Over the past 130 years of industrialisation, compliance has been the fundamental of safety principles. During the last 2-3 decades, the exponential technologies have transformed the business environments as we exploit emerging technologies in new ways in existing environments, different to those originally intended by design.
As the modern world is amid a following transformation from exponential technologies to exponential innovation, most organisations are holding themselves hostage by hanging on to compliance as safety principles.
Compliance as Safety Principle is of the past, as it promotes an isolated and fragmented risk discipline understanding by simplification of reality.
Analysis of future potential scenarios are documented by a perception of likelihood of past experiences being similar of those in the future. In essence, risks are often only accepted and/or understood at a (too) late point in time.
The history of “Compliance” as Industry norm
Ever since Ford introduced the modern worlds Industry Norm of standardization, Compliance has been Safety Principles of design, execution, training and learning. Single line perspective i.e., domino effect thinking was the starting point.
When things go wrong, we analyze perceived domino effect by constructing root causes and associated barriers accordingly. This to prevent a repeat of future incidents. By nature, a reactive approach as incidents never occur in the exact same order.
The traditional original safety model as per compliance, has only been slightly matured to the changing business environment of the last 130 years. Although the change of pace has been acknowledged, the initial, simple linear model have over the years only been upgraded to an “complex, linear model, best known as the Swiss cheese model of 1991. This is the preferred model adapted in most industries, especially Oil & Gas and Process Industry in general.
The fundamental improvements of the mentioned models have happened in steps. The initial linear model evolved into a complex, single linear model. The change made is within the method of reaction, going from elimination of causes i.e. improve response to strengthen barriers and defenses i.e. improve observations. The below illustration (Hollnagel), demonstrates the basic principle, purpose of analysis and typical reaction for both:
In the aftermath of the NASA Challenger disaster in 1986, the concept of a non-linear systemic (later known as Resilience Engineering) emerged and was conceptualized in 2003. The Aviation and Nuclear Industries adapted partly to the concept; however, one could argue, that the industries in general are (still) kept hostage by compliance thinking.
As described in the table above, the new model of non-linear (systemic) has a transformational approach to typical reaction measures. By accepting the systemic environment, the need for understanding i.e. anticipating potential future outcomes are key.
Monitoring and control performance variability calls for improved skills of anticipation. This could dramatically change the way we learn from failure and upsets. The knowledge of understanding why things goes well is an obvious more reliable source than the 1:1000 occurrence of failure.
Events never occur in the exact same way and/or order. However, we only recognized failures as they manifests as a serious scare or an accident, despite knowing that they represent a significant less portfolio (1:1000) of learning points as to those of successes (999:1000). Research of incidents have documented that clear warning indicators (EWI) were almost always identified prior to the upset. The failure to share obvious crucial internal knowledge to the right people at the right time stands out.
Current Environment
Going back to present model and methodology of the complex, linear model, learnings are mostly constructed by disregarding combined activities. We seek understanding of non-compliance to procedures, describing practices & design as intended in isolation.
Focus on failure naturally drives focus towards Accountability and thus most learnings become painful and reactive. This will over the years facilitate a culture of protectionism rather than one encouraging initiatives. This is documented by incidents and research repeatedly.
As reality has transformed from single linear 1:1 dependency to multiple non-linear interface interactions, the concept of likelihood of future outcome has become a source of failure when used in the traditional risk assessment discipline based on historical events.
The existing learning paradigm of single linear systems is challenged by hidden future interfaces within these new introduced tangled networks. There is often little room and acceptance of scenarios not yet manifested, and when advocating for potentials, it often becomes a reverse “proof to me it is unsafe” conversation.
We aim to mange our businesses within the acceptable boundaries of safety, economic and workload. In many organisations, there are often little room and acceptance of scenarios not yet manifested as a visible negative close-call or incident. In the name of efficiency, boundaries are stretched, and those advocating for precautions and timeouts are facing an upside-down conversation, to demonstrate “why it is NOT safe” as nothing has happen so far.
Any Organisation is trying the best to improve efficiency thus pushing resources to maximize value. The tensions within a system, as illustrated below, is all about managing the tensions of pushing too hard or too little.
A remaining question is: “How Close are we to the boundary of acceptable”. We only know once it is crossed – Proof of reactiveness, yet we keep going and only refines our methodology.
Accidents do not necessarily happens once we cross the line of “compliance”. Often we rely on luck, but eventually, the incident manifests, and organisations , not the people within, are surprised by the actual consequences. The fundamentals of risk blindness (see paper under reflections in menu) drives behaviors with people to (over)react to blame rather the specific problem. The compliance issue suddenly becomes a black or white discussion, completely different to those scenarios where nothing happens.
At this point we are trapped in the reactive hamster wheel, “constructing” root causes and flood the organisation with new “Safety Critical” work. The wheel keeps spinning, but most organisations still hang on to compliance as “Safety Principles”.
When employees and middle management expresses concerns by addressing relevant EWIs’, it is a result of having the capability to anticipate a potential negative outcome. Unfortunately, they are often ignored and even subject to top down pressure in the name of departmental KPIs’, efficiency or “here and now” challenges of obtaining short term objectives.
Drift into failure should be identified as a learning process rather than a failure to learn, however, most Organisations seems stuck with the simplified version of the failure to learn paradigme. The main reason for this is the misperception of how failure and successes manifests. Success and failure happen the same way, it’s only the outcome that differs. and competences different to traditional barrier and prevention thinking is required.
Going forward
Further reflection and understanding of the ignored consequences of working out of “Compliance” as safety principle, engrained throughout learning, training and decision making ever since early days of the industrialization is required.
Resilience Engineering and Safety II are concepts worth while studying. They build on the model og non-linear systemic principles. The ideas have within the last decade found its way to especially the Aviation and Nuclear Industry. Only few other companies have integrated some of the learnings. Most of the experiences made, are within Human Factors SMEs and Aviation.
The Cure and prevention of Risk Blindness
Concepts like Operational Excellence, Asset Integrity, Risk Management and recently Business Continuity are allocated significant resources, without necessarily ensuring business critical objectives. Furthermore, traditional engineering concepts of project maturation, design, project execution, maintenance and operation also require resources across disciplines. Common to both is that they are predominantly managed as isolated actions in the respective technical department. Once combined in the real world, complexity and interfaces not foreseen and addressed prior to this, will introduce new results of combined activities.
DEFRAGMENTOR have experience and knowledge of embedding a Risk Management system, based on a hybrid of the fundamentals of Resilience Engineering, LEAN principles, traditional Risk Management principles to transform the work with Risks and more importantly Decision Management.
The transformation to a focus on successes i.e. “Why it works” prior to review our failures is important. We work towards models and mindsets, all building on systemic non-linear nature.
December 2022, Kim Petersen