Unlike traditional approaches to safety, we see deviations from the rules as a reason to analyse the situation rather than as a violation. We defer judgement and try to understand how the work is actually done, especially when conditions are challenging and resources are scarce. Rather than citing “human error” as the cause of an adverse event, we assume that the error is a symptom of underlying causes, such as system design, training, supervision or conflicting objectives.
Our approach requires top-down guidance because its rationale is somewhat controversial. In the approach, I reject the term “human error”, question the established culture of absolute compliance with rules, suggest that a “zero harm” policy is counterproductive and defend the acceptance of accidents as part of the job. Your team should be curious about events without judging, to find out how work is really done in practice. The press, the public, politicians and even our colleagues generally demand that we comply with our own procedures, and we should indeed work to improve compliance. But first we need to know what is really going on and your guidance is needed to support managers and safety staff in embracing bad news.
I explain how you can tackle safety by outlining the concrete steps you can take. I strive for clarity, conciseness and practical applicability. First, you and your team identify where safety might be at risk and then I help you address those risks. I explain how stories and sensemaking help to get clear about what is going on. I explain how you can innovate wisely and monitor the impact of improvements on safety and performance. I explain how to keep the discussion about risk alive and how to ensure that those involved have the necessary skills to continue to perform even in difficult circumstances.