The Real Focus of Safety-II

Safety-II has become a talking point. It is discussed not only among safety professionals, but – perhaps more importantly – among front line practitioners, managers, board members and regulators in a wide array of industries. Its practical and inclusive focus on everyday work seems to strike a chord, acknowledging the reality of work for those who actually do the work.

There are, however, a few myths and misconceptions about Safety-II, some of which I highlighted in What Safety-II Isn’t. One is that Safety-II is about exceptional performance – excellence. This is perhaps associated with the use of the term ‘success’ and the phrase ‘go well’ in the literature on Safety-II (e.g., the EUROCONTROL [2013] White Paper). ‘Success’ is used here in a rather general sense, that work achieves its goals, in line with one definition of the term: The success of something is the fact that it works in a satisfactory way or has the result that is intended. (Collins). The word is also commonly used to refer to exceptional attainment (i.e., that someone is. ‘successful’). This is not what is meant from the viewpoint of Safety-II, though the scope of Safety-II is inclusive of excellence, or especially desirable sociotechnical system performance.

Safety-II should be seen as focusing on all forms of work and all outcomes, routine and (perceived as) ‘unremarkable’ work, incidents and accidents, and exceptional performance. It is not about how things go well, so much as how thing go, but with the aim of course that things do go well. This is clearly depicted in the graph from the EUROCONTROL White Paper in Safety-I and Safety-II.

The focus of Safety-I and Safety-II. From EUROCONTROL (2013). From Safety-I to Safety-II: A White Paper. Brussels, p. 25. https://www.skybrary.aero/bookshelf/books/2437.pdf

What this shows is that the focus of Safety-II in terms of work and outcomes includes the focus of Safety-I. But Safety-II does not include Safety-I in terms of its precepts and concepts, which are quite different. (Importantly, both approaches can and should be practised – see Mind your Mindset: Safety-I and Safety-II – though some adjustments and compromises are naturally to be expected.) Both Safety- I and Safety-II include a focus on accidents, actual and potential. (In reality, accidents are a typically fraction of the 0.1%, in the graph above, though potential accident scenarios are a much greater, albeit unquantifiable, proportion.) The difference is that this is the whole focus of Safety-I, which reacts to events and risks primarily via an analytical approach, considering the human role in terms of contributions to accidents (causal or mitigating).

For Safety-II, the major focus is on less remarked-upon work and outcomes, as well as work and outcomes that are especially wanted (and might be seen as goals) or especially unwanted (anti-goals). But Safety-II does not focus specifically on ‘excellence’, and does not ignore accidents and other unwanted events (And ‘best practice’ really makes no sense, since what is best in one context – place or time – will not be best in another. Practice is always contextual.)

A key reason for this focus on everyday work is that work-as-done is the reason why sociotechnical systems are effective, including safe operations, and also the reason why they fail. By ignoring work-as-done, whether it is more or less congruent with work-as-prescribed or work-as-imagined, or whether it is quite different (see the messy reality), we don’t know how the system is functioning and whether it is drifting into an unwanted state, or shifting toward an especially wanted state (see Work and how to survive it: Lesson 2. Understand variation inside your organisation).

Focusing on normal work also makes sense from a Safety-I point of view, with its focus on accidents, actual or potential. This was highlighted in 1984 by sociologist Charles Perrow in his book Normal Accidents. Perrow was making the point that unusual events such as accidents are not fundamentally different to normal, everyday system functioning. They are, in some important senses, equivalent. Big accidents don’t have big causes. It’s just that ‘normal disorders’ combine in unexpected, often emergent, ways. ‘Normal disorders’ might be seen as degraded aspects of the system and context (e.g., technology used beyond design intent, degraded tools, excessive and overly complex procedures, stretched shift systems, competency gaps) along with differences between work-as-imagined and work-as-done. An important point is that it is normally the context of work that is disordered, while work-as-done tends to adapt, adjust and stretch to make things work, in locally rational ways. Work-as-done strives to create order in a system that is fundamentally disordered and not as-imagined from afar.

Adapted from EUROCONTROL (2013). From Safety-I to Safety-II: A White Paper. Brussels. https://www.skybrary.aero/bookshelf/books/2437.pdf

So while we want to ensure that work goes well, aiming for excellence, the focus of Safety-II is on the whole picture, but especially work that we might consider routine, everyday, and even unremarkable. This is the work that may end up in incident reports, or excellence reports, or simply keep the organisation running effectively. If we don’t look, we’ll never know.

About stevenshorrock

I am a systems ergonomist/human factors specialist and work psychologist with a background in practice and research in safety-critical industries. My main interest is human and system behaviour in the context of safety-related organisations. I seek to enable improvement via a combination of systems thinking, design thinking and humanistic thinking. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also Adjunct Associate Professor at University of the Sunshine Coast, Centre for Human Factors & Sociotechnical Systems. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock or email contact[at]humanisticsystems[dot]com.
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