Health & Safety System Approaches
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Systems are deeply embedded in the way an organisation manages health and safety (H&S). Over the last century there are recognizable shifts in the approaches taken toward H&S systems. Four Health ...

Systems are deeply embedded in the way an organisation manages health and safety (H&S). Over the last century there are recognizable shifts in the approaches taken toward H&S systems. Four Health and Safety System Approaches are identified and covered showing how the perspective taken by each of H&S and related accident analysis differ. These Health and Safety System Approaches are not substitutable options, rather they can be viewed as progressively adding to ways in which H&S is improved by organisations, in a sense reflecting a progression in the level of maturity of organisational H&S. The multi-level perspectives reflected in Health & Safety System Approaches can be similarly reflected in the law of tort and in Commissions of Inquiry into H&S failures.

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Health & Safety System Approaches Health & Safety System Approaches Document Transcript

  • Health & Safety System Approaches Systems are deeply embedded in the way an organisation manages health and safety (H&S). Over the last century there are recognizable shifts in the approaches taken toward H&S systems. Four Health and Safety System Approaches are identified and covered showing how the perspective taken by each of H&S and related accident analysis differ. These Health and Safety System Approaches are not substitutable options, rather they can be viewed as progressively adding to ways in which H&S is improved by organisations, in a sense reflecting a progression in the level of maturity of organisational H&S. The multilevel perspectives reflected in Health & Safety System Approaches can be similarly reflected in the law of tort and in Commissions of Inquiry into H&S failures. David Alman Version 3. November 2013
  • Health & Safety System Approaches David Alman Contents Acknowledgements................................................................................................................................. 3 1. Systems of Work a basis for improved Health and Safety .................................................................. 4 2. What is meant by the terms Hazard and Risk in a systems context ................................................... 6 3. Four Health &Safety System Approaches ........................................................................................... 9 4. Health & Safety System Approaches Explored ................................................................................. 14 4.1 Transactional System Approach: Compliance based ................................................................. 14 4.2 Governance System Approach: Resilience based ...................................................................... 17 4.3 Referential System Approach: “Drift” affected systems ............................................................ 21 4.4 Interpretive System Approach: “Dissonance” and crisis............................................................ 26 5. Maturity of Health and Safely Systems, and Tort. ............................................................................ 29 Conclusion ............................................................................................................................................. 30 Notations............................................................................................................................................... 31 References ............................................................................................................................................ 35 About the author .................................................................................................................................. 38 Proventive Solutions Page 2
  • Health & Safety System Approaches David Alman Acknowledgements This article arose from a LinkedIn Systems Thinking World (STW) Thread discussion. My thanks to Gene Bellinger for encouraging such discussions on, and learning in, Systems Thinking, and through the way he has managed and supported this LinkedIn Group. My Thanks to Frank Wood who raised a Thread covering systems thinking in relation to the field of Health & Safety and, through the Thread’s postings, for highlighting the lack of public information linking Systems Thinking to Health & Safety. My thanks to T.A. Balasubramanian who referenced Nancy Leveson and her e-book Engineering a Safer World. This is not the first time that Tabby has referenced Leveson’s publications and from a previous discussion and reference to Leveson I found online elsewhere that excellent article by Zahid Qureshi A Review of accident modelling approaches for complex socio-technical systems. This article highlights how the approach to Health & Safety has shifted over time; introduces the concept of Complex Sociotechnical Systems; and leads to exploring the more recent authors in the field such as Erik Hollnagel, Jens Rasmussen, Anthony Hopkins, and Peter Ladkin. In this respect my thanks too to Frank Verschueren for his enthusiasm for Health & Safety and its link to Systems Thinking. Through his interests I have picked up and included the work of Sydney Dekker. My thanks also to Sanjiv Bhamre for referencing Karl Weick’s work in Health & Safety that subsequently led me to a particular Karl Weick article which helped finalise the four Health & Safety System Approaches applied in this article. My thanks to all those who post on STW that helped develop my interests and musings; to others across the world who I share my drafts with and who kindly review and offer comment; and, more close to home, those who not only take the time to read, review, and offer feedback but who also sit down with me and share and discuss their views such as my wife, Donna, and good friend Peter Wojciechowski. Non, in my view, receive the acknowledged appreciation they deserve. Proventive Solutions Page 3
  • Health & Safety System Approaches David Alman 1. Systems of Work a basis for improved Health and Safety According to the International Labour Organization (ILO) and the World Health Organization (WHO), health and safety at work is aimed at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention among workers of leaving work due to health problems caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his or her physiological and psychological capabilities; and, to summarise, the adaptation of work to the person and of each person to their job. [1]. Health and Safety (H&S) at work is influenced by “hard” legislation that provides directives and regulation about what is to be complied with by organisations and accountable persons, as well as covering the means of its legal enforcement. In addition there is “soft” legislation that provides unenforceable guidelines. It should be noted, however, in H&S matters before a court an employer’s actual practices, for example when considering what are the causes of an accident, can be compared to such published legislative guidelines and this is taken into account in a court’s decision. H&S is viewed as improved by considering H&S issues within a systems approach, and this is confirmed as there is health & safety legislation where safety in a systems sense is specifically referred to for employer application. This may be through “hard” legislation as in Australia and the UK where “safe systems of work” are sought [2]. A safe system of work is a framework resulting from a systematic examination of work to identify hazards and design specific work methods to eliminate or minimise hazards. A safe system of work therefore refers to systems of work that have been assessed for safety and where hazards have been identified and addressed. What is involved in making a system of work safe is based on Risk Assessments [3], unless specifically a matter to be addressed in a manner covered by regulation. Safe systems of work can be further supported, as in Australia, by “soft” legislation that provides guidance through, for example, reference to the use of H&S Management Systems [4]. Despite some countries H&S legislation not referencing the application of safety in a systems context there are large organisations in such countries that voluntarily set up and apply H & S Management Proventive Solutions Page 4
