The Foundation for Industrial Safety Culture

Toulouse, France

APPROACHES TO SAFETY: ONE SIZE DOES

NOT FIT ALL

René AMALBERTI, Prof, MD, PhD

Director FONCSI
 Professional Fishing
Fatal Iatrogenic
adverse events

Cardiac Surgery
Road Safety (UK) Blood transfusion

Patient ASA 3-5

Medical risk (total EU)
Chartered Flight Civil Aviation

No system beyond
Trading (banks)
Railways (EU)

this point
Hymalaya Railways (UK)
mountaineering Off shore
Drilling
Microlight spreading Oil industry)
activity
Nuclear Industry
Chemical Industry (total EU)

10-2 10-3 10-4 10-5 10-6 Fatal

Very unsafe Unsafe Safe Ultra safe risk

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Huge pressures, frequent planning

changes, missing or failing material,
repetitive interruptions, poor sync
between services, inadequate/
malfunctioning IT systems, understaffing,
junior staff with lack of supervision.

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 Quality and Safety protocol and standards inflations

 When there are so many rules that it is impossible to obey all of them,
rule-breaking becomes "normal" behaviour
 Especially if the management breaks rules to increase productivity

 To sum up…regular experience responding to handle anomalies or

SNAFUs (Woods, 2017)

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 System Migration to Boundaries
INDIVIDUAL Safety regs & good practices
BENEFITS ‘Illegal normal’
Certification/ accreditation standards
‘ Real life standards

BTCUs Market demand

Border line Tolerated
Conditions of use
‘Illegal Usual Space
of Action
Illegal’ Expected safe space of
VERY UNSAFE

action
Space as defined by
Always professional standards
Technology
sometimes
Never
Sometimes
Always always
SPACE

Never
never
Individua
l
concerns
ACCIDENT Time on duty,
Life quality, Amalberti, 2001
PERFORMANC ... Amalberti & al, IJQHC,
E 2006 6
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Adaptive system
WORK AS
IMAGINE

’Illegal-normal’
space of action

‘never-
WORK AS sometimes’
DONE High pressure,
space special contexts
of action
SNAFUs

END OF ADAPTATION
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ACCIDENT

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9

 Not really, still taboo subject

 Expected to be the result of self-learning, assimilated to experience
 But wrong assumption
 Great variance of competence among managers, whether they are
executive or middle/frontline managers
 Need for formal education, learning how to conduct “safe
arbitrations in normal and abnormal degraded conditions”
 Pedagogic material available

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 Brittleness
 All systems have an envelope of performance, or a range of adaptive behaviour,
due to finite resources and the inherent variability of its environment in a
continuously changing world.
 Descriptively, brittleness is how rapidly a system's performance declines when it
nears and reaches its boundary.
 Brittle systems experience rapid performance collapses, or failures, when events
challenge boundaries. Of course, one difficulty is that the location of the
boundary is normally uncertain and moves as capabilities and conditions
change.

 Adaptive capacity means a system is poised to adapt, it has some readiness or

potential to change how it currently works— its models, plans, processes, behaviours

 Regular experience responding to handle anomalies or SNAFUs,

Dave Woods, 2018, Essentials of Resilience, Revisited

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 MAX BAR 1: REFERENCE
OPTIMAL
2: COMPENSATIONS TO MAINTAIN
ACCEPTABLE BAR OPTIMAL SAFETY DESPITE NON
+ ADHERENCE TO THE MAX BAR

Area of full
compensation OPERATIONAL GOAL

Safety
utmost ACCEPTABLE BAR 3: END OF FULL
priority - Growing risk
Partial COMPENSATION
compensation

MIN BAR
High risk

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 MACRO
EXECUTIVE MESO
MICRO
BOARD
GOVERN DEPARTMENTS
TEAM on DUTY
Long term AND SERVICES
Tactical
investment Preparation
arbitrations
Strategic • Weeks and days Real time
arbitrations •
before
Build the team and their management
• Years and months values and adequate
before • Build leadership
• Build trust and • Anticipation compensation
transparency • Pre-organized
responses

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 The effectiveness of short term compensation strategies depend on long term
investments and arbitrations

