This article is a reproduction of the Editorial published in HindSight magazine issue 31 in December 2020 (all issues available at SKYbrary)
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. In my estimation, based on contact with safety practitioners in many countries, this tends to take up around 90% of work hours for safety specialists. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath?
Understanding failure isn’t enough to ensure effective performance. No organisation, team or family can be understood by focusing only what goes wrong. And more than this is needed to thrive and flourish. We have to look at what goes on. We don’t tend to pay much attention to what goes on under our noses to keep things safe and effective because it’s so…ordinary. And sometimes, things also change slowly over time, and we find these slow changes hard to ‘see’.
When we stop to take a closer look, especially with the help of an ‘outsider’, we see things below the surface that we’ve not noticed before. These include individual, team and organisational practices, and the conditions of work. How do we communicate and coordinate? How do we train? How do we do handovers? How do we supervise? How do we manage? And why do we do these things in the way that we do them? Such issues are often taken for granted. But, to be able to get things right, we all have to pay attention to these and other issues. There are a few reasons why this is a good idea.
1. Learning from everyday work helps to improve all aspects of performance and wellbeing
In any organisation, several goals must be considered and achieved to an acceptable level. When we learn from everyday work, we understand safety in the context of efficiency, capacity, security, the environment and human wellbeing. When work is viewed in the whole, rather than through the lens of isolated incidents alone, many things emerge. We start to see patterns rather than just individual events. The goal conflicts, trade-offs, and dilemmas that are part of normal work become clearer. With that understanding, we start to see how everything is connected, and we can improve all aspects of performance and wellbeing, including our experience of work – satisfaction, meaning, comfort, connection, and so on. And since it is better to improve on several dimensions than just one, it is easier to get the resources and commitment for learning that we need, at all levels of the organisation.
2. Learning from everyday work does not require unwanted events
Learning from unwanted events such as incidents is essential, and there is much to be learned from them. But it is not necessary to have unwanted events to learn. Extraordinary events can be a symptom of a failure to learn from ordinary work. We can learn much from the ordinary, if we pay attention to it. The conditions for wanted and unwanted outcomes are often hiding in plain sight, especially things that happen frequently and conditions that are always present. Once these are understood, incidents seem less exceptional and more of an expression of everyday challenges and changes. By discussion and observation, along with other sources of information, we can learn about both problems and opportunities.
3. Learning from everyday work helps to see and build on what’s strong
By focusing on a few trees, we don’t see the forest. By looking at the forest as a whole, we can see what’s strong, as well as what’s wrong. We can see what works well and why. In any part of an organisation, there are good practices and favourable conditions that we appreciate. These might relate to operational, technical, specialist, support, management and regulatory activities, and everything that connects these activities up. These practices and conditions need to be protected, reinforced, extended and expanded. But to do this, we have to understand them. We can reveal what we have done together that we are proud of, what we wish we would have done earlier, what we would recommend to others, and what help we might be able to offer.
4. Learning from everyday work helps to see slow changes
Things often change slowly over time. One kind of change is what is sometimes called ‘practical drift’. In his book Friendly Fire, Scott Snook defines this as “the slow uncoupling of practice from procedure” (p. 24). Without paying attention to everyday work, we don’t see such changes until a noticeable unwanted event occurs, especially when changes happen slowly and are only known to those who are closely associated with the work, whether front- line staff or management. Another kind of shift or change is where performance moves towards exceptionally good performance, where work is sustainably productive, innovative, healthy, joyful, etc. Again, if everyday work is unknown and generally ignored, then we may not see the way that work is changing for the better.
5. Learning from everyday work can involve everyone
When we focus on everyday work, we can – and should – involve those who do it, support it, and are affected by it. Learning and change are activities that should primarily be done BY and WITH the people involved and affected, not just FOR them (see HindSight 28). Learning from everyday work is not easy, but much can be done without specialist technical skills. Most important are three essential attitudes and three essential skills (see below).
All of this requires reflection and practice. Some learning activities are led by specialists (in human factors, psychology, safety investigation, and so on), but most aspects of learning need a range of people with different things to give. Learning and improvement can also be a valuable and worthwhile experience for everyone involved. So we need to think of our jobs as having two parts: doing the work and improving the work.
Once it becomes clear that learning from everyday work is a good thing to do, the next question is how? This question is explored in different ways in the Issue 31 of HindSight.