In this installment, we cover more chapters from Sidney Dekker’s book about just culture. Last week we covered the core ideas of just culture. This week, we go over retributive and restorative culture and the impetus behind rule-breaking. Topics:The problem with rewarding good behavior.How a retributive system functions.The standard for risk assessment.How restorative culture functions.Why sharing experiences is key.What is expected under a solid restorative justice system.Understanding rule-breakers.How the book fails to properly dissect rule-breaking.Practical takeaways. Quotes:“If our purpose is to make a better workplace, then we need a system that for most people, most of the time, it’s doing a good job.”“When we talk about safety, we’re not talking about elements of a typical criminal offense; we’re talking about things that in the criminal courts would be talking about negligence. Which is all about meeting acceptable standards.”“Sidney emphasizes a lot the importance of all stakeholders to share their stories with each other.” Resources:Just CultureFeedback@safetyofwork.com

For the next few weeks, we are going to cover ‘just culture’ and focus mainly on Sidney Dekker’s book of the same name.The laws currently on the books encourage businesses to focus on liability instead of actual safety. By focusing on culpability for an accident, this is a way for businesses to get out of compensating the worker for injury. This is just some of what we will discuss today. Topics:Safety theory vs. safety practice.Safety culture and the Swiss Cheese Model.Updates in the third edition.The definition of just culture.To whom you apply the process and why it’s important.Listening and actually hearing.Systemic and individual action.Can an individual be too much of a danger?Preventing unnecessary blame.What to expect from this series of episodes.Practical takeaways. Quotes:“We both know that Dekker a bit of a problem...a bit of a habit of being pretty harsh about how he characterizes some of the older safety practices.”“The ability of people to tell their stories and have those stories heard by all the other stakeholders, is a key part of restorative justice.”“We’re all in the same boat, we’re all, after that accident, have an individual responsibility to stop this happening again by making the system better.” Resources:Just CultureFeedback@safetyofwork.com

As risk assessment is such a central topic in the world of safety science, we thought we would dedicate another episode to discussing a facet of this subject. We loop back to risk matrices and determine how to score risks.Join us as we try to determine the subjectivity of risk assessment and the pitfalls of such an endeavor. Topics:Risk matrices.Why the paper we reference is a trustworthy source.Scoring risks.How objective are we?How to interpret risk scores.What the risk-rating is dependent upon.Practical takeaways. Quotes:“The difference between an enumeration and a quantitative value is that enumeration has an order attached to it. So it let’s us say that ‘this thing is more than that thing.’ ““I think this was a good way of seeing whether the differences or alignment happened in familiar activities or unfamiliar activities. Because then you can sort of get an idea into the process, as well as the shared knowledge of the group…”“So, what we see is, if you stick to a single organization and eliminate the outliers, you’ve still got a wide spread of scores on every project.”“We’re already trying pretty hard and if we’re still not converging on a common answer, then I think we need to rethink the original assumption that there is a common answer that can be found…” Resources:Are We Objective?Risk Perceptions & Decision-Making in the Water IndustryFeedback@safetyofwork.com

It’s difficult to give an introduction to this topic, given that a JSA is such an amorphous topic. Generally speaking, we’re talking about job or task-hazard analysis; the idea behind task-hazard analysis is that you break the task down into steps and figure out what controls are necessary to keep the task safe.Tune in to hear us clarify the idea of and benefits from job safety analysis. Topics:The lack of standard terminology.Why some claims from JSA’s are implausible.The structure of the study covered in the paper.Why the analysis in the study is more of a comparison.The overconfident optimism of the researchers.How JSA’s clarify worker’s duties.Who makes the decisions.Hazard awareness.Loss prevention.Practical takeaways. Quotes:“I think it would be fair to say that I’ve never yet met a method of risk assessment that I fell in love with.”“The researchers are too optimistic about how much the documented JSA’s reflect what actually went on.”“Ultimately, in high risk work, the immediate hazard awareness of people is important for safety.” Resources:The Application and Benefits of Job Safety AnalysisFeedback@safetyofwork.com

The article we reference provides a historical account of the “Swiss Cheese Model”. Since there are many versions of this same diagram, we thought it best to look back through time and see the evolution of this particular safety model. Topics:Why the model represents the presence of folklore in safety.The methods used in Good and Bad Reasons.The cognitive processes that lead to errors.Whether the model represents accident causation appropriately.A defense of the model. Quotes:“He’s just trying to understand this broad range of errors and sort of work with the assumption that there must be different cognitive processes.”“It was initially, sort of, only published once in a medical journal as an oversimplification of his own diagram.”“The other critique is that the model lacks guidance.”“ ‘I never intended to produce a scientific model’ is the worst excuse possible that an academic can give in defense of their own model.” Resources:Good and Bad Reasons: The Swiss Cheese Model and its CriticsFeedback@safetyofwork.com

In this episode, the hosts discuss the practical implications of Safety II for safety professionals. They explore the shift from centralized control to guided adaptability in safety theories. They also highlight the importance of understanding technical specialists and integrating effective safety practices across the organization. Other topics include generating operational scenarios, facilitating task level hazard analysis, and the differences between Safety I and Safety II approaches.

