System Safety: Seven Foes of Explanation

In this short series, I highlight seven foes and seven friends of system safety, both for explanation and intervention. Each is a concept, meme, or device used in thinking, language, and intervention (reinforced by more fundamental foes that act as barriers to thinking).  They are not the only foes or friends, of course, but they are significant ones that either crop up regularly in discussions and writings about safety, or else – in the case of friends – should do.

In this post, I outline seven foes of explanation. To keep it short (because I usually intend that, but rarely succeed), I limit each explanation to an arbitrary limit of 100 words.

In this series:

  1. Seven foes of explanation in system safety (this post)
  2. Seven foes of intervention in system safety
  3. Seven friends of explanation in system safety
  4. Seven friends of intervention in system safety

Ken Douglas CC BY-NC-ND 2.0

1. Human-error-as-cause

‘Human error’ is a vague, ambiguous and poorly defined bucket concept that tends to combine psychological variables (such as intention and expectation) and outcome variables (unwanted, by someone). From a psychological perspective (concerning departures from one’s own intentions or expectations), the concept is less problematic, but focuses on the head to the expense of the world. As an explanation in a complex system, the concept it widely misused and abused, especially to infer causation. 

2. Causal chains

The idea of causal chains, including domino or ‘5 Whys’ approaches, implies a linear ordering of cause and effect. Causal chains force people to think of complex socio-technical systems as if they were ordered technical systems, with clear, linear cause-effect relationships between components. In reality, complex socio-technical systems are defined more by non-linearity, temporariness of influence, and emergence.

3. Root cause(s)

At face value, the idea of a root cause “that, if removed, prevents recurrence” is obviously nonsensical; why-because arguments can go on ad infinitum. The oft-used stopping point “that management can control” is convenient and easily abused.  The concept encourages the idea of a single root cause, ignoring causal loops, emergent, synergistic or holistic effects, and often even multiple, jointly necessary, contributory causes. It is, of course, an efficiency-thoroughness trade-off by the analyst, but hidden behind an illusion, that going ‘down and in’ will get you to the ‘real cause’, which is actually a social construction. 

4. Causes, generally

The way we think of ’causes’ in the analysis of complex work situations is often at odds with the conceptual and theoretical basis of causation. While the concept may seem unproblematic when it comes to physical cause-effect relationships, such as a hand pressing a button or pulling a lever, the same cannot be said for relationships involving less visible, less tangible system components. As one goes up and out into the system and context or environment, or – at a psychological level – down and in to the human mind, it more advisable to refer to interaction and influence.

5. Loss of situation(al) awareness/crew resource management

‘Situation(al) awareness’ is an aggressive concept that emerged from the pilot community, and subsequently human factors engineering, before taking on a life of its own, gobbling up more useful and theoretically valid concepts with long histories in psychological research, and which better define and specify the cognitive processes. CRM has a similar heritage. Both are often used counterfactually as a proxy for ‘human error’, individually or collectively. In the case of loss of SA, it refers to the ‘loss’ of awareness – of past, present, or future (!) – with implications for individuals and system safety.

6. Violations

The term ‘violation’ has an intensity of connotation and implication that – especially in the context of its more common uses – makes it inherently violent. It is one of a few terms in safety that tends to prejudge and label work behaviour without really understanding why work-as-done is not always in accordance with work-as-prescribed, and very often is not and cannot be completely so. Rather than truly understanding these differences, we tend to classify the violations. The term itself acts as a barrier to discussion and reporting of messy reality situations. 

7. Monolithic explanations, generally

Monolithic explanations act as proxies for real understanding, in the form of big ideas wrapped in simple labels. The labels are ill-defined and come in and out of fashion – poor/lack of safety culture, lack of CRM, human error, loss of situation awareness – but tend to give some reassurance and allow the problem to be passed on and ‘managed’, for instance via training and safety campaigns. Often, the same term in reverse may be used to ‘explain’ success, meaning that almost all wanted/unwanted outcomes are due to the same one thing, absent or present.

If you want to learn more about how complex systems fail, in the most concise and easy-to-digest form, read this by read Richard Cook.

Posted in Safety, systems thinking | Tagged , , , , , , , , , , ,

HindSight 28 on Change is out now!

HindSight Issue 28 is now available in print and online at SKYbrary and on the EUROCONTROL website. You can download the full issue, and individual articles. HindSight magazine is free and published twice a year, reaching tens of thousands of readers in aviation and other sectors worldwide. You will find an introduction to this Issue below, along with links to the magazine and the individual articles.


“Welcome to Issue 28 of HindSight magazine. The theme of this Issue is ‘Change’. Changes in aviation – in organisations, in industry and in society generally – affect us all, and can affect the safety of air traffic management. The pace of change is increasing. Change is necessary to adapt to the changing world, and we need to adapt to these changes as individuals, teams, and organisations. In this issue, we have articles from the front-line, as well as from safety, legal, leadership, human factors and psychology specialists. All HindSight articles are written and selected to be interesting and useful to the primary readers of HindSight: air traffic controllers and professional pilots, and hopefully to all others who support operational work. Let us know what you think about this edition and about the magazine in general. And tell your colleagues about it, whether the paper version or HindSight online, at SKYbrary. If you need more copies for your Ops room, then please let us know. This Issue starts with a section on the nature of change and some fundamental issues and implications. The following sections consider various types of changes, to airport operations, equipment and tools, airspace, procedures and traffic flows, jobs, and laws and regulations. The regular feature on ‘Views from Elsewhere’ includes articles from shipping, healthcare, banking, and psychotherapy for front- line professions. The articles cover many different types of change: large and small, systemic and individual, long- and short-term, obvious and subtle. The authors address a number of questions, such as: Why is there a need for change? What needs to change? Who makes changes, for whom? How should changes occur? When should change occur, and over how long? What influences whether change is successful, or not? What happens after change? How do we adapt to changing situations? Throughout, there is an emphasis on front-line involvement in change. The next Issue of HindSight is on the theme of ‘Goal Conflicts and Trade-offs’. Safety is the focus of this magazine and is obviously critical to air traffic management, but it is one of several goals, including cost-efficiency, CO2 emissions, noise, capacity, and security. How do these goals interact? What kinds of trade-offs are made as a result? Let us know, in a few words or more, for your magazine on the safety or air traffic management – HindSight.”