Good arbitrations made by Board govern

Poor arbitrations made by Board govern
MAX BAR

ACCEPTABLE BAR +
ACCEPTABLE BAR +
Range of
Reduced range
adaptive
of adaptive
behavior
behavior
ACCEPTABLE BAR-
ACCEPTABLE BAR -
Min
bar
MIN BAR

13

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 1_EXECUTIVE
BOARD GOVERN DEPARTMENTS
Long term investment AND SERVICES
Strategic arbitrations Preparation TEAM on DUTY
Tactical
• Weeks and days
• Years and months before before
arbitrations
• Conduct safe arbitrations • Build the team and Real time
• Build trust and their values
management
transparency • Build leadership
• Anticipation and adequate
• Pre-organized
responses
compensation

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15

 Companies and Production Units may collapse

for many reasons
 Loosing markets, unable to expand
− inability to cover market demands, offer falling behind innovations
− Fierce market competition, poor image, economic recession
 Unable to generate high quality product in a timely manner,
at affordable cost (including maintenance)
− Endemic defect on the production chain / care chain
− Excessive junior staff
Poor maintenance
−

− Social peace at risk, strike actions Risks are not

 Finance crisis, unable to fund development
− Business model
only Adverse
−

−
Cash flow, financial debts, loans
Partnership, alliances, … economic and political dependencies
events!
 Unsafe macro, meso and micro systems
− Adverse events, Dramas, accidents, public scandals
− Blame from authorities, possibly loss of authorization

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 Every CODIR/COMEX/BOARD GOVERN reshuffles the

cards according to the most imminent threat,
which takes the token

 Accept the idea that making concessions is the norm

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 “The optimal wishful plans”
 Each manager in charge of a dimension (Finance, Production, Marketing, Human
resources, Safety) attends executive meetings with a wishful optimal plan in mind
 This wishful plan reflects a risk matrix associated with recommended interventions

 “The Dictatorship of short-term”

 Each executive meeting, at several levels of the management chain, prioritizes the
topics of the day perceived as the most harmful short-term effects.
 Hence, one or two dimensions among Finance, Production, Marketing, Safety,
human resources and social climate, overwhelm all other dimensions.

 Optimal wishful plan of dimensions are competitive with one another.

 Giving the token of the day to one dimension inevitably asks the other
dimensions stepping back in their optimal wishful plan

 Prepare each direction to make concessions and

‘step back’ from its ideal plan, while maintaining
acceptable results.

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 Sales/
Safety Financ attractiv Benefits
Soci
Anticipated es New
maximum
Produc Maintena al
Positive
investments in Increased eness Timely & Optimal
climate, joy
MAX search of Net profitmarkets,
expansion
tion
high nce
preventive
at work,
BAR Quality maintenan
above standard strategy Rewarding
production ce
results culture
Full legal Contextual Conformity
Market Unspoile
compliance limited Just-on with
control. d quality
on a 24/7/365 losses collective
stabilisati at high time
basis agreement
MIN on of social maintenanc
Increased and usual
Borderline volume
BAR?? debt cost e local social
conditions of
18 habits
Social
use Loss in
‘illegal- Financial Low Reactive tension
market
normal’ losses Quality maintenanc
Understaff share Penalties Social
practices e
and Under crisis
authorized by
?? local equipment
managers. required
Serious / Maintenance Strikes,
frequent Near Significant Productio induced loss losses of
incidents Bankruptcy commerci n defect, of production productivit
mostly al collapse loss of & safety y
recovered costumers issues

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 Sales/
Safety
attractiv Benefits

Anticipated New
maximum
Produc Maintena
investments in eness Timely & Optimal
search of
markets,
tion
high nce
preventive
MAX expansion Quality
above standard strategy
maintenanc
BAR production
results e
Full legal
Unspoile
compliance Just-on
d quality
on a time
at high
24/7/365basis maintenanc
social
Borderline e
cost
conditions of
use
‘illegal- Low Reactive
normal’ Quality maintenan
MIN practices Penalties ce
BAR ?? authorized by
local
managers. Maintenance
Serious /
frequent Productio induced loss
incidents n defect, of production
mostly loss of & safety
recovered costumers issues
??

