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Paul Clark and Erik Hollnagel | A Deep Dive into Safety Differently | HSE UK Congress

Paul Clark and Erik Hollnagel | A Deep Dive into Safety Differently and Implementing it | HSE UK Congress (Expert Interview #16)


“Ask yourself, how can we make things go well instead of just not going wrong”Erik Hollnagel

Safety Differently is one of the most talked-about new ideas in health and safety at the moment and a lot of the best and brightest in the field are promoting it as a new way of thinking about the profession and the benefits that it can bring to your workplace. Here we interview Erik Hollnagel to talk about what Safety Differently means and how you can take the first steps towards implementing it in your organisation.



– [Paul] I’m absolutely delighted today to interview Erik, the senior professor of patient safety. Here we go. Jönköping? – [Erik]

Jönköping, that’s good enough.

– Jönköping University. Putting all that aside. I mean I’m new to safety. I’m an events organizer, a digital media specialist, but, you know, I’m very passionate about health and safety. Who wouldn’t be, I mean, you know, staring down the face of quite troubling times, really. I think there’s a little bit of mixed messaging, an element of misunderstanding to how simple perhaps some of the major challenges are and the rise of major incidents and fatalities.

I guess the whole misconception of safety and the mismessaging of the importance and the secrets, particularly around strengthening the resilience of potentials. And I know you did a fantastic workshop at HSE UK Congress this week… thank you so much for coming, which demonstrated some of the ethos of safety and some of the challenges around reducing the unwanted and harmful events and looking at eliminating them to zero accidents and changing the theories around how do we perhaps demonstrate investigating when things are going well, in a nutshell, when things are going bad, which is traditionally what we’re doing, a lot, have I got that right?

– That’s absolutely right, yes.

– Superb. Well, there are for the benefit of the viewers that weren’t there, I’ve actually got a question outside of the questions, which perhaps could maybe sort of demonstrate for us your ethos around the transition from the way that perhaps safety professionals are working right now, to the way you think practically we should be approaching safety.

– Well, I think you already hinted at it. But we all want to avoid accidents and harm and injury and personally, in work, in the companies, and in the nations, of course. And traditionally, we’ve sort of done that by looking at what went wrong and say how can we prevent that?

And I see that every time something happens in Denmark, where, from on a national level, the government says, oh we need to have a new law, a new rule so we make sure it doesn’t happen again in the future. But I think the point is you cannot become safe by preventing things from happening but you can turn it around and say how could we make sure that it goes well, instead of how can we prevent it from failing?

Also because if you put all your eggs in the preventing from failing basket then you’re investing in making sure that something does not happen which doesn’t create any profit. But if you turn it around and say, how can we make sure that it goes well then you’re investing in making sure that things happen that you would like to have which actually create a profit.

So I think from that point of view, it just makes more sense to look at things going well and try to make sure that more things go well. But then that requires that we look at things going well which we traditionally haven’t done in safety, we’ve only looked at the accidents.

– Where do you think that’s come from? I mean, we had a brief chat before the interview, but do you think there’s any… where was the challenge initially and how can we resolve as quickly as possible?

– I mean, obviously, we’re all concerned about when we are hurt and then one of our loved ones or friends or relatives are hurt, I mean, nobody wants that. But I think if you look at the history of safety, then the first book on really popular book on safety was called The Industrial Accident Preventionfrom 1931, it was written by a man, Heinrich, who was a superintendent in an insurance company.

And of course the insurance companies they don’t produce anything, I’m sure they’ll blast me for this, but not like a factory or car manufacturer and so on. But their focus is accidents and that’s why in his book, which is very eloquent and full of examples and even though it’s 90 years old now is still worth reading.

That’s why the focus became on accidents and that somehow stopped because he was a very convincing person and had very good arguments. I think we have sort of have stayed with that for that reason.

– Brilliant. With that then, if we look at how can we understand, perhaps, based on what we’ve learned from what happens when nothing happens?