HindSight 28 Articles




Fundamental Issues

Changes to Airport Operations

Changes to Equipment and Tools

Changes to Airspace, Procedures and Traffic Flows

Changes to Jobs

Changes in Law and Regulation

Change Management

View from the Air

Views from elsewhere

In Conversation

Online Supplement

See all editions of HindSight magazine

Posted in Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , , , , , , ,

Work and how to survive it: Lesson 3. Encourage the whole self

Much of my practice is informed by counselling and psychotherapy as well as humanistic psychology more generally. One of my problems with these fields, however, is that insights and discussions are largely kept within the world of psychotherapy. What a waste! The vast majority of people are not engaged in psychotherapy and for the most part, psychotherapy pays little attention to applying itself to the mundane issues of everyday life, outside of counselling rooms. This is the third in a series reflecting on excerpts from Life and How To Survive It, by the psychotherapist Robin Skynner and the comedian John Cleese, with some reflections on work and organisations. 

Posts in the series:

Systems thinking and humanistic psychology have something important in common: holism. In Lesson 2, I noted that we need to look at the whole of work when it comes to understanding safety, and not just the relatively small fragments of failure. This has been a theme of other posts. In the whole picture, I reflected on the need for multiple perspectives in order to move toward a more holistic understanding of a given situation or system. In organisations and the ghosts of failures past, present and yet to come, I reflected on how failure is a partial and ineffective form of feedback, when used in isolation of the work as a whole. But there is a third aspect to this, which is our whole selves.

In Life and How To Survive It, Robin and John talk about very healthy people, and families:

Robin … The better I’ve come to understand these findings, the more I’ve come to think that healthy people live more fully because they’re able to use more of themselves. They seem able to handle comfortably parts of their personality that more ordinary, mid-range people are scared of, and therefore suppress, keep under tight control, keep the brakes on. I once suggested to the Timberlawn researchers that perhaps one big difference in very healthy people is that they can be more comfortable with their ‘madness’ than the rest of us. But of course, for them it isn’t ‘madness’, but just the wilder, more spontaneous reactions that we keep under tight control in case they get out of hand. They can handle it all, and put it all to use. (p. 29)
John … my experience of therapy is that the bits of myself I thought were ‘slightly strange’, and therefore better kept nailed down and out of sight, turned out to be just those qualities I needed and always thought I lacked.

John asks Robin about how this might relate to upbringing.

Robin It’s presumably because there’s been so much trust and confidence and mutual support. When you’re given a lot of freedom and encouragement, yet also feel contained and supported, you learn to express your energy outwardly, fully and freely, without fearing the consequences.

In this post, I look at the issue of the whole self through three lenses.

Gifts, skills and passions

As a child and teen I was a writer, an observer, a listener, a thinker, and an artist. If my mother were alive today, she would say that these were my ‘gifts’. Over time, I became interested in people, relationships, and experience, and decided to study psychology instead of art and design. After graduation, I became interested in work in particular, and began work in human factors and ergonomics.

What I found, working in very technical safety-critical contexts, was that the work was not very ‘human’. Most of my work, and that of my colleagues, was very analytical – reducing humans to components (factors of humans) and analysing their micro-interactions via cognitivism and engineering. The ‘person’ was not really relevant. In effect, some of the five postulates of humanistic psychology were sacrificed.

I spent many years analysing (breaking down) failure (see Lesson 1) and analysing micro-interactions with other people, and (especially) technology and procedures. I became skilled at this, and turned this work into a PhD.

But didn’t get much joy or meaning from it. It was a skill, but not a gift or passion. Over the years, as a practitioner and academic, I became dissatisfied with human factors and safety, and decided instead to train as a counsellor. During the training, I found that, really, I was distressed at discarding so much of my whole self at work for the sake of a skill. It is only in the last few years that my natural gifts and passions have been fully brought to my work in human factors and safety.

I know that many people feel or have felt similarly restricted at work, lacking the opportunity to express anything other than narrow aspects of their selves. Many people have gifts and passions but no opportunity to exercise them, perhaps because they are not known, or not valued enough to create space for them to flourish.

What are your first memories as a child when you remember yourself feeling joy? What were you doing? The chances are you were engaged in a passion, using and perhaps giving your natural gifts. There would have been sheer pleasure in the doing. Left to our own devices, as children we would often do the things that came naturally to us. Looking back on our lives in this way can give us insight into our natural strengths, interests and abilities.

Image: clement127 CC BY-NC-ND 2.0

Norms and subpersonalities

In work, as in families and in other social contexts life, we tend to split ourselves off into different ‘selves’, comparable in some ways to sub-personalities (see Rowan, 1990). Subpersonalities are found in many approaches to psychotherapy and can be seen as patterns in the way we perceive, feel, behave, see ourselves and bring aspects of ourselves into particular situations.

We may experience ourselves, and others may experience us, quite differently in different contexts: work, partnership, family, friendship, alone, etc. Of course there are some ways of behaving that are more appropriate for certain contexts, and we understand these norms. Walking on a beach in a bikini or swimming trunks is completely unremarkable. Walking down the high street in the same clothing is highly irregular!

But in our desire to keep our many selves separate, we can form rigid boundaries around expression and experiencing, restrict our way of being in accordance with expectations, norms, roles and stereotypes, to the detriment of performance, well-being, and joy.