We dive into the final chapters of the book and analyze Hollnagel’s intent and offer our commentary on his ideas. Though our ideas don’t necessarily jibe with all of Hollnagel’s, we appreciate our time dissecting this seminal book. Tune in to hear our thoughts on the final four chapters. Make sure to let us know if you also read the book and your thoughts on the content.We hope you enjoyed our little end-of-year deep-dive. Have a happy and healthy New Year! Topics:A recap of the chapters we’ve covered thus far.Chapter 6Dealing with complexity,The role of resilience.Chapter 7Correct and incorrect functions.Determining the cause of accidents in complex systems.The faulty definition of Safety II.The purpose of Safety II.Chapter 8Recognizing, monitoring, and controlling performance variability. Why Hollnagel criticizes Safety I.Methods and techniques.Chapter 9Hollnagel’s predictions about the creation of Safety III.Practical takeaways from the book.Quotes:“So you think of Safety I just as it protects against lots of specific things, but it doesn’t protect against generic things that we haven’t specifically protected against.”“The fact is...we can make some fairly reliable and valid conclusions about what happened leading up to something going wrong.”“I think all theorists we should take seriously and not literally.” Resources:Safety I and Safety II: The Past and Future of Safety ManagementFeedback@safetyofwork.com 

Picking up where we left off, we begin our discussion with chapter three. Over the course of this episode, we talk about Hollnagel’s definition of Safety I, the myths of safety, and causality (among other things). Tune in for part two of our in-depth look at this important book. Topics:Chapter 3.Habituation.Preoccupation with failure.Work as imagined vs. work as actually performed.A definition of Safety I.Chapter 4.The four myths of Safety I.Causality.Misinterpreting Heinrich.Human error.Chapter 5.Deconstruction.Linear and non-linear systems.Cause and effect.General takeaways from chapters 3-5. Quotes:“...I think this one particular idea of work as imagined/work as done has been thought about a lot in the time since this book was published…”“What is this measure of successful work? What is this way that we would categorize something as successful, if it’s not, not having accidents?”“It’s a misinterpretation of Heinrich to apply the ratios.”“And that sort of criticism of the old to explain the new, I think is never as firm a foundation as clearly explaining what you’re sort of underlying ideas and principles are and then building on top of them.” Resources:Safety I and Safety II: The Past and Future of Safety ManagementFeedback@safetyofwork.com

For this episode, we are breaking away from the standard formula for this show. We thought it best to split this topic into three episodes, as we don’t want to oversimplify our breakdown of this seminal, two-hundred page book. We encourage all of our listeners to follow along and read the book with us. Join us as we dig into this influential book by Erik Hollnagel. Topics:Interpretations of new theories.Hollnagel being the direct intellectual descendant of Professor Rasmussen.Chapter 1: The Issues.The denominator problem.The regulator paradox.The problems with defining safety.Overall thoughts on Chapter 1.What to skim and what to read closely. Quotes:“Most theories are billed as critiques of other theories. So, any new theory implicitly, and usually, explicitly criticizes a lot of existing stuff. And it’s important to separate those two things out.”“He says that success and failure are not opposites.”“It means that every single data point, then, has a lot of uncertainty attached around to it, because they’re such isolated examples, such extraordinary events…” Resources:Safety I and Safety II: The Past and Future of Safety ManagementFeedback@safetyofwork.com

Ultimately, we want to help everyone understand the role of organizations and individuals when it comes to safety regulation.  Topics:Why regulators are often spoken of negatively.The two forms of deregulation.Goal-based and rule-based frameworks.The progressive pulling-back of Government involvement in safety.Why overregulation occurs.What is actually being regulated.Conclusions from our conversation. Quotes:“So, the intention of this goal-based regulatory strategy is for organizations to understand their broad obligations to adopt a risk-based management strategy and to set their own safety management requirements inside their own organization.”“The second theme that came out of the analysis was that overregulation is because of liability management and management insecurity.”“The next important question to ask is are we regulating safety work or regulating safety of work?” Resources:Seeing Like a StateHow Deregulation can Become OverregulationFeedback@safetyofwork.com