” - Drew Rae“When we induct workers, it’s not just about knowledge transfer, it’s not just about uploading the knowledge they need, it’s about how do we get them to start taking part in discussions and decisions and arguments and thinking about the way work happens.” - Drew Rae“The one thing that we maybe can maintain is the formal standards that we communicate in the induction in the hope that creating some of that tension, creates discussion.” - David Provan“Onboarding a person into the workplace is an investment in the person, so people are maybe likely to invest more if there’s more return.” - David Provan Resources:Griffith University Safety Science Innovation LabThe Safety of Work [email protected] Paper Discussed