In a study cited by Skynner, senior nurses (matrons) adopted a strict and fearsome demeanor. This had a function of preventing mistakes and ensuring things were done properly. Student nurses, on the other hand, were more in touch with the playful sides of themselves, while restricted from exercising responsibility. We can become trapped in particular roles and ways of being, suffering dissatisfaction because we can only express parts of our selves.

This has a parallel, I think, for many in that their ‘professional self’ crowds out other aspects of their self. This phenomenon seems to be increasing, especially with technology and social media, to the point that, for some, the professional self is at the forefront of much of one’s experience. 

Congruence and full functioning

In some ways, this resonates with Carl Rogers’ notion of realness, congruence, genuineness or authenticity. Rogers – a pioneer in the person-centred approach to counselling – emphasised the need for congruence in the therapeutic relationship, and more generally. “By this I mean that when my experiencing of this moment is present in my awareness and when what is present in my awareness is present in my communication, then each of these three levels matches or is congruent. At such moments I am integrated or whole, I am completely in one piece” (Rogers, 1980, p. 15), “without front or façade” (1961, p. 61).

Rogers made many remarks about wholeness in On Becoming a Person: A Therapist’s View of Psychotherapy (1961) and A Way of Being (1980). He said that congruence “is a fundamental basis for the best of communication” (1980, p. 15) and is “a basis for living together in a climate of realness” (1980, p. 160). Rogers encouraged more open expression of feelings, and not acting “as though I were something that I am not” (1961, p. 16).

Also related to the whole self, Rogers wrote about the ‘fully functioning person’. He listed seven characteristics. which we might consider in a work context. To what degree do we feel we can exercise these in a work context, which is, after all, much of our lived experience?

  1. A growing openness to experience
  2. An increasingly existential lifestyle
  3. Increasing organismic trust
  4. Freedom of choice
  5. Creativity
  6. Reliability and constructiveness
  7. A rich full life

We are often not very congruent at work and there can be many barriers to full functioning within professions and organisations. This is especially true in tight knit groups and command-and-control style management regimes. In both of these, there tend to be tight constraints on expression, mostly of the soft, unwritten, unspoken variety. They are observed and often communicated indirectly or unconsciously, or self-imposed based on acculturation. We do need to exercise some sensible limits to our expression. But perhaps we can also have a little more courage to be truer to our whole selves, instead of wearing only the ‘professional’ cloak.

When it comes to my own way of being and my own practice, I feel called to bring more of my whole self and my individuality to my working life. I find that being open and authentic has more advantages than disadvantages. More to the point, it simply feels right, and restricting my expression and self feels unnatural, artificial, and ultimately intolerable. Over time, expressing my true self at work has become less of a choice and more of an imperative. Perhaps being truer to our whole selves at work can allow us to give, and receive, gifts of joy, meaning, connection, and responsibility

Look out on for my conversation with David Murphy on learning form psychotherapy and psychology in a forthcoming post and in HindSight Magazine Issue 28, to be published in February 2019.

Posted in Humanistic Psychology | Tagged , , , , ,

Learning Teams, Learning from Communities

Image: Oliver CC BY-NC-ND 2.0

Over the last decade, I have spent a lot of time listening to operational, technical, specialist, support and managerial staff in small groups around Europe. The conversations – aimed at learning about safety – have changed over the years. What started off as strongly facilitated workshops to interrogate safety culture questionnaire results, became only loosely based on questionnaire results, and more on what mattered to participants, but still with predetermined issues in mind. Finally, the conversations became much more open still. In small groups, we sat in a circle to understand the issues that mattered to the participants, concerning safety and the effectiveness of work more generally. 

This latter transition has occurred alongside an increasing interest that I have developed over the last few years in natural communities. It is rare that organisations and professions try to learn from communities, and yet there is much to be learned from how healthy communities work. 

Descriptions of healthy communities can be found in asset-based community development (ABCD). ABCD is an approach to understanding and developing communities from the inside based on that they have– assets. As well as being asset-based, it is citizen-led, relationship-oriented, place-based, and inclusion-based (Russell, 2017). 

This interest has paralleled the development of Safety-II – learning from ‘what goes’, including how things normally go right, as well as how thing occasionally go wrong (see EUROCONTROL, 2013). Both resonate with a longstanding interest – humanistic psychology, which is more interested in human potentials than deficits.

Having listened to thousands of people in person, what people most often said was critical to safety was relationships with direct colleagues (including direct managers). This is backed up by quantitative data from tens of thousands of completed questionnaires. Years ago, we would gratefully accept this finding, and ask few more questions of it, focusing only on deficits. Now I find relationships to be fundamental assets – just as people said – worthy of much deeper understanding and development.

A major figure in the history ABCD has been Professor John McKnight. He has worked in activist organisations and civil rights agencies, and learned the Alinsky approach to community organising before developing ABCD, along with John Kretzmann. McKnight went on to create university departments to support urban change agents. Another major figure in community development has been Peter Block, known for work on organisation development, community building, and civic engagement. He works on building the capacity of community to value its gifts and see its own possibility. The work has been developed and applied further by Cormac Russell, a faculty member of the ABCD Institute, who has worked with communities in over 30 countries and has brought ABCD to many. Cormac and I have worked together with 20 or so small group Learning Teams, bringing insights from ABCD to working groups.  

In this article, I refer to some of the ideas and writings of ABCD to reflect on Learning Teams, and small group conversations and action more generally in organisations. I highlight four lessons from ABCD for Learning Teams, health and safety professionals, and their host organisations. The lessons do not form a complete set, and there are of course other lessons from outside of ABCD, but I hope that the lessons are of value to those work with Learning Teams, or plan to. 

Lesson 1: Talk about everyday work

ABCD is about everyday life in communities, and the capacities and potentials that exist and are used (or could be used, or extended) to improve community life. Everyday life is rich, with many values, goals and activities jostling for attention. There is no singular focus. Health, safety, security, education, housing, mobility…all are important, all interact, though each can be more important at particular times for different people. 