  • Health & Safety System Approaches David Alman Systems [5]. The voluntary implementation and application of Health and Safety systems at work can also extend to and include, for example, the establishment of behavioural based safety systems. Traditionally there has been a separate practice by some large organisations to focus on behavioural based safety systems, however behavioural based safety systems can also be integrated with procedurally based H&S Management systems [6]. Whether through procedurally based H&S Management Systems; behavioural based systems; or safe systems of work, the intention is to better address risk of injury from hazard sources. What is meant generically by an H&S system should be explained before proceeding further so there is a common understanding of how the term is used in this article. A system can be generally and broadly described as: A purposeful organisation of its component parts, each with varying attributes, that results in intended (and unintended) consequences resulting from its interactions. [7] Within this context H&S systems can include, for example [8]:  A purpose such as to develop, maintain, and improve safe ways of working by identifying hazards and addressing risks to the health and safety of employees and others <why>.  Components such as materials, people, plant, equipment, process(es), tasks and environment <what>.  H&S influences and constraints that address system component hazards and the risks in their interactions <how>. What an H&S system is and what its component parts are, along with their interactions and attributes, can be viewed in different ways. These different ways, or perspectives, are grouped under the four H&S System Approaches described in this article. Proventive Solutions Page 5
  • Health & Safety System Approaches David Alman 2. What is meant by the terms Hazard and Risk in a systems context There are two common terms used when considering hazard sources and their effects on H&S: Hazard and Risk [9]. A Hazard is a direct or indirect source of potential, harm. A hazard consequence is personal injury or death resulting from a hazard. A risk is a measure of the likelihood of personal injury or death. Sources of hazards can come from three types of systems: Human Designed systems; Psychosocial systems, and Natural Environment systems, as illustrated in Diagram 1. Human Designed Systems Process & practice systems Built environment Management Systems PsychoSocial Systems Interpersonal Intrapersonal Natural Environment Systems Physical Biological Chemical Diagram 1. Types of Systems encompassing Health & Safety Hazards Proventive Solutions Page 6
  • Health & Safety System Approaches David Alman Examples of hazards arising from these three systems types are provided in Table 1. SYSTEM TYPE Human Designed HAZARD AREA  HAZARD EXAMPLES Process & practice systems Dangerous processes & practices.  Built Environment Plant & Equipment layout & condition Work area design  Management System H&S Management System status Communication system condition Accountability structure design Mechanical & electrical exposure; excessive heat or noise. Poor lighting; slippery surfaces; entrapment – no exit. Unaddressed identified risks. Inadequate network support issues. Lack of accountability or delegation, or overlapping authority. Psychosocial  Interpersonal relations  Intrapersonal values & priorities  Biological contamination Exposure to infection from bacteria and viruses.  Chemical containment Acid, heavy metal, vapour exposure.  Physical environment Extreme weather, unsafe landscape. Harassment/bullying, interpersonal conflict & relationship breakdowns Emotional stressors, belief conflicts in values and priorities. Natural Environment Table 1. Examples of hazards that can arise within the three System Types. These three System Types are not separate in a work environment but interlinked along with their potential hazards. The subsequent integration of these System Types results in another form of System Type termed a Human Activity System (HAS) [10]. Diagram 2 illustrates how the three System Types merge within a Human Activity System (HAS) Type. It is within this Human Activity System Type that all Health & Safety related systems discussed on this article are considered. Proventive Solutions Page 7
  • Health & Safety System Approaches Human Activity System (HAS) David Alman Human Designed • Process & practice systems •Built environment •Management Systems Psychosocial Natural Environment •Interpersonal •Intrapersonal •Biological •Chemical • Physical Diagram 2. The Human Activity System (HAS) Type as an integration of three other System Types Proventive Solutions Page 8
  • Health & Safety System Approaches David Alman 3. Four Health &Safety System Approaches The approach taken to assessing and solving a problem situation, in systems terms - the” Systems Approach” -is based on the paradigms of reality (the perspective) taken. System approaches (also referred to as Systems Thinking Approaches) therefore reflect different perspectives of reality applied to problem situations, in systems terms. Within this context four Health & Safety System Approaches are explained in this article:  Transactional System Approach;  Governance System Approach;  Referential System Approach; and  Interpretive System Approach. The following Diagram 3, Table 2, and Diagram 4 illustrate and outline these four distinct Health & Safety System Approaches. In Diagram 3 the four Health & Safety System Approaches (Transactional; Governance; Referential, and Interpretive) are very briefly explained and also shown as interconnected yet separated by considering them along two dimensions:  The Work Level where the Health & Safety System Approach is either more focused at the organisational level or more focused on specifics at the Workplace Level.  The Socio-technical where the Health & Safety System Approach is either more focused on (technical) issues, such as legislation, regulations, policies, and procedures to address health and safety, or more focused on the specific (socio) needs of individuals and groups [12]. Proventive Solutions Page 9
  • Health & Safety System Approaches David Alman Governance Approach Plan, implement, and review content reliability to a given context. Organisational Work Level For example, develop and improve reliability management control systems, and rules. (Analyse and Act) Referential Approach Identify and apply content values and priorities in a context. For example, appreciate and apply what is valued and of priority to a given situation. (Probe and Act) Transactional Approach Ensure compliance within a given context and content. Interpretive Approach Address dissonance in context and content. For example, compliance with prescribed work practices. (Categorise and Act) For example, decide how to manage issues in an unanticipated emergency or injustice cases. (Sense and Act) Workplace Regulatory Needs Socio-technical Diagram 3. The four H&S System Approaches compared though two dimensions. In Table 2 the four Health & Safety System Approaches are briefly explained, with a matching column that highlights the H&S System Approach (i.e. Compliance; Reliability; Drift; and Dissonance). The four H&S System Approaches are also aligned to the key H&S issue addressed; and each H&S System Approach in the table is provided with further Descriptions of hazards identified and relevant supporting methodologies. The four Health &Safety System Approaches are more fully explained in the subsections of Section 4 of this article. Proventive Solutions Page 10
