David Bond, Thiess, presents at the OHS Leaders Summit 2013
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David Bond, Thiess, presents at the OHS Leaders Summit 2013

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David Bond, Thiess, presents at the OHS Leaders Summit 2013 David Bond, Thiess, presents at the OHS Leaders Summit 2013 Presentation Transcript

  • Relationship Based SafetyDavid Bond – 21st February 2013
  • RelationshipsSystemic• Complex Systems• Layers• Interactions• EmergencePersonal• Motivation• Accountability• Consequences• Just Culture
  • Some Persistent Myths• That systems are inherently safe, it is the behaviors ofunreliable individuals that create unsafe conditions• More than 80% of accidents are the result of errors or unsafebehaviours• Safety rules and procedures are there to correct or controlunreliable human behaviour• Accidents are the result of someone not paying enoughattention – ‘they lost situational awareness’
  • New View of Human Error• Human error is a symptom of trouble deeper inside asystem• We can never explain failure by finding mistakes.• Find why peoples actions made sense at the time, giventhe circumstances that surrounded them.• Complex systems are not inherently safe• Complex systems are trade-offs between conflictinggoals• People create safety through practiceDekker, Sydney (2006) The Field Guide to Understanding Human Error
  • Complexity & Failure - Before• Normal Accidents• Drift into Failure• Incompatible Goals• AdaptationPractices do not follow rules; rather, rulesfollow evolving practices.Brian Wynne
  • Complexity & Failure - After• Oversimplification• Hindsight bias• Outcome bias• Local rationalityLooking for cause or control?“There is almost no human action or decision thatcannot be made to look flawed and less sensible inthe misleading light of hindsight.Lord Anthony Hidden
  • Is there really a ‘cause’anyway?• The identification, after the fact, of a limited set of aspects ofthe situation that are seen as necessary and sufficientconditions for the observed effects to have occurred.The cause, in other words, is constructed rather than found .• Erik Hollnagel,• The cause of an accident is not found in the rubble, it isconstructed in the mind of the investigator.- Sydney Dekker,
  • Is there a need for change?• Is safety a science?• Rote answers• Pre-packaged solutions• Safety education - Are wereinforcing the paradigm?The point is not a set of answers, butmaking possible a different practice.Susanne Kappeler
  • Where to from here…Evolution, not Revolution• Focus on critical thinking, not answers.• Promote action rather than constraint.• Faster feedback loops.• Minimise irreconcilable goals.• People (not systems) create safetyDeclarations of the real operate as conversationstoppers; they establish the limits of what otherscan say, who can be heard.Kenneth Gergen
  • Thank You