As we know, workers are often only marginally interested in ‘health and safety’, and even caricature “elf ‘n’ safety gone mad”as a counter against bureaucratic controls. What workers are interested in is work and worklife. When work is viewed in the whole, rather than through the lens of health and safety (or accidents) alone, many things emerge: the patterns, the goal conflicts, the trade-offs, the dilemmas, the messy details, the joys, the successes, the meanings. Holistic discussions inevitably include health and safety, and other things, all of which are inextricably linked. There are benefits to this broader perspective that extend beyond traditional conceptions of health and safety and connect different values.

Lesson 2: Start with what’s strong, not what’s wrong

Health and safety, like many medical specialities, is one of few professions that views what it wants through the lens of what is doesn’t want – what’s wrong or what could be wrong. This is rather like viewing happiness through the lens of misery. We know that we don’t want people to be harmed in accidents. And so we tend to organise around avoidance. Yet we also know that we don’t get what we want by only avoiding what we don’t want. I don’t want to have an accident on the way to work. One way to guarantee that is not to go work. 

In The Careless Society: Community And Its Counterfeits, John McKnight (1995) noted that “The obvious centre of the medical mentality is the focus upon malady, deficiency, disease, and need – the empty half of the glass. Clearly, the empty half is present. And just as clearly, the half full is present.” (p.75). He also made a remark that challenges many ‘helping’ professions: “The medical system needs the empty half. The healthful community needs the full half …The raw material of community is capacity. The raw material of medicine is deficiency.”(p.76). In health and safety, do we need the empty half more than the organisation and workers needs the full half? Perhaps such a ‘need’ is legitimate, as a counter against an organisational focus on efficiency and productivity. But what are the unintended consequences of a deficit-based approach? How does it affect our view of the world?

In Cormac Russell’s (2018) conversation with McKnight on the heritage of ABCD, McKnight remarked that “many people, and even whole institutional systems, live by inaccurate maps; they have incorrect definitions or perceptions of people, places and things. They judge people and events through the labels they assign them, such as “needy”, rather than through observable actions and verifiable accounts.” (p. 84). 

In health and safety, we can fall into the trap of viewing work, those who do the work, and their behaviour, through a deficit lens. This is easy to demonstrate. Take the content and glossary of any safety report, or the minutes of a safety meeting. The language and terms tend to be overwhelmingly negative. And yet, everyday work is mostly rather effective. Our lens reflects a sort of ‘déformation professionelle’ or ‘trained incapacity’ – a tendency to look at things from our limited professional perspective, developed via professional acculturation, means that our abilities function as inadequacies or blind spots (see Shorrock, 2013).

When we view people through a deficit lens, we tend to view them also in terms of their needs, as we imagine them. But our imagination of the work and needs of others is vastly simplified. It is also wrong in important ways. Imagined work and imagined needs is the wrong way to look and the wrong place to start. We need to startwith their assets, as they understand them. This is the startingplace for ABCD, and is a way of thinking that resonates with Safety-II. It is valuable to focus firston what we have and what is working well, including our gifts, skills and passions, which can be illuminated, connected and mobilised in Learning Teams. Starting on an asset footing results in a profoundly different conversation compared with starting on a deficit footing.

The valuable capacities of people, and other assets, that create safetyneed to be illuminated and connected. I find it helpful to start discussions with questions like, “What is going well for you/us in the day-to-day work”, or “If you had to explain to a neighbour why things work well here, what would you say?”I’m trying to understand the assets (relating to people, environments, activities, processes). I’m also interested in what people perceive to be limits of these. If everyone’s answer is very local to their self or immediate team, I’d have more questions to ask about the organisation as a whole.  

Lesson 3: Find ways to cross departmental boundaries

When we think of a ‘team’, we often think of people who routinely work together doing similar sorts of things. When it comes to Learning Teams, this means that people understand their own work and know the relevant health and safety issues. And there will be bonding social capital, bringing trust, commitment, and reciprocity. But people in teams also tend to be more like-minded, and less diverse. There will be unstated assumptions and taboo topics. Drifts in behaviour may be hard to see. There will tend to be pressure to conform (to opinions, beliefs, behaviour patterns, etc) in order to belong. These latter features of teams are, unfortunately, often the enemies of learning. The ‘divisional’ design of organisations can reinforce this. Divisions and departments, and the teams within them, can make it hard to see how our work interacts with that of others.

John McKnight recalled to Cormac Russell a story about John’s ‘County Labrador Retriever Owner Association’, where people and their Labrador dogs got together. One day, someone with a beautiful dog approached the group. The trouble was, it wasn’t a Labrador. It was a German Shepherd. In a delightfully Monty Python-esque scenario, it illustrated something about the often arbitrary boundaries that we create and maintain. In organisations, we tend to organise around function instead of the flow of work and information. 

Teams exist within a much larger, interconnected network, and a flow of work. ABCD would encourage us to think about the boundaries of Learning Teams. Where are the edges? Is there an invitation to the stranger at the edge? Crossing boundaries requires invitation, participation and connection (see Shorrock, 2017). 

In my podcast conversation with Cormac Russell (see Shorrock, 2018), he highlighted roles in ABCD discourse that are important in crossing organisational boundaries. ‘Gappers’ link together functions and people at the edges or boundaries, often quite purposively. ‘Connectors’ connect individuals in a special and natural way. Connectors are well connected, see the best of others, are trusted & create trust. They believe in community & move around comfortably between different groups. They get joy from connecting people. You can probably identify people with these informal roles in your own workplace or organisations you’ve worked with. They are as important as ‘leaders’, but rarely recognised as such.