  • Health & Safety System Approaches David Alman H&S System Approach Characteristics H&S System Approaches H&S Issue addressed Transactional. Compliance to H&S Risk manage at the event and process activity level Descriptions Hazards Identified  requirements in Workplace Systems Governance. Reliability in Manage by “structuring’ depth in defences through an H&S Management system.  H&S Management Systems Methodologies The “System of work” either works as required, or fails to meet preset standards. Stop the direct “Domino” cause and effect chain that results in accidents.  Accidents and risks cannot be managed at the workplace without greater policy and planning to handle “variation”. More “defences” in a much wider range of direct (“sharp end”) and support policies, processes and practices (“blunt end”) to stop accidents from getting through a “Swiss Cheese” of holes in H&S defences that end in accidents.       Referential. Manage culturally influenced issues to improve H&S Interpretive Manage and address personal experiences of hazards beyond those addressed by existing H&S systems. Drift in H&S Culture.   Dissonance  in H&S environment  Planning and preparation of H&S Management System still leaves risk exposures and serious accidents. Whatever is organised, there can be a “drift” and lack of recognition of how priorities and values are influencing H&S.  Crises caused by exposure to hazards that are not covered by previous experience, or prescribed processes and practices. Social justice issues are outside the cultural values and priorities in the workplace.  The two above points create crisis and/or conflict: mental Dissonance between individuals and group experience of work environment hazards.    Check and control through linear “Root cause” Analysis at the workplace. Check and investigate against standards using direct root cause analysis methods. Standards of H&S practice tightened through procedural rule changes, and through behavioural based programs. Variations in risk exposures and accidents require greater planning and preparation to identify hazards and improve the management of risks. A “Swiss Cheese” approach used through additional OH&S defences in both direct and indirect support areas by anticipating hazards and risks and developing and improving a “resilient” OH&S Management System. Check and investigate using audits and non linear root cause analysis. Reengineer for High Reliability in system processes and behaviours. Resolution of conflicting emergent influences. Systems can be dynamic and unpredictable where what was safe one day is now unsafe. Hazards and risks are “emergent” from “drift” in processes and practices due to competing priorities. Influence of values and priorities to be checked and investigated through multiple perspective root cause analysis. Reframe work practices and values (Transactional, Governance, Referential Levels) to address the issues that Dissonance raises. This involves organisations being open to changing existing H&S systems to accommodate experiences viewed as inadequately coped with through existing processes, practices, values, and priorities. Table 2. The four Health & Safety System Approach characteristics compared. Proventive Solutions Page 11
  • Health & Safety System Approaches David Alman In Diagram 4 the four Health & Safety System Approaches that influence the way H&S is practiced are aligned to the “ages of work”, reflecting an evolution of both in Western Society [13]:  An Industrial Age going back to the 18th Century where mechanical equipment and mechanistic systems of work in manufacturing were common, and at a workplace level health and safety and accident investigations fitted in by comparing “compliance” failures to preset standards.  A Technological Age going back to the mid 20th Century where industries sought to coordinate and organise safe systems of work at an organisational level, where H&S Management Systems built incompliance defences to improve “reliability” against accidents and incidents;  An Information Age, or knowledge based age, starting in the latter part of the 20th Century sought team or individual flexibility in responding quickly and effectively to emergent situations. In a Referential Systems Approach ‘drifts” in priority and values have overridden laid down prescribed H&S practices. Where “drifts”, because of hazards and accidents, have caused a difference, and discretion, between “what ought to be done” (as prescribed) and “what needs to be done” to address current work pressures and influences (Referential System Approach issues). Also in certain situations, such as where there is a health & safety crisis faces a team or individual, a difference between “what ought to be done” and “what needs to be done” can result. Where, for example, emergent emergency issues cause personal “dissonance” between inadequacies in what (prescriptively) ought to be done compared to “what needs to be done” to survive and be safe (Interpretive Systems Approach issues). Proventive Solutions Page 12
  • Health & Safety System Approaches David Alman Interpretive System Approach Addressing “Dissonance” issues e.g. Personal distressors Need Focus Referential System Approach Addressing “Drift” issues e.g. Priority & value influenced H&S System Approaches Regulatory Focus Governance System Approach Addressing “Reliability” issues e.g. H&S Management Systems Transactional System Approach Addressing “compliance” issues e.g. physical equipment, human failure Industrial Age Technological Age Information Age “Ages of work” aligned to the start of certain H&S System Approaches Diagram 4. An evolution in “Ages of work” and H&S System Approaches Proventive Solutions Page 13
  • Health & Safety System Approaches David Alman 4. Health & Safety System Approaches Explored 4.1 Transactional System Approach: Compliance based A “Transactional” System Approach refers to linked and interrelated activities (procedural, technical, behavioural) at the workplace where the focus is on producing something providing a service, or building something, or making something. Within this Transactional System Approach, H&S workplace practices are identified and built into the way activities are carried out to develop “safe systems of work”. Diagram 5 illustrates a three stepped process for identifying and addressing workplace hazards [14]. Identify Hazards Assess the risks Control the risk Diagram 5. Three Stepped Risk Management Process Within this Transactional Systems Approach, hazards are identified, for example, through a Job Safety Analysis; inspection checks on compliance to standards; and through incident and accident reports. Incident and accident reporting, as shown in Diagram 6, can include a “root cause” analysis of an accident/incidence that has occurred, and is carried out by asking, for example, a number of “why” questions of the cause of the accident or incident. Through this Root Cause Analysis levels of direct cause and effect are established. Service or production Transactional System based on employee & technical interactions Root Cause Analysis of accident Diagram 6. Root Cause Analysis of a Safe System of Work Failure. Proventive Solutions Page 14
