Relationship Based SafetyDavid Bond – 21st February 2013

Relationships

Systemic• Complex Systems• Layers• Interactions• Emergence

Personal• Motivation• Accountability• Consequences• Just Culture

Some Persistent Myths

• That systems are inherently safe, it is the behaviors of unreliable individuals that create unsafe conditions

• More than 80% of accidents are the result of errors or unsafe behaviours

• Safety rules and procedures are there to correct or control unreliable human behaviour

• Accidents are the result of someone not paying enough attention – ‘they lost situational awareness’

New View of Human Error

• Human error is a symptom of trouble deeper inside a system

• We can never explain failure by finding mistakes.

• Find why peoples actions made sense at the time, given the circumstances that surrounded them.

• Complex systems are not inherently safe

• Complex systems are trade-offs between conflicting goals

• People create safety through practice

Dekker, Sydney (2006) The Field Guide to Understanding Human Error

Complexity & Failure - Before

• Normal Accidents

• Drift into Failure

• Incompatible Goals

• Adaptation

Practices do not follow rules; rather, rules follow evolving practices.

Brian Wynne

Complexity & Failure - After

• Oversimplification

• Hindsight bias

• Outcome bias

• Local rationality

Looking for cause or control?

“There is almost no human action or decision that cannot be made to look flawed and less sensible in

the misleading light of hindsight.

Lord Anthony Hidden

Is there really a ‘cause’ anyway?

• The identification, after the fact, of a limited set of aspects of the situation that are seen as necessary and sufficient conditions for the observed effects to have occurred.

The cause, in other words, is constructed rather than found´.• Erik Hollnagel,

• The cause of an accident is not found in the rubble, it is constructed in the mind of the investigator.´

- Sydney Dekker,

Is there a need for change?

• Is safety a science?

• Rote answers

• Pre-packaged solutions

• Safety education - Are we reinforcing the paradigm?

The point is not a set of answers, but making possible a different practice.

Susanne Kappeler

Where to from here…

Evolution, not Revolution

• Focus on critical thinking, not answers.

• Promote action rather than constraint.

• Faster feedback loops.

• Minimise irreconcilable goals.

• People (not systems) create safety

Declarations of the real operate as conversation stoppers; they establish the limits of what others

can say, who can be heard.

Kenneth Gergen

Thank You