In The Abundant Community, McKnight and Block (2010) wrote of community connectors, “we want to elevate and make more visible people who have this connecting capacity. We also want to encourage each of us to discover the connecting possibility in our own selves … The operating question becomes, who are the proven and potential connectors of our acquaintance? Who sees the gifts of local people and figures out ways to share them? Whom do people turn to when something needs to be done on the block? Who are the people who take responsibility for civic events? Who are the leaders of our local associations?” The same questions could be asked in organisations. But do we?

In working with interdisciplinary Learning Teams, Cormac and I asked each person what they appreciated about the sessions. The responses of the 200 or so people were heart-warming, but also sometimes sad. We heard from many people who said that they work in the same corridor, or do work that affects each other, or passing one another daily for years or even decades, and had a conversation for the first time during these small group conversations. 

Lesson 4: Understand first what can be done BY teams

One parallel for Learning Teams in communities is ‘Listening Tables’ of neighbours and their representative associations, and institutions that want to become friendly with communities. McKnight and Block (2010) remarked that“these initiatives can create a dialogue that begins to redefine the powers and responsibilities of institutions and communities. This dialogue can be framed by three questions: First: What functions can neighborhood people perform by themselves? Second: What functions can neighbors achieve with some additional help from the institutions? Finally: What functions must institutions perform on their own?” 

They go on to say that “the order of these questions is very important. It shows that the basic productive force is the local community. What citizens can do for themselves is the primary question. What institutions can do is a secondary question. A neighborhood doesn’t know what it needs from outside until it is clear on what is has inside.” This message is echoed by Russell (2019), using the question of change done BY, WITH, FOR, and TO people.The question of agency and power in health and safety is important. If we start by asking what can be done TO or FOR people, rather than BY people, we end up disempowering them.

Just as systems and professionals cannot provide health and safety for communities, health and safety professionals cannot provide health and safety for workers. Safety is created at many levels of organisations, and by startingwith what health and safety professionals can do, we end up colonising health and safety, perhaps creating and even believing an illusion that only the professional has the capacity to create safety. As McKnight (1995) remarked, “As you are the problem, the assumption is that, I the professional service, am the answer. You are not the answer. Your peers are not the answer. The political, social and economic environment is not the answer. Nor is it possible that there is no answer. I, the professional, am the answer.”(p.46). 

McKnight went on to say that “the disabling function of unilateral professional help is the hidden assumption that ‘you will be better because I, the professional, know better’”.

He identifies a second disabling characteristic of professionalised remedial assumptions as the remedy defining the need. “As professionalised service systems create more elegant techniques and magnificent tools, they create an imperative demanding their use.” (McKnight, 1995, p.47). By making workers the subjects of systems, rather than co-creators, we disable their capacities – gifts that are essential to health and safety, and effectiveness more generally.

Health and safety professionals, and organisations, can help learning teams by creating space and time for them to convene, illuminate what’s going well, document their dilemmas, state what they want, and what they can offer.

Summing up

I find it hard to think of a more important aspect of organisational life when it comes to health and safety, and effectiveness more generally, than small group conversations and action. Learning Teams are nothing new in this regard (being similar to action learning) but there are some useful orienting insights to be had from fields such as community development. To sum up:

  • talk about everyday work
  • start with what’s strong, not what’s wrong
  • find ways to cross departmental boundaries and get multiple perspectives
  • understand first what can be done BY teams.

Our recent feedback from around 200 people, is that Learning Teams, integrating insights from Asset-Based Community Development, can: 

  • help better understand one’s own work
  • introduce new perspectives on problems and opportunities
  • illuminate the work of others, and how it interacts with one’s own
  • introduce colleagues to one another
  • foster a sense of inclusion, and 
  • give hope and optimism. 

These outcomes relate to health and safety, but go further still to help focus on what matters to those who do the work, to make work as effective as possible and worklife as fulling as possible.


EUROCONTROL (2013, September). From Safety-I to Safety-II. A White Paper. Brussels: EUROCONTROL Network Manager. Retrieved from

McKnight, J. (2008). The careless society: Community and its counterfeits. Basic Books. 

McKnight, J. and Block, P. (2010). The abundant community: awakening the power of families and neighborhoods. Berrett-Koehler Publishers.

Russell, C. (2017). Asset-based community development – 5 core principles. Retrieved from

Russell, C. (2018). Asset based community development (ABCD): Looking back to look forward. Cormac Russell.

Russell, C. (2019). Four modes of change: to, for, with, by. HindSight, Issue 28, Winter 2018-2019, EUROCONTROL: Brussels. Forthcoming at

Shorrock, S. (2013). Déformation professionnelle: How profession distorts perspective. [Blog post]. Retrieved from

Shorrock, S. (2017). Editorial: Invitation, participation, connection. HindSight, Issue 25, Summer 2017, EUROCONTROL: Brussels. Retrieved from

Shorrock, S. and Russell, C. (2018). Learning from communities: a conversation with Cormac Russell. Retrieved from

Posted in Humanistic Psychology, Safety, systems thinking | Tagged , , , , , , , , , ,

The Real Second Victims

In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example that has played on my mind over recent years is the term ‘second victim’.

The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following:

“although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”.

As someone with a PhD in ‘human error’, the potential for trauma associated with one’s own actions and decisions is a phenomenon that I have come across in many interviews and discussions, albeit in a different context – air traffic control. In this context, professionals’ decisions and actions are almost never associated with death, but there are rare examples, and the prospect of hundreds of lives being lost at once can be devastating in the context of a near miss.

The term ‘second victim’ in healthcare was further popularised by Sidney Dekker in his 2013 book Second Victim: Error, Guilt, Trauma, and Resilience. There are tens of thousands of webpages on ‘second victims’. It is a term that is accepted by healthcare practitioners who see only too clearly the immediate consequences of mistakes and actions-not-as-planned.