  • Health & Safety System Approaches David Alman In the Transactional System Approach once hazards are identified the level of H&S risk can be assessed (based on Consequences and Likelihood of harm), as exampled in Table 3. Consequences Likelihood Insignificant Minor Moderate Major Critical Medium Medium High Extreme Extreme Likely Low Medium High High Extreme Possible Low Medium High High High Unlikely Low Low Medium Medium High Rare Low Low Low Low Medium Almost certain Table 3. A H&S Risk Assessment Matrix Example [15] Having identified hazards, and assessed their risks, the means of controlling those risks are then considered and actioned. Both hazard management and accident analysis in a Transactional System Approach take a common view based on compliance. That is, safe systems of work provide preset standards of safe work activity that are to be complied with, where causes of accidents can be a failure to comply with preset safe systems of work. Whether a single event or a chain of events causes an incident or accident, the relationship between an event’s cause and effect is direct (linear) within workplace (Transactional) systems of work. Root Cause analyses can indicate multiple direct chains of causes, as illustrated in Diagram 6. In Diagram 7 a single sequential chain of direct events causing an accident or incident is visually shown and described as the “Domino Effect” [16]. Diagram 7. Domino Effect Proventive Solutions Page 15
  • Health & Safety System Approaches David Alman In reality, however, accidents and incident have more than one contributing factor and have multiple root causes. To support safe systems of work based on compliance two different methods can be taken and integrated:  Compliance of work practices to a system of work, as discussed above.  Compliance of work practices to a Behaviour Based Safety program. Behaviour Based Safety programs focus on identifying “at risk” behaviours and developing ways to encourage safe behaviours, and include using behaviour observation checklists [17]. A limitation of the Transactional System Approach to health & safety is that an accident or incident investigation based on direct (linear) causes and effects at the workplace level can be an incomplete analysis by excluding relevant additional causal factors influencing and affecting work level practices, for example from an established Health & Safety Management System; from management decisions; and an organisation’s culture that are identifiable through other Health and Safety System Approaches [18]. Proventive Solutions Page 16
  • Health & Safety System Approaches David Alman 4.2 Governance System Approach: Resilience based The Transactional System Approach refers to “safe systems of work” based on risk assessed preplanned and pre-set activities along with associated compliance standards that work together to safely produce some output and outcome. Safe systems of work based on the Transactional System Approach may stand alone at the workplace level, or may be part of larger Governance System Approach to H&S that covers a wide range of issues that support the safety of a transactional system of activities, such as training, incentive schemes, IT support, life cycle maintenance, replacement of plant etc. The Governance System Approach to H&S can include established Health & Safety Management System frameworks such as ISO 18001, AS/NZS 4801, SafetyMap, 5 Star. Health & Safety Management System frameworks tend to cover similar areas, the performances of which are auditable (by internal or external Auditors) which assess compliance [19]. Table 4 examples areas that can be covered. Example Elements found in Health & Safety Management Systems  Responsibility and accountability  Consultation, communication and reporting  Hazard identification, risk assessment and control measures  Safe work practices, including in normal and abnormal circumstances  Training and competency  Managing contractors  Equipment integrity  Reporting and investigating incidents – internal systems  Emergency planning  Procurement  Management of change and its affect on the Health & Safety System  Documentation and data control Proventive Solutions Page 17
  • Health & Safety System Approaches David Alman Table 4. Example of elements of a Health & Safety Management System In addition Health & Safety Management Systems are designed to apply a concept of a continuous improvement cycle (from Policy & objective through to Review), as exampled in Diagram 8. Policy & objectives Planning & prioritising Review Audit Continuous improvement Corrective action Standards & targets Implementation Monitoring Diagram 8. Example of continuous improvement areas in a Health & Safety Management System Through the development and application of a Health and Safety Management System two aspects of H&S can be considered relevant beyond the idea of “compliance”: Reliability and Resilience. While reliability and resilience are interconnected ideas their emphasis is different:  Reliability relates to increasing the reliability in parts of, and the whole of, a Health & Safety Management System so accidents do not occur.  Resilience relates to improving the depth of defences built (through multiple layers of defences, barriers, and safeguards) into a Health & Safety Management System against incidents and accidents occurring. Proventive Solutions Page 18
  • Health & Safety System Approaches David Alman Diagram 9 illustrates this idea of defences against accidents and incidents [20]. First it shows that defences can be forms of “sharp end” health and safety protection such as equipment used, human practices, procedural processes, workplace conditions. ThIs also shows that defences can have depth in terms of “blunt end” support factors, such as policies, purchasing practices, training programs. Accidents can occur at a point in time where potential hazards slip through “gaps” in these layered defences, analogous to the holes in a “Swiss Cheese”. A Governance System Approach H&S Management System Organisational Level Safety factors e.g. OSH 18001, AS/NZS 4801, SafetyMap, 5 Star (includes “Blunt end” factors) CAUSES Workplace Level H&S factors e.g. workplace conditions and practices (“Sharp end” factors) INVESTIGATIONS Accidents DEFENCES Accident Diagram 9. Adaptation of a “Swiss Cheese” Model developed by Reason Improved reliability is therefore by adding defences that fill “gaps”. Proventive Solutions Page 19
  • Health & Safety System Approaches David Alman A limitation with focusing on reliability and “High Reliability” is that health and safety is not necessarily improved by increasing reliability of, for example, Health & Safety Management Systems. Nor by improving their resilience by improving the defences built into Health & Safety Management Systems. This is because accidents can result from unanticipated interactions. So whilst a Health & Safety Management System can continue to satisfy auditable safe performance requirements, as a Governance System Approach, it is system interactions and not system elements/system parts that can also fail [21]. To further improve H&S a move toward identifying and addressing “emergent” and “emerging” hazards and risks is beneficial. This involves applying a Referential System Approach. Proventive Solutions Page 20
  • Health & Safety System Approaches David Alman 4.3 Referential System Approach: “Drift” affected systems There are three aspects about a Referential System Approach that can be recognised in their application:  They are based on an organisation’s cultural values and priorities; group “norms”; and individual values and priorities, and assumptions, in decision making.  They involve the influence of values and priorities on, and through, perspectives that are common and consistent within other Health & Safety System Approaches.  They include and combine the “multi-level” perspectives found in different Health & Safety System Approaches. This multi perspective level, and how they interrelate within the Referential System Approach, is shown in Diagram 10. Referential Perspective Level Values and priorities that give “meaning” to what is decided. Governance Perspective Level Organisation of “rules” to manage, control, and coordinate what is done Transactional Perspective Level Technical & social activities & Physical conditions such as equipment and work layout Outcomes Diagram 10. Multi-level perspectives of the Referential System Approach Diagram 11 shows an accident investigation, based on a Referential System Approach, using a Human Activity System (HAS) Map. The HAS Map highlights the application of multi-level perspectives (Referential, Governance, Transactional) [22]. Proventive Solutions Page 21