– Well, I think the important point is to question this idea of nothing happens because that’s what people often say. They say, well, look at everyday activity and then they’ll say, “Well, yeah, but nothing happened.” By which they mean that nothing bad happened. But of course something happened.

I mean, it would be stupid to say that nothing happened because lots of things happen. Like we are on this resort here and everything happens, catering works and everything is in place so lots of things happened but we don’t notice it because they always happen and they always work and we just take them for granted, which we should. As, you know, normal individuals, but as safety experts, we shouldn’t take it for granted.

We should say, “But why did this go well?How can we learn from that?How can we improve that?Do other things work in the same way?And how can we benefit from that?”

– It’s a lot of awareness.

– It’s very much paying attention to things that you don’t pay attention to because you just get used to them.

– That opens things up. Interestingly enough, I teach a lot of mindfulness in my CBT and it says about if you’ve got a string of notes, you only notice the loud notes, you don’t notice the gaps between.

– True, true. I mean, maybe the other example I use when I’m near the sea in a like a hotel by the beach and facing the sea. And the first night and the second night always hear the waves come crashing in and the third night I don’t hear them any longer. It’s not because the waves have stopped crashing in. It’s because you get used to it.

And it’s the same with things that go well every day, we just get used to it and we stop paying attention and that’s okay except if you’re a safety provisioner, then you shouldn’t stop paying attention to it.

– So I guess the question outside of these questions…sorry, I’m really enjoying this because it’s really triggering, is it a behavioral change, in terms of does that behavior come from the individual or because obviously we can’t change the things in the surrounding accidents and things that are going to happen around us from a safety perspective but we can change the way that we think and the way we behave, will that reduce incidents?

– I wouldn’t call it a behavioral change but it’s change of attitude or change of perspective and that’s when we refer to what we call safety one and safety two. To me, they’re two different perspectives, two different ways we’re looking that’s what happens, but what happens is what happens. So in that sense, it’s a change of…wouldn’t even say a change in mindset, it’s realizing there is an additional way of looking at things.

It’s not replacing one by the other, but it’s saying we can look at it this way, but we can also look at it this way and maybe if we combine them, we see more things than we did before. So I think that’s the way to go about it, it’s not a radical change and it’s not an either-or it’s both.

– Coming back then to the workshop yesterday, I think there was a question we were really keen to answer. I’m not sure we had time. It was around recognizing the potentials than an organization needs to perform resiliently, what are your thoughts there?

– Well, we’ve been talking since I was part of the group that started Resilience Engineering in 2004, and there were people who were talked about it even before that. And we’d be sort of working a lot with that and thinking about it and trying to apply it with quite some success. And of course, the question is what is it?

What is necessary in order to behave or perform in a way that we say is resilient that is you’re able to withstand the… slings and …what’s the monologue? slings and arrows of outrageous fortune, but also to make use of the opportunities that you see.

What do we need to do that? And so what we’ve come to over the years is the conclusion or suggestion that you need to be able to do four things. You need to be able to respond when something happens, obviously, that almost goes without saying. You need to be able to monitor the situation to know what’s going on and to know what’s going to happen because otherwise, everything is a surprise and not everything that happens throughout the day should be a surprise, that’s not very good.

And you need to be able to learn because if you don’t learn, then you’ll always do things in the same way and you can’t do things in the same way unless the environment is perfectly stable, which it isn’t. And you need to be able to anticipate, to look ahead beyond the situation you’re in, to be prepared to what might happen. It’s not sure it’s going to happen but what might happen like now, all governments are thinking what happens if the coronavirus goes out of control?

I mean they’re seriously thinking about that. So these four, we call them potentials, is what we need as individuals, what we need as organizations, what we need as companies and nations and so on.

– Do you think that perhaps projecting a little bit too further forward to being too vigilant about what might happen, we’re going to create and install more sort of fear based behaviors around things that we do?