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20

An example of the limit of making concession

EDF Executive Board,

JULY 2016
EDF board member resigns,
The token and priority of attacking Hinkley Point nuclear
the day was given to project as financially 'risky’
Hinkley Point C has proved highly controversial CREDIT: EDF
commercial and political Emily Gosden, energy editor

issues 28 JULY 2016 • 2:54PM

As usual, all other Aboard member of EDF has quit ahead of its meeting to approve
the Hinkley Point Nuclear plant, calling the project “very risky”
dimension had to step and suggesting it could drag the French utility giant into an
“abyss”
back, including Finances.
The resignation of Gerard Magnin, who was proposed to EDF's 18-
The chief financial man board by the French Government, is not expected to prevent
the £18bn project gaining approval in a vote later on Thursday.
considered that the But his comments will stoke further doubts over the financial
viability of project, following the resignation of chief financial
decision was too much officer Thomas Piquemal in March and the opposition of unions
who fear EDF cannot afford to build the reactors.
consequential for
Finance asking to step
back so far on his
dimension that he was Dubrovnik
unable to provide a
compromise.
He resigned from the
board.
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When safety does not win 100 %...

 Accept the idea that making concessions is the norm
 Prepare each direction to make concessions and ‘step back’ from its
ideal plan, while maintaining acceptable results.
 Stepping back requires counterparties

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When safety does not win 100 %...

 Accept the idea that making concessions is the norm

 Prepare each direction to make concessions and ‘step back’ from its ideal
plan, while maintaining acceptable results.
 Stepping back requires counterparties
 Whatever the amplitude of concessions, concessions need
to be communicated in full transparency to the middle
and front line managers who will have to manage

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 Illusion of control: the procedures cover every possible

case
 Corporate illusion of being informed
 Continuous improvement deficit: Unresolved problems
are a source of errors and risks.
 Difficulties and errors are never reported.
 Alerts have little effect or no information
 Ideology: “a real pro doesn't have problems”; “the unions
are never satisfied”
 This confirms the management's illusion that the
present situation is compliant with the rules and that
they have the right managerial model.
 The workers are convinced that reporting problems
makes no difference.

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When safety does not win 100 %...

 Accept the idea that making concessions is the norm

 Prepare each direction to make concessions and ‘step back’ from its ideal
plan, while maintaining acceptable results.
 Stepping back requires counterparties
 Whatever the amplitude of concessions, concessions need to be
communicated in full transparency to the middle and front line managers
who will have to manage
 Train front line et middle managers to compensation
strategies

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When safety does not win 100 %...

 Accept the idea that making concessions is the norm

 Prepare each direction to make concessions and ‘step back’ from its ideal
plan, while maintaining acceptable results.
 Stepping back requires counterparties
 Whatever the amplitude of concessions, concessions need to be
communicated in full transparency to the middle and front line managers
who will have to manage
 Train front line et middle managers to compensation strategies
 Set a memory of concessions. Never cumulate arbitrations
on a long period of time on the same direction, especially on
the safety dimension.

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 2. MESO
Preparation

• Adaptation to
MACRO context
Long term • Maintain Values MICRO
investment and Safety culture Real time
• Manage Hospital • Weeks and days management
boards govern before and adequate
arbitration
• Years and months • Anticipation compensation
before • Pre-organized
• Install safety values
and safety culture responses
• Build leadership
• Build trust and
transparency

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ULTRA RESILIENT
Embracing risk
Context : Taking risks is the essence of the profession.
Cultural trait: Fighter spirit, cult of champions and
heroes
Safety model : Power to experts
‘Give me best chances and safest tools to survive in
these adverse conditions and make exploits’
Success analysis more important than accident analysis
Safety training: Priority to expertise
xperts talk to juniors, acquisition of expertise,
understanding own limitations
Three Contrasted Safety models
HRO model
Managing risk
Context : Risk is not sought out, but it is inherent in
the profession.
Cult of group intelligence and adaptation to changing
situations.
Safety model : Power to the group,
Organization, roles, and procedures
Mutual protection team members. Suspicion of simple
explanations
Priority to recovery and mitigation
Safety training: Training in teamwork
Training and safety focused on adaptability and
flexibility of procedures
ULTRA SAFE
Excluding risk
Context : Risk is excluded as far as possible.
Cult of applying procedures and safety organized by an
effective supervisory organization.
Safety model : Power to the regulators of the system
to avoid exposing front-line actors to unnecessary risks.
Priority to prevention
Training in teamwork to apply procedures and
apportion the work even if abnormal events occur.
‘Training only inside the tube’: training limited to what
the organization considers the need for expected
operations.
No improvisation permitted.