  • Health & Safety System Approaches David Alman + Human Activity System (HAS) Map Purpose: Accident investigation Referential Level H&S risk management practices not reinforced Priority on efficiency & cost cutting Management priority on production outcomes Governance Level Machine maintenance schedules affected by cost cutting decisions H&S checks not carried out Delays in routine machine maintenance schedules Transactional Level Machine guard sensor not operating Machine guard not functioning Slip on oil leak on machine platform Employee rushing to complete job Outcomes Press operator injured by machine Time off on Workers Compensation Injury subject to external investigation and penalty Diagram 11. HAS Map of an Accident Investigation. Proventive Solutions Page 22
  • Health & Safety System Approaches David Alman In terms of a Referential System Approach Diagram 12 also illustrates the analysis of multi-level perspective relationships to incidences occurring at a workplace level [23]. Contributory Factors Supervisor and certain team Supervisor & certain team members members coercive and disrespectful to female staff. Referential Level (values & intentions) Female employees part of set work teams and affected by Team Team attitudes of certain other team members and by Team Supervisor style and attitudes. Governance Level (organisation structure) METHODOLOGICAL CONSIDERATIONS IN Female employees ostracised USING ACCIMAPS AND breakdowns in relationships THE RISK MANAGEMENT Transactional Level (role activities and behaviours) FRAMEWORK TO and belittled, with and loss of coordination of work. Loss of attendance of female staff, poor resulting performance, drop in workplace productivity. ANALYSE LARGE Diagram 12. Workplace Level Example of a Referential System Approach - SCALE SYSTEMIC Proventive Solutions FAILURES P.E. Waterson Page 23
  • Health & Safety System Approaches David Alman On a broader sense the Referential System Approach highlights the importance of checking for “emergent” issues and emerging shifts in H&S that can expose organisations and humans to hazards and risks. A way of exampling these shifts, or Drifts, as it relates to the Referential System Approach with its multi-level perspectives is exampled in Diagram 13. Increasing organisational Performance Referential Governance Transactional Multi-Levels Past work processes and role requirements based on balancing performance & H&S requirements (“What ought to be done”) Past Safety Net DRIFT Current work & role processes and practices based on an emphasis on improving performance needs yet affecting H&S wellbeing (“What needs to be done”) D R I F T Current Safety Net Transactional Legend Governance = Safety Net Referential = Accidents & Incidents Multi-Levels Supporting Employee wellbeing Diagram 13. Example of a “drift” in work practices beyond pre planned safety nets. A key concept inherent in Diagram 13 is one of “drift” toward increased incidents and accidents. Proventive Solutions Page 24
  • Health & Safety System Approaches David Alman The concept of “drift” and the “emergence” of incidents and accidents from apparently safe work systems can be discussed in terms of four associated concepts: 1. Hollnagle’s “ETTO” Principle”; 2. The term “Drift” coined by Dekker; 3. Rasmussen’s shift through influencing constraints in his Dynamic Safety model; and 4. Hopkins AcciMap examples: The insights that can be gained from these four associated concepts are: 1. The ETTO Principle relates to “Efficiency- Thoroughness Trade Off”. If thoroughness dominates, there may be too little time to carry out the actions efficiently. If efficiency dominates, actions may be badly prepared or wrong for lack of thoroughness. Making an efficiency – thoroughness trade-off is never wrong in itself. Employees are expected to be both efficient and thorough at the same time – or rather to be thorough, when with hindsight it was wrong to be efficient and where the consequence was an accident. The greater the need of performance adjustments is, the less thorough they are likely to be as demands to increase efficiency may overrule thoroughness and health and safety [24]. 2. Dekker defines “drift” as the “slow, incremental movement of systems operations towards the edge of their safety envelope”. Drift occurs as small deviations from accepted practice that build upon one another to a become a huge deviation from stated (safe) practices [25] 3. Rasmussen developed a Dynamic Safety Model of which Diagram 13 is a simplified and adapted version of his model that demonstrates how three influencing constraints cause drift into accidents [26]. 4. Hopkins has developed a number of AcciMaps that provide an easy visual description of the causes underlying major accidents. This work is based on Jens Rasmussen’s work on AcciMap that recognises multi-levels of perspective. Diagrams 11 and 12 are illustrative of this [27]. A limitation with using AcciMaps and HAS Maps is that it is possible to develop different multilevel causal maps of the same accident, showing different sets of causes depending on the analyst’s focus [28]. Proventive Solutions Page 25
  • Health & Safety System Approaches David Alman 4.4 Interpretive System Approach: “Dissonance” and crisis. The Interpretive System Approach is similar to the Referential Approach in that both apply a multilevel perspective. They differ, however, as the Interpretive System Approach relates to:  Situations at the workplace level only;  Individual and group personal beliefs and assumptions in the circumstances they find themselves.  Interpretive System Approach that is separate from organisation based Health & Safety System Approaches previously described. Diagram 14 provides a comparison between a Referential and Interpretive System Approaches and illustrates how they can interact. Referential System Approach Referential Perspective Organisation Level Governance Perspective Interpretive System Approach Workplace Level Transactional Perspective Organisation focus Referential Governance Transactional Perspectives Employee focus Diagram 14. Comparison of Referential and Interpretive System Approaches The Interpretive System Approach is relevant to employee health & safety in the areas such as: Proventive Solutions Page 26
  • Health & Safety System Approaches  David Alman An emergency where existing practices fail to address serious hazard exposures and risks to employees. For example where in a forest firestorm, fighting equipment and practices fail to keep employees safe and they are left to their own devices to work out survival solutions [29].  A “secondary victim” where an employee or ex-employee suicides or gives up career as a result of being blamed as the cause of an accident, such as a nurse or doctor over a patient’s death or an airline pilot as a result of a crash. In such instances organisations could seek a just culture that protects people's honest mistakes from being seen as culpable [30].  A violation of valued expectations in relation to, for example, social justice as in the way an accident is treated. For example where there is harassment or bullying of employees unrecognised by management. Also where the workplace environment causes high levels of employee stress. In such cases “dissonance” and a personal crisis can occur. An example is illustrated in the following formal employee harassment complaint that “Maps” causes through a multi-level perspective from outcomes at the Transactional Level, to causes at Governance Level, then the Referential Level. See Diagram 15. Proventive Solutions Page 27
