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Safety clutter: the accumulation and persistence of ‘safety’ work that does not contribute to operational safety
Abstract
In this paper, we provide a description of a previously unlabelled and under-theorised problem in safety management – ‘safety clutter’. Safety clutter is the accumulation of safety procedures, documents, roles, and activities that are performed in the name of safety, but do not contribute to the safety of operations. Safety clutter is a problem because of the opportunity cost of ineffective activity, because clutter results in cynicism and ‘surface compliance,’ and because clutter can hamper innovation and get in the way of getting work done. We identify three main mechanisms that generate clutter: duplication, generalization, and over-specification of safety activities. These mechanisms in turn are driven by asymmetry between the ease and the opportunity of adding or expanding safety activities, and the difficulty and lack of opportunity for reducing or removing safety activities. At the end of the paper, we provide some concrete suggestions for reducing safety clutter, based on our analysis of the problem.
... When the performance of everyday activities is significantly burdened by safety rules, this can be detrimental to both work and safety [38]. To ensure that safety work actually contributes to safety, the concept of "safety clutter", which is defined as "the accumulation of safety procedures, documents, J o u r n a l P r e -p r o o f roles, and activities that are performed in the name of safety, but do not contribute to the safety of operational work" is useful [38]. ...
... When the performance of everyday activities is significantly burdened by safety rules, this can be detrimental to both work and safety [38]. To ensure that safety work actually contributes to safety, the concept of "safety clutter", which is defined as "the accumulation of safety procedures, documents, J o u r n a l P r e -p r o o f roles, and activities that are performed in the name of safety, but do not contribute to the safety of operational work" is useful [38]. In other words, the implementation of (redundant) safety procedures might increase the safety risks, particularly when companies are simultaneously attempting to keep production efficiency at the required level. ...
... Consensus: the level of agreement about the safety value of the activity between those who mandate the activity, those who perform the activity, and those who are ostensibly kept safe by the activity" [38]. ...
Background
Safety management is required to ensure health and safety of personnel in Norwegian fish farming. However, few studies have addressed the status and practical relevance of this risk-reducing measure.
Methods
This article provides new knowledge through interviews with 35 employees at different company levels, addressing perceptions of various safety management activities according to managers and operational personnel.
Results
Interviews show that managers and operational personnel at the fish farms agree that the quantity of measures aimed to improve safety have increased in recent years. However, some activities are perceived to have ha higher practical relevance than others. In general, measures that fit well with the practical reality are well received by the employees at the fish farms.
Conclusion
Suggested improvements include involving operational personnel in design of procedures, considering all risk dimensions that may affect occupational health and safety, and challenging the value of specific safety activities based on a detailed knowledge of the distinctive characteristics of work practice in fish farming.
... In organizations, ill-fitting procedures and ever-expanding documentation are understood as a necessary and largely unavoidable evil that even might induce accidents (Størkersen et al., 2017). Safety researchers have diagnosed the organizations with over-proceduralization and safety clutter (Bieder and Bourrier, 2013;Rae et al., 2018). ...
... Many organizations have tried to simplify their safety management systems, but still have ended up with at least as many procedures as before (Power, 1999). Indeed, Amalberti (2001) and Rae et al. (2018) have traced how it is easier to add than to remove rules; how new procedures hardly replace older ones but typically become part of a purely 'additive' system. In this article, we describe