While the term is accepted within the medical professions, important questions have been asked by those who have lost more than their confidence, profession or even – for however long – mental health. Sara Ryan – the mother of Connor Sparrowhawk (popularly known as LB, or Laughing Boy), is one of several families who have questioned the use of the term in healthcare. Sara remarked on twitter:

The thread continued:

She later clarified:

Surely families are the second victim? It was one of those questions that could perhaps only come from the profound truth of pain. LB was “a fit and healthy young man, who loved buses, London, Eddie Stobart and speaking his mind” (see the #JusticeforLB website). As described on #JusticeforLB:

LB’s mood changed as he approached adulthood and on 19 March 2013 he was admitted to hospital, the STATT (Short Term Assessment and Treatment Team) inpatient unit run by Southern Health NHS Foundation Trust). LB drowned in the bath on 4 July 2013. An entirely preventable death.

Sara and her family were not only victims following the death of Connor. They were further victimised by organisations responsible for Connor’s death. The process of getting justice has involved an inhumane ordeal, including a good deal of ‘mother blame’, detailed in Sara’s book ‘Justice for Laughing Boy’. This is a book that should be standard reading on a wide range of courses, from medicine to law. But in a paragraph, from the website #JusticeforLB:

How are you all doing?

Mmm. Good question. Not sure really. I can probably only speak for myself [Sara]. Not brilliant really. The death of a child is an unimaginable happening. That it could have been so simply and easily avoided, in a space in which no one would have thought he was at risk of harm, is almost impossible to make sense of. The actions of Oxfordshire County Council and Southern Health NHS Foundation Trust since his death have been relentlessly battering.

So perhaps it takes an experience of being a real second victim, and of being victimised, to see that the the term ‘second victim’ is one that only applies to loved ones.

Then again, it’s obvious. Of course family are the second victims. How could they not be?

But it is not obvious to tens of thousands, perhaps hundreds of thousands or more, of healthcare workers who find personal meaning in the term ‘second victim’, as applied to themselves – actually or potentially.

I asked my partner – an experienced practising psychotherapist and trainee counselling psychologist – what came to mind with the term ‘second victim’. Without hesitation, she said “family“. She had never heard the term ‘second victim’ before and did not know why I was asking.

She said, “If you’d have said ‘secondary trauma’, I’d have said the professional“. That is because, in this sense, the primary trauma is with the family who survive a person who has died. She also mentioned the difference in choice and control between clinicians and family, in that a clinician for instance, while unable to control the environment and resources, has control over whether she or he is a clinician. While my partner has no control over clients, she has control over her choice to remain a psychotherapist.

Some have tried to combine those who have died and their families as first victims (e.g., But this casual combination of the dead and their loved ones is unconvincing, and seems like a fudge. My own mother died at 45 years old (following delays in treatment and lack of communication between a private and public hospital, which I won’t go into here). I remember my father at the time saying, “People tell me they feel sorry for me. I say they should feel sorry for her. She died at 45!”

There is a very real difference between a someone who has died, and a loved one who is grieving for that person, and someone who is suffering having witnessed or somehow been involved as a healthcare professional before the person died. Sara writes more about that here. She notes that “I’m not ignoring or denying that healthcare staff may/must be devastated by the death or serious harm of a patient here. It simply ain’t comparable to the experiences of families.”

Questions about first and second victims inevitably imply a ranking. So if loved ones are the real second victims, different in a very real sense to the deceased, then where does this leave professionals, who are different in a very real sense to bereaved families? Logically, however unsavoury the ranking exercise, professionals are third victims. The conversation in the third tweet above continued on this line of inquiry:

While ranking victimhood may seem like a troubling exercise, professionals in healthcare have, in effect, already created a ranking by establishing – quite uncritically it seems – the term ‘second victim’. ‘Second victim’ indicates a first victim, and implies a third victim.

During bereavement, families are sometimes victimised further still by organisations during the natural quest for justice. Justice, in this context, includes apology, truth, genuine involvement, learning, and change. For LB and his loved ones, it included this and this. In effect, justice involves the proper meeting of needs. There are millions more like LB, and millions of families like his, who feel forgotten and discounted by the professionals, organisations, and society, who morally and ethically should be involved in meeting these needs.

Sadly, the established ‘second victim’ concept, in effect, further victimises the forgotten. Acknowledging and helping to meet the needs of loved ones as the real second victims, as well as healthcare professionals as third victims, would be a truly restorative act of justice.


Wu, A.W. (2000). Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal, 320, 726–727.

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The Commercialisation and Commodification of Competency


Image: CC BY-NC-ND 3.0

Two or three years ago, I undertook a course involving UX ‘certification’. I had already undertaken courses in HCI and design as part of an MSc(Eng) in Work Design and Ergonomics some years (ahem…21) earlier. And I had already been involved in most aspects of the design and evaluation of interactive systems. So I was interested in what was new. In fact, the course was an overview of an ergonomics standard (and a good one: ISO 9241-210, 2010), which was not new to me but was enjoyable nonetheless. The course lasted two days, with a half day revision session, and a multiple choice exam. The course was well delivered, and the exam was properly invigilated.

But the test, in my view, was primarily a memory test that tested recall or recognition of specific vocabulary. Aspects of the test seemed to focus on dubious and debateable semantic differences, using very similar options that seemed to be designed to confuse. The certification arrangement seemed to encourage teaching to the test, and ironically felt like UX (and accessibility) had been ignored in the certification process, which required a high level of English to wade through the semantic quagmire.

Those who undertook the test came out feeling deflated, doubtful, discouraged and demoralised. Their passion for the subject as newcomers was gone, while existing practitioners were now skeptical of certification, at least of this sort. I know this because I spoke to many immediately after the course. After a while, we either learned that we had passed, or not, the test. Some of the questions were so vague and convoluted that complaints were made. People waited to hear whether their money – or moreover that of their employer – had been well spent and whether they were now certified. I am quite sure though that a ‘pass’ would give most a feeling of relief and pride. We humans, indeed mammals generally, like to be members of clubs, and we like ranks. We see this natural preference throughout organisational life.