  • Health & Safety System Approaches David Alman Human Activity System Map Purpose: Identify causes of workplace harassment complaint Work Group Employee Management Referential Level Long term employees in an established team, providing consistent service New employee to team with history of providing new ideas that improve services Inexperienced manager with attention on senior management relationships Governance Level No regular meetings or planning meetings with work group to address work issues Transactional Level Work group rejects suggestion Employee raises a suggested improvement to group work practices New idea implemented into work group by manager Work group criticises employee and makes repeated fun of a disfigurement Outcomes Employee informally raises harassment concerns Improvement suggestion raised with manager in front of an executive, who supports the idea. Manager dismisses and ignores employee concerns New employee to team with history of Employee raises formal providing new ideas that harassment complaint improve services Diagram 15. Human Activity System (HAS) Map of an Employee Workplace Harassment Proventive Solutions Page 28
  • Health & Safety System Approaches David Alman 5. Maturity of Health and Safely Systems, and Tort. From Commissions of Inquiry into H&S related issues, such as accidents, it can be seen that multilevels of perspective are taken in examining and assessing the evidence. This is illustrated through a number of AcciMaps and supporting publications around AcciMaps published by Hopkins [31]. In this document those differing multi-levels of perspective found in AcciMaps are reflected in the Referential System Approach, such as in Diagram 11 and 15 HAS Maps. In the AcciMaps of Hopkins a “but for” approach is used to analyse serious accidents and develop their cause and effect relationships across the different multi-levels of perspective within the AcciMaps. The “but for” rational is that it is also applied in law to work out liability based on Tort [32]. This “but for” legal liability for accidents can be traced through multi-level perspectives in the Referential Approach to H&S, because both AcciMaps and HAS Mapping can apply and trace causal relationships through a “but for” (tort) analysis. Alternatively HAS Maps can be developed using a “why-because” analysis across the multi-level perspectives [33]. This article also proposes that the Health & Safety System Approaches applied in supporting organisational H&S can be viewed as building up from a Transactional System Approach, with a particular transactional perspective level, through to the Governance System Approach with a particular governance level perspective (and also includes the Transactional System Approach perspective), to the Referential System Approach where its perspective includes all perspectives from the other Health and Safety System Approaches. Beyond this is the manner in which the multi-level perspectives of the Referential System Approach also supports employee wellbeing by identifying and addressing “dissonance” and crises issues they face through an Interpretive System Approach. From this it could be argued that the “maturity” of organisational H&S relates to which Health and Safety System Approaches they apply. This highlights two points, that:  The “maturity” of an organisation’s H&S can be assessed based on what Health and Safety System Approaches are applied;  An organisation’s potential tort liability can be tried to be addressed through the application of a Referential System Approach or an organisation can take a higher risk by not recognising and addressing its liability exposure by managing H&S through limited or no use of Health and Safety System Approaches. Proventive Solutions Page 29
  • Health & Safety System Approaches David Alman Conclusion H&S is associated, historically, with the way organisations perceive and manage themselves using one or more Health and Safety System Approaches. Different Health and Safety System Approaches can also be viewed as developing across four “ages of work” during the last century in the western world: From industrial; to technological; to knowledge Ages, as illustrated in Diagram 4. Through Health and Safety System Approaches several aspects about H&S can be recognised:  Health & Safety System Approaches, progressively and systemically, extend addressing H&S from the immediate, tangible and direct (“sharp end”) workplace H&S issues that effect people, to include (“blunt end”) organisational Health and Safety Management support that are indirect and intangible influences such as priorities and values on H&S;  Health and Safety System Approaches are Human Activity Systems (HAS). HAS integrate and include three system Types: Natural Environment; Human Designed; and the Psychosocial systems.  The Transactional, Governance, Referential, and Interpretive Health and Safety System Approaches each reflect a different perspective, or paradigm, in thinking about H&S. H&S improves by adding and integrating the different Health and Safety System Approaches, as each adds a different level of H&S perspective until creating multi-level perspectives. In this sense an organisation’s level of maturity in health and safety can be reflected based on which Health and Safety System Approaches (and perspectives) are applied.  Health and Safety System Approaches, overall, include considering both a “unitary” (i.e.an organisation focus) and a “pluristic” one to address “dissonance” and crises affecting individuals and groups. Because later Health and Safety System Approaches (e.g. Referential and Interpretive) are not widely understood there is a very real question regarding the “maturity” of Health and Safety System Approaches applied by organisations, and through this their level of risk exposure, and their ability to manage tort liability at senior management levels: Those who are accountable for organisational H&S. Proventive Solutions Page 30
  • Health & Safety System Approaches David Alman Notations [1] The Eurofound Dictionary provides explanations and definitions for the term Health and Safety. Ref http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety. htm [2] Safe System of Work Division 2.2 Clause 19(3)(c) Work Health & Safety Act 2011 Ref http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf and Safe Systems of Work (p2) Ref http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFESYSTEMS-OF-WORK.pdf [3] An OH&S Risk Assessment can be found in How to manage work health and safety risks from Safe Work Australia. Ref http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Man age_Work_Health_and_Safety_Risks.pdf [4] A Safety Management Systems explanation is provided by Safe Work Australia. Ref http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManage mentSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf [5] References to specific Health & Safety Management Systems from a Wikipedia on Safety Management Systems. Ref http://en.wikipedia.org/wiki/Safety_management_systems and OHSAS 18001 Occupational Health and Safety from the bsi group. Ref http://www.bsigroup.com.au/enau/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS18001/ AS/NZS 4801 Safety Management Systems. Ref http://www.ncsi.com.au/as-4801-OHSCertification.html The 5 Star Health & Safety Management System and others are discussed in Pomfret In Occupational Health and Safety Management System Auditing. Ref http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf [6] SafeMap . Ref http://www.safemap.com/english/cb_safety.html and Beyond the behaviourbased safety plateau . Ref http://pipeliner.com.au/news/beyond_the_behaviourbased_safety_plateau/067203/ [7] Armson in Growing wings on the way: Systems Thinking for messy situations (p 134) sates “A system is a collection of elements connected together to form a purposive whole with properties that differ from those of its component parts”. Also “A system can be defined as “a set of objects together with relationships between the objects and between their attributes” (Hall & Fagen, 1969, p. 81) referenced by Hollnagel in Modelling of failures: From chains to coincidences (p 8). Ref http://www.resist-noe.org/DOC/Budapest/KeynoteHollnagel.pdf [8] Armson in Growing wings on the way: Systems Thinking for messy situations (p 215) indicates, in simple terms, that a system can be viewed as containing three aspects, as shown in this template “A system to do < what> by means of <how> in order to contribute to achieving <why>” this template is exampled in the text. [9] In terms of Terminology covering “Hazard and Risks in the workplace”; “Hazard”, and “Hazard consequences” is provided in ref http://www.engica.com/engica-terminology.aspx Proventive Solutions Page 31