– You can certainly all do that. And certainly some people are in all kinds of situations trying to sort of paint the worst possible picture to sort of force others to behave in a certain way and I’m not going to either go into politics or anything.

– Of course, I see it all day.

– I see that when you have the national elections and so on absolutely.

– Not the time, maybe.

– Not the time, well they have one in some other…in a big country and all that. So I think one needs to be realistic. There’s sort of two attitudes. One is, no we don’t want to look at the future because the future’s uncertain and we can’t deal with things that are uncertain. That’s why we only want to respond to what has happened because it’s certain That’s sort of the heads in the sand argument, that’s not very good.

But the other extreme is to say to be sort of hyper anxious about what could possibly happen but that’s also paralyzing. So you need to find a balance there, you need to look ahead, you need to… and we all do that in our lives. We think about what’s going to happen next year or in 10 years or whatever, and what’s going to happen to our kids and what are the educational system going to be like?

Well, we can’t worry too much about that, but we just need to consider it because denying it or neglecting to do it is not going to improve our own situation.

– Sure, sure, sure, that makes perfect sense. Resilience. I’ve got one more question after this, but I just want to hit on resilience. There will be people…there’s 3000 plus members of network all over the world. How would you define resilience in your professional opinion?

– Well, the answer is I don’t define resilience, I define resilient performance because I don’t think there is something called resilience as a quality or something that’s tangible you can measure or do anything about. But we can say performance is resilient if the system, a company is able to perform as it should under expected and unexpected conditions alike because that’s what we want it to be able to.

– That’s awesome. Absolutely. Okay. The final question then is how do we measure and manage those resilience potentials? What are your thoughts? Well, that’s partly why we thought of it because we initially realized if there isn’t anything called resilience, you can’t manage resilience as such and that’s where it’s almost a bit like safety culture.

People talk about safety culture and they want to meant safety culture as if it was something by itself, which isn’t of course. So we said but the resilience potentials are potentials, say the potential to respond, you can then look at it what does it take? And for any company you can say, well, if you look at how are we able to respond? What are we able to respond to, market changes, changes in prices of materials and so on, delays in the system, the new opportunities, what are we not prepared to respond to?

Why haven’t we thought of that? Are we happy with our response set? How do we have the assigned resources to do it? Can we do it quick enough? Because being able to respond immediately is a cost because you can’t use that resource for something else.

– Sure.

– So where’s the optimal time? For some things, you’ll have to be able to respond immediately like if you have a fire here, the fire brigade is on standby and they don’t do anything else. And as a society, we had agreed this is worth the cost, ambulances and so on. Other things we said, “No, we… well, we should be ready to respond in no X minutes, hours, days, weeks.So any company can ask yourself questions like that.What can respond to?How ready are we?How much have we invested in it?How do we maintain the response?How do we verify we are able to respond?How long can we respond?”

And you can ask very concrete questions about that and you cannot use that to assess what is your potential to respond. And you can use that to say, “Well, this is not as good as we would like it, how can we improve that?” Because then you’re talking about something concrete, and then you can actually think about concretely how to improve that. Thinking in terms of the potentials and the details of the potentials enables you to get an assessment.

That’s why we call it the resilience assessment, an assessment of the status of the potentials at any given time in the company but it also gives you an idea about what should you do either to improve a part of a potential that’s not good enough but also what should we do to sustain a capacity or potential that is good enough because that’s equally important.

– That’s wonderful, wonderful. Well, thank you so much. I think it’s lots of food for thought and a wonderful presentation yesterday at the event, and I’m sure this will really help to benefit people’s thinking and certainly thought-provoking in terms of the difference and the channels that we should be looking down in order to improve across the industry. So thank you so much for your time, Erik today.

– My pleasure too being here.

– And we’ll look forward to having you again. Thank you very much.

– Thank you.

– Thank you.