There are many other such courses, often a day or a few days in duration, relating to all aspects of work (e.g., safety management, crew resource management [sometimes sold as ‘human factors‘], safety culture, just culture, error management, etc). In my experience, at their best, they offer a starting point for further exploration, but usually little more than that. That is enough. But they are often sold as much more. Importantly, rather than acting as a springboard for reflection, exploration and divergent learning, they act as a dragnet for further convergent indoctrination and up-selling of a defined set of ideas and tools. More worrying still is when they infer membership of an ‘exclusive’ club (which may benefit the owner of the club much more than the members).

Such training is often associated with ‘tools’ (almost always trademarked) that are licensed for profit, often combined with mandatory commercial training, refresher training, and ongoing subscription by the tool developer. Trade-marking and licensing is often a legitimate and necessary way to protect intellectual property (especially for small businesses). But it does not infer quality. Some of these tools lack innovation, have been overtaken by fundamental changes in theory, or are available in similar form elsewhere freely or at reduced cost, and yet subscription and licensing services can lock users into hard or soft dependency.

So here are a five things to look out for, and associated questions to consider, when considering products and services of this nature. They are not in any way definitive. There will be other criteria and questions, and some of these may not indicate a problem, but they may be useful things to think about.

  1. Dependency: Does it lock you into dependency? Is it hard to move to something more suitable, with a different supplier or service provider, for hard reasons (e.g., contracts; subscription) or soft reasons (e.g., feelings of commitment; sunk cost)?
  2. Manufactured exclusivity: Does it create ‘exclusivity’, and the sense of being an ‘insider’, or ‘part of something’ (a club, scheme, network, community, user group, benchmarking group)? Does your feeling about it, and evaluation of it, depend on your membership status, or whether you pass a test? Does it involve ranks (belts, ‘Master’ status, bronze/silver/gold) or other appeals to pride?
  3. Dubious value: Can your need realistically be met by reading along with online/in person discussion groups, supervised practice, etc? Is something comparable available elsewhere that provides much of the value, at much reduced cost? Is the product or service outside of a respected, independent not-for-profit regulation or certification body?
  4. Closed: Does it remain fixed, and not updated in light of scientific developments and changes in theory and method? Is independent evaluation precluded? Does it ignore fundamental challenges to its assumptions, theory, method, etc? Is critical reflection and inquiry discouraged? Is exploration of alternative approaches discouraged, without good reason?
  5. Control: Is control (over ideas, information, method, theory, means of interaction and exchange) highly centralised into one person or private commercial entity?

If you can answer ‘Yes’ to a few of these questions, this may not be a problem. The product or service may provide sufficient value, or the questions answered ‘Yes’ may not be significant. But increasing ‘Yes’ responses may indicate a problem, and in this case you might want to consider whether the product or service is what you need, or what someone else wants you to need.

Posted in Human Factors/Ergonomics, Safety, systems thinking | Tagged , , , , , , ,

Giving Guidance to Government

This article was published in The Ergonomist, published by the Chartered Institute of Ergonomics and Human Factors, No. 568, Nov-Dec 2018.


From healthcare and patient safety, to the latest developments in driver automation, human factors is not only relevant across many issues of societal concern, it can achieve significant impact too. Steven Shorrock and Sarah Sharples share their experiences contributing to three key government reports.

Human factors and ergonomics seeks to optimise interactions between people and all other elements of the system at all levels. Much of the time, practitioners and researchers are concerned with evaluating and designing work, tools and environments for specific applications. Occasionally, however, opportunities arise at the level of organisational decision-making, regulation and at government level. For many issues of societal concern, human factors expertise is particularly relevant and could have significant impact, if it secures a place at the table.

The following three reports illustrate the span of issues and impact that human factors advisers can achieve when working closely with government.

Learning in the NHS

Steven Shorrock gave oral evidence, with Scott Morrish, father of the late Sam Morrish and Member of the Healthcare Safety Investigation Branch (HSIB) Expert Advisory Group, on Tuesday 8 November 2016 in a meeting Chaired by Bernard Jenkin MP in the Houses of Parliament.

This report focused on the issues arising from the Parliamentary and Health Service Ombudsman’s (PHSO) July 2016 report, ‘Learning from Mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS in England failed to properly investigate the death of a three-year old child’.

‘Learning from Mistakes’ was the PHSO’s second report on the tragic death of a three-year old child, Sam Morrish, on 23 December 2010. It set out four key findings:

  1. A defensive culture in the NHS.
  2. A lack of competence and sufficient independence in the conduct of NHS investigations into potentially avoidable harm and death.
  3. Poor coordination and cooperation between NHS organisations involved in investigations, and failure to collectively identify and act on lessons.
  4. Insufficient involvement of families and staff in NHS investigations.

The report made conclusions and recommendations regarding:

  • The Investigative Landscape in the NHS in England.
  • HSIB and the learning culture.
  • Learning and accountability: implementation of the ‘safe space’ .
  • System-wide ‘just culture’.
  • Improving local competence.
  • Measuring improvement.

In response to discussion surrounding a ‘just culture’ taskforce, Steven said that from his experience in aviation, there must be consensus on the need for a just and fair culture that is about learning as a whole. He said that if you don’t have that consensus from a range of stakeholders, you’ll always have something in your system that is pushing against it. “An inclusive taskforce where people are trying to understand each other’s worlds is really the only way to go about it,” he said. “We have certainly learned that that is the only way to get people to understand the need for a just culture, and also to understand each other’s worlds, that the world of the judiciary is very different to the world of practitioners, and both of those worlds do need to co-exist,” he added.

