From counting errors to creating organisational resilience
in managing safety
Matita Tshabalala
• Introduction
• Signs of strategic weakness
• Safety Currently - Safety Differently
Presentation
outline
• Safety I vs Resilience
• The Four Cornerstones of Resilience
• The bottom line
Introduction
"As far as the laws of mathematics refer to reality, they are
not certain; and as far as they are certain, they do not refer to
reality.“
Albert Einstein
How did we get here?
Signs of strategic weakness?
Signs of strategic weakness?
Demonstrated vulnerability to unanticipated
events
• Do we need to do better, and more
intensively, what we already do…
 ‘Try harder…’
• Or is the current safety paradigm itself
challenged?
Safety Currently
• People are a problem to control
• Tell them what to do
• Count success by the absence of negatives
Safety Currently - Effects
• Growing safety bureaucracy
– No measurable improvements
– Measuring and managing wrong risk
• Numbers game
• Disengagement
Safety Management
• Sticks
– Compliance demands, surveillance, sanctions
• Carrots
– Rewards for showing low numbers
Safety Management
“There’s a mismatch between what science knows and what business
does.”
Dan Pink
Safety Differently
• People are the solution
• Ask them what they need
• Count positive capacities
Safety Leadership
• Autonomy
– Task, timing, technique, team
• Mastery
– Ever better at something that matters
•
Purpose
– Part of something larger than self
Safety I vs Resilience
Safety I vs Resilience
Traditional safety
management (Safety I)
Resilience Engineering
Definition of safety
Freedom from unacceptable risk
Ability to succeed under varying
conditions
Understanding of safety
Systems are tractable and
performance conditions can be
completely specified
Systems are intractable, and
performance conditions are always
underspecified
Explanations of accidents/incidents
Accidents/incidents are caused by
failures and malfunctions
Things basically happen in the same
way, regardless of the outcome
View of the human factor
Liability
Resource
Safety management principle
Reactive, respond when
something happens
Proactive, try to anticipate
developments and events
Aim for safety management
Learn from mistakes and calculate
the probability of future failure
Improve the capability to cope with
the complexity of the present and
the future
What is Resilience?
“Resilience is the intrinsic ability of a system to adjust its
functioning prior to, during, or following changes and
disturbances, so that it can sustain required operations even
after a major mishap or in the presence of continuous stress”.
Hollnagel, 2008
Resilient Performance
Organisations good at resilient performance do the following:
1. They do not take past results as guarantee for future success
2. They keep the discussion about risk alive even when nothing
wrong has happened
3. They bring in different and fresh perspectives around safety
(listen to minority view points)
4. They have the function or the resource to put the foot down
(around safety)
From the Negative to the Positive
Negative outcomes are
caused by failures and
malfunctions.
Safety = Reduced
number of adverse
events.
Eliminate failures and
malfunctions as far
as possible.
All outcomes (positive and
negative) are due to
performance variability..
Safety = Ability to
respond when
something fails.
Improve ability to
respond to adverse
events.
Safety = Ability to
succeed under varying
conditions.
Improve resilience.
The Four Cornerstones of Resilience
The Four Cornerstones of Resilience
Responding: Knowing
what to do, being
capable of doing it.
Anticipating: Finding
out and knowing what
to expect
Actual
Factual
Learning:
Knowing what has
happened
Critical
Potential
Monitoring:
Knowing what to
look for (attention)
An increased availability and reliability of functioning on all levels will not only
improve safety but also enhance control, hence the ability to predict, plan, and produce.
BOTTOM LINE
Bottom Line
It is possible to summarise the arguments of this presentation by
the following simple statements:
(1) When something goes wrong, then there is no safety (safety
is missing or not there).
(2) When nothing goes wrong, when things just work as they
should, then there is safety.
Therefore:
(3) The scientific study of safety should focus on situations
where nothing goes wrong, i.e., where there is safety, rather
than on situations where something goes wrong – where
there is no safety.
“Every body perseveres in its state of being at rest or of moving
uniformly straight forward, except insofar as it is compelled to
change its state by forces impressed”.
Isaac Newton
Are you ready to think about
“safety differently”?