No system beyond this

Medical risk (total) Food Industry

point
Civil Aviation
Hymalaya Finance_stock exchange Fire Fighting
mountaineering Chartered Flight Railways

Combat A/C, war time Drilling Industry Processing Industry Subways

Professional fishing Chemical Industry (total) Nuclear Industry

10-2 10-3 10-4 10-5 10-6 Fatal

Very unsafe Unsafe Safe Ultra safe risk

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Optimisatio Risk
n strategies managemen
Restrain range of activity to
t strategies
Ensure that best practices in what can be properly performed
prevention are in place and Adopt Increas • Specify, share and respect ‘no
being implemented Best e Risk go’ issues
• Encourage compliance Practice Control
• Build and update best standards s Accept intelligent adaptation to context
• Build capacities and resources • Share situation awareness and risks in the
Adapt and team
recover • Detect and recover errors
• Improve failure to rescue and team decision
Optimize Human and Organizational Optimise making
factors working • Adopt a context adapted safety culture
• Improved style of Leadership conditions (Ultra safe, HRO, Adaptive)
• Improved working hours Mitigate
• Improved utilization of skills
• Share values among the team Foresee and mitigate consequences of
• Improved working conditions Innovate
flaws
Report incidents and accidents
• Celebrate team effort and recovery
• Adopt new solutions redefining boundaries • Say sorry to clients
of playability, quality and safety • Invest on a blameless just culture
• Analyse risk associated with innovative
solutions
 St (Safety total) = SR (Rule-Based safety)+ Sg(Safety managed)

NORMS / QUALITY + HUMAN ADAPTATION

Error avoidance Surprises
Observed BBS/CBS/HRA management
Safety
Based on Based on
Technology Human expertise
Regulations Adaptive learning
Constraints systems

Human factors, 2008, 1, 1-16

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 Significant safety improvements always detrimental to Sm

Craftman industry Stotal= Srule-based + Smanaged

Safety improvement

Ultrasafe systems Stotal = Srule-based + Smanaged

The almost impossible challenge : Preverving Sr while Improving Si

St Sr Sm
= +
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 3. MICRO

Real time management

Long term and adequate compensation
investment Front line management
• Years and months Day-to-day.
before
MACRO management
• Build the team and
their values Preparation
• Build leadership
• Build trust and • Weeks and days before
transparency • Anticipation
• Dialogue
• Complications and AE
Analysis
• Pre-organized responses

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① I practice Daily operational Brief at job start and anytime the situation is changing
 Take stock of the situation, share with the team
 Reorganize resources to do the job by limiting the potential risks
② I set the absolute no go issues of today and voice it to the team
③ I manage available colleagues' competencies according to today risk (task and program allocation)
④ All team members are required to publicly voice alerts
 Professionals voice and share alerts and bad feeling about changing contexts
 The manager publicly acknowledges alerts and voice how to adapt
⑤ I increase error detection, recovery and mitigation
⑥ I thank the team for efforts made to control the situation within acceptable boundaries, I give
apologies to clients as required
⑦ I report incidents and intervention strategies to the hierarchy (within the group and to the
hierarchy)

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Adaptive system DESIGN AND TEACH REFERENCES

WORK AS ’Illusory ‘legal’
IMAGINE
space of action
BET ON SAFETY CULTURE
’Illegal-normal’
space of action
ACCEPT THE REALITY GAP AND CONTROL
High pressure, special contexts
‘never-
WORK AS DONE sometimes’
SNAFUs
FIXspace
CLEARof action
BOTTOM LINE
PREPARE TO UNSTABLE CONDITIONS

END OF ADAPTATION
NO GO

ACCIDENT

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