Responding to Scott Morrish’s comments around blame culture, Steven said he felt there that healthcare needed to start looking more at similarities between the ways that things work in different parts of the system. “Fundamentally, most adverse events in healthcare do have at their heart a certain level of pressure, which is one of the system vulnerabilities,” he said.

“Understanding that the system as imagined and system as found, are two different things, is vital,” he said. “The system that we imagine is a very different one to the system that really exists, where resources are often inadequate, the constraints affect the work in a way that is counterproductive, and pressure makes everyone’s job, especially practitioners, much more difficult.” Steven went on to say that healthcare managers must focus on the system as they find it; the work as it’s actually done, and not the one that they imagine. “That means we need to involve an awful lot of people to understand how the system really works if we want to understand and improve it.”

Autonomous vehicles

Oral evidence was provided by Professor Sarah Sharples on Tuesday 22 November 2017 in Committee Room 4A at the Palace of Westminster.

The House of Lords Science and Technology Committee heard evidence from the Department for Transport, the Department for Business, Energy and Industrial Strategy as well as leading academics. The Committee explored with Government Ministers how driverless vehicles fit into wider transport strategy and policy and what the Government is doing to ensure knowledge gained in their development benefits all sectors. The Committee also examined with the academics the socio-economic aspects of the deployment of self-driving cars such as how much is really understood about human interaction with the technology.

The four main findings of the report into connected and autonomous vehicles (CAV) were:

  • The Government is too focused on highly-automated private road vehicles (‘driverless cars’), when the early benefits are likely to appear in other sectors, such as maritime and agriculture.
  • The development of CAV across different sectors needs coordination and the Government, working with key stakeholders, must get a grip on this chiefly by establishing a Robotics and Autonomous Systems (RAS) Leadership Council as soon as possible to play a key role in developing a strategy for CAV.
  • There is a clear need for further Government-commissioned social and economic research to weigh the potential human and financial implications of CAV.
  • This is a fast-moving area of technology and the Government has much to do, alongside industry and other partners, to position the UK so that it can take full advantage of the opportunities that CAV offer in different sectors.

Asked for her view on full-scale trials and live testing, Sarah recommended a mixed-methods approach. Referencing early data from a Transport Systems Catapult demonstration, she said public attitude towards the vehicles was very positive. “It’s only when the public see those vehicles deployed in a real situation that we can start to understand what people might think when they see these new technologies implemented in the context they are so familiar with,” she said.

“Humans are fallible, but humans are also brilliant,” said Sarah in response to the notion that people could be the biggest barrier to autonomous vehicle success. “We know that humans are great at adapting to new situations and changing the way they work with new technologies, but we need to be aware of their capabilities and limitations when we design those technologies.”

Commenting on the potential loss of skills and the responsibility of the driver, Sarah highlighted the control task of the vehicle and the need to maintain both the skills and understanding, and that people gain an appropriate level of competence through a driving test. “Even with fully automated vehicles we need to build in contingency for when the driver will need to take control,” she said.

She went on to suggest that within the conventional driving test, an understanding of the capabilities of those different types of vehicles could be introduced.

Gross negligence manslaughter

Oral evidence was provided by Steven Shorrock at De Vere Grand Connaught Rooms, London, on 6 April 2018.

The Williams Review was a rapid policy review into gross negligence manslaughter in healthcare and was chaired by Professor Sir Norman Williams. The review was set up to make recommendations to support a more just and learning culture in the healthcare system. It covered:

  • The process for investigating gross negligence manslaughter.
  • Reflective practice of healthcare professionals.
  • The regulation of healthcare professionals.

The review heard evidence from a variety of organisations and individuals. It was set up to look at the wider patient safety impact of concerns among healthcare professionals that simple errors could result in prosecution for gross negligence manslaughter, even if they happen in the context of broader organisation and system failings.

Providing evidence

Based on Steven and Sarah’s experience of providing evidence, they offer nine pieces of advice:

  1. Ask for a list of topics or likely questions. You can then consider the kinds of things that you want to discuss. Prepare, but don’t rehearse answers to the questions.
  2. Get advice from people who have done it before. There are likely to be CIEHF members who have participated in similar kinds of committees or reviews.
  3. Maintain good contact with the clerks. They’ll help you to understand what is expected and when.
  4. Find out whether the evidence will be recorded, and how. Evidence may be televised, or transcribed, or not. If the evidence is not recorded, then you may wish to take notes on the themes of your answers during and after the session, in case the notes don’t reflect your answers.
  5. Be comfortable with yourself as an expert. You are expected to base your views on the state of the art, but your opinions are also respected.
  6. Don’t campaign. You need to be objective and evidence-based where possible, and not political. Your answers may be professional opinion or fact, but this must be clearly distinguished.
  7. Follow up with resources and information. There will be things that you won’t mention during oral evidence, or that were not recorded, that you think are pertinent and it’s fine to send these to the clerk after you have given evidence.
  8. Check what extra input will be required and when. You may be sent information to fact check, with very little notice, maybe 24 hours.
  9. Be mindful that your evidence may be used selectively. On publication, you may find that your evidence is used very partially or not in a way that you expect. This may relate to the terms of reference of the review or committee.

Authors’ affiliations

Steven Shorrock is a Chartered Psychologist and Chartered Ergonomist & Human Factors Specialist with experience in various safety-critical industries, including aviation, rail, chemical manufacturing and healthcare.

A former CIEHF President, Sarah Sharples is Faculty Pro-Vice-Chancellor for Research & Knowledge Exchange, and Professor of Human Factors at the Faculty of Engineering at the University of Nottingham. She is also Non-Executive Director of the Transport Systems Catapult.

Further reading

Learning from Mistakes: Oral evidence was given, recorded and broadcast at The evidence transcription is at The report is available at

Autonomous vehicles: The evidence transcription is at Supplementary written evidence is at The report is available at

The Williams Review report is available at

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