  • Health & Safety System Approaches David Alman [10] In Practical Soft Systems Analysis (p8) Patching states Human Activity Systems are “systems where humans are undertaking activities that achieve some purpose. These systems would normally include other types, such as social, man-mad, natural systems.” [11] The explanation of what “Systems Approaches” means is based on, and adapted from, the Flood & Jackson book Problem solving: Total System Intervention (1991, p 32) and technically equates to the terms “Systems Thinking Approaches”. [12] In Diagram 3 the four H&S System Approaches can be variously considered as a Framework or illustrating differing perspectives or paradigms or domains, or “ways of thinking”. There is some resonance in this diagram’s explanation of the difference in H&S System Approaches to Dave Snowden’s Cynefin in that both can be viewed as different forms of sensing in that there is a brief reference to “Categorise & Act”, “Analyse & Act”; “Probe & Act’; “Sense & Act” though clearly there are differences to Cynefin’s “Sense Making” Domains, refer to The Origins of Cynefin. Ref http://cognitive-edge.com/uploads/articles/Origins_of_Cynefin.pdf . [13] Hollnagel in Resilience Health Care slide 7 outlines Three Types of Accident Models over time and the explanation within this article is intended to be consistent with this. Age or time is not necessarily the key factor, rather that certain industries arose at different times in the Western world that is reflected in the time lines and these industries have influence on H&S Approaches that are considered relevant. Ref http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf [14] There are a number of fairly typical risk assessment processes that can be accessed. Two have been drawn on in this paper as they provide additional supporting information. The Risk Management Process of the Northern Territory Government ref http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf and Safe Systems of Work of the Footwear and Leather Industries ref http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OFWORK.pdf [15] There can be variants in the formatting of a H&S Risk Assessment Matrix. This example is from the Queensland Government, Department of Education, Training and Employment document “Health & Safety Risk Assessment Template” issued in August 2012 ref http://bit.ly/1bcCqm7 [16] The Domino Effect is described in this paper as a linear causal chain that results in an accident. The term originally has more specific causal factors based on the Domino Theory by Heinrich. Ref p5 in A Review of Accident Modelling Approaches for Complex Socio-Technical Systems by Zahid Qureshi ref http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543 [17] Behaviour Based Safety programs are broadly explained on this Wiki ref http://en.wikipedia.org/wiki/Behavior-based_safety. With more detail in terms of their effectiveness in Behavioural Safety Interventions by M.D. Cooper ref http://www.behavioralsafety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf [18] Nancy Leveson in Chapter 2 of her e-book Engineering a safer world identifies the weakness and limitation of relying on event chain models for accident investigation (p36-49). https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_S afer_World.pdf [19] COMCARE have produced a booklet that covers Safety Management Systems in major hazard facilities that can be viewed as relevant to Health and Safety Management Systems in general. Ref Proventive Solutions Page 32
  • Health & Safety System Approaches David Alman http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=ht tp%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafet y_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouF yAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw [20] Reason developed a “Swiss Cheese” model of accident causation where accidents emerged due to holes (failures) in barriers and safeguards. The model used in this paper is an adaptation of another adaptation of the model Reason used in his publication Managing the Risks of Organizational Accidents (1998). The “Swiss Cheese “model is drawn from URL reference found here http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html [21] Nancy Leveson in her e-book Engineering a safer world explains how safety is not increased with increased H&S system reliability (p 28-35). https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_S afer_World.pdf [22] Reference to Human Activity System (HAS) can be found in Human Activity System (HAS) Mapping article by D. Alman ref http://en.calameo.com/read/0014509349aed27553fc3. [23] Work Level Referential System example is an adaptation based on Rasmussen & Svedung publication Proactive Risk Management in a Dynamic Society (2000 p 53) figure 7.3 ref https://www.msb.se/RibData/Filer/pdf/16252.pdf . To this has been added a “Contributory Factors” table, as exampled in Figure 1 Risk Management (ActorMap) Framework in Methodological considerations in using AcciMaps and the Risk Management Framework to analyse large scale systemic failures by P.E. Waterson and D.P. Jenkins ref https://dspace.lboro.ac.uk/dspacejspui/handle/2134/7944?mode=full [24] The ETTO Principle -Efficiency-Thoroughness Trade-Off Or Why Things That Go Right, Sometimes Go Wrong Erik Hollnagel ref http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf [25] Modeling drift in the OR: A conceptual framework for research by Richard Severinghaus, Taryn Cuper, and C. Donald Combs. Ref http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Sub mission.pdf [26] ‘‘Going solid’’: a model of system dynamics and consequences for patient safety R Cook, J Rasmussen. Ref http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html and The role of error in organizing behaviour by J Rasmussen ref http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf [27] AcciMaps in use by Anthony Hopkins ref http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf [28] In Root Cause Analysis: Terms and Definitions, Ladkin (p10) explains the limitations (and strengths) of AcciMaps ref http://www.rvs.unibielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf by Peter Ladkin. [29] Karl E. Weick The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster ref http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Org anizations_The_Mann_Gulch.pdf Proventive Solutions Page 33
  • Health & Safety System Approaches David Alman [30] Sidney Dekker identified and coined the term “secondary victim” in recognising that not only are there victims as a result of an accident, but that those blamed by organisations and others can end up consequentially as “secondary victims” and in this organisations need to seek A just culture to protect employee honest mistakes from being seen as culpable. Explained in “Just culture: Balancing safety and accountability” ref http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+A ccountability.pdf [31] An AcciMap of the Esso Australia Gas Plant Explosion by Anthony Hopkins ref http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf An AcciMap overview can be found in Root Cause Analysis: Terms and Definitions by Peter Ladkin at http://www.rvs.unibielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf . [32] “but for” test discussed with an example ref http://www.mcmillan.ca/The-Crucial-but-for-Testin-Determining-Causation [33] Peter Ladkin in “Why-Because Analysis of the Glenbrook, NSW Rail Accident and Comparison with Hopkins’s AcciMap”, examples the application of “Why-Because Analysis” on a “But-for” AcciMap, and provides two methodologies to cross check the accuracy and adequacy of HAS Maps. In effect this means that on a HAS Map one could:  Apply a Why-Because Analysis approach to Governance and Transactional Perspective Levels;  Apply, subsequently, a Cultural – Causal Analysis to the Referential Perspective Level. Ref Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf Proventive Solutions Page 34
  • Health & Safety System Approaches David Alman References D. Alman 2013 Human Activity System (HAS) Mapping http://en.calameo.com/read/0014509349aed27553fc3 Armson, R. (2011). Growing wings on the way: Systems Thinking for messy situations. Axminster, UK: Triarchy Press AS/NZS 4801 Safety Management Systems. URL reference http://www.ncsi.com.au/as-4801-OHSCertification.html Eurofound Dictionary of Health and Safety. URL reference http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety. htm Behaviour Based Safety programs Wiki URL reference http://en.wikipedia.org/wiki/Behaviorbased_safety Beyond the behaviour-based safety URL reference. plateau http://pipeliner.com.au/news/beyond_the_behaviour-based_safety_plateau/067203/ But for test http://www.mcmillan.ca/The-Crucial-but-for-Test-in-Determining-Causation COMCARE Safety Management Systems in major hazard facilities. URL reference http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=ht tp%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafet y_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouF yAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw Cook, R. Rasmussen, J. ‘‘Going solid’’: a model of system dynamics and consequences for patient safety. URL reference http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html Cooper M.D. Behavioural Safety Interventions. URL reference http://www.behavioralsafety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf Dekker, S. (2007). Just culture: Balancing safety and accountability. URL reference http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+A ccountability.pdf Flood, R.L. & Jackson, M.C. (1991). Creative problem solving: Total Systems Intervention. Chichester, England: John Wiley & Sons Ltd. Hazard and Risks in the workplace; Hazard, and Hazard consequences terminologies. URL reference http://www.engica.com/engica-terminology.aspx Health & Safety Management Systems Wiki URL reference http://en.wikipedia.org/wiki/Safety_management_systems Hollnagel, E. The ETTO Principle -Efficiency-Thoroughness Trade-Off Or Why Things That Go Right, Sometimes Go Wrong. URL reference http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf Proventive Solutions Page 35
  • Health & Safety System Approaches David Alman Hollnagel, E. Modelling of failures: From chains to coincidences. URL reference http://www.resistnoe.org/DOC/Budapest/Keynote-Hollnagel.pdf Hollnagel. E. Resilience Health Care. URL reference http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf Hopkins, A. AcciMaps in use. URL reference http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf Hopkins, A. An AcciMap of the Esso Australia Gas Plant Explosion. URL reference http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf How to manage work health and safety risks Safe Work Australia. URL reference http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Man age_Work_Health_and_Safety_Risks.pdf Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf Leveson, N.G. (2011) Engineering a safer world: Systems Thinking applied to safety. E-book URL reference https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_S afer_World.pdf OHSAS 18001 Occupational Health and Safety. URL reference http://www.bsigroup.com.au/enau/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS18001/ Patching.D. (1995). Practical Soft Systems Analysis. London: Pitman Publishing. Pomfret, W. Occupational Health and Safety Management System Auditing. URL reference http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf Queensland Government, Department of Education, Training and Employment document “Health & Safety Risk Assessment Template” issued in August 2012 URL ref http://bit.ly/1bcCqm7 Qureshi.Z, H. (2008) A Review of Accident Modelling Approaches for Complex Socio-Technical Systems. URL reference http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543 Rasmussen, J. The role of error in organizing behaviour. URL reference http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf Rasmussen, J & Svedung, I. Proactive Risk Management in a Dynamic Society (2000) URL reference https://www.msb.se/RibData/Filer/pdf/16252.pdf The Risk Management Process Northern Territory Government. URL reference http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf Safety Management Systems from Safe Work Australia. URL reference http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManage mentSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf Proventive Solutions Page 36
  • Health & Safety System Approaches David Alman SafeMap. URL reference http://www.safemap.com/english/cb_safety.html Safe Systems of Work Footwear and Leather Industries. URL reference http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OFWORK.pdf Severinghaus, R. Cuper, T. & C. Combs, D. Modeling drift in the OR: A conceptual framework for research . URL reference http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Sub mission.pdf Snowden, D. The Origins of Cynefin. URL reference http://cognitiveedge.com/uploads/articles/Origins_of_Cynefin.pdf Swiss Cheese model. URL reference http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html Waterson , P.E. & Jenkin D.P. Risk Management (ActorMap) Framework in Methodological considerations in using AcciMaps and the Risk Management Framework to analyse large scale systemic failures. URL reference https://dspace.lboro.ac.uk/dspacejspui/handle/2134/7944?mode=full Weick, K E. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. URL reference http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Org anizations_The_Mann_Gulch.pdf Work Health & Safety Act 2011 Division 2.2 Clause 19(3)(c). URL reference http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf Proventive Solutions Page 37
  • Health & Safety System Approaches David Alman About the author David Alman lives in Brisbane, Queensland, Australia, and is the business owner of Proventive Solutions, which offers services in Organisational Health. Organisational Health is a broad overview term that refers to assessing and improving performance and well being of both an organisation and its employees, recognising there is a nexus between the two. Further explanation through various articles, blogs, slides, on different subjects can be found on Proventive Solutions at WordPress, along with contact details. Please refer to: http://proventivesolutions.wordpress.com/2012/07/13/about-proventive-solutions/ This article is part of a body of work on Systems Thinking with a common base around the idea of looking at, and addressing, situations through different “Perspective Levels”. Other articles in this body of work include: Multilevel System Analysis: An introduction to Systems Thinking at http://www.slideshare.net/davidalman/multilevel-system-analysis and http://en.calameo.com/read/001450934d8a5a5d9b090 Human Activity Systems (HAS) Mapping at http://www.slideshare.net/davidalman/human-activitysystem-has-mapping and http://en.calameo.com/read/0014509349aed27553fc3 Proventive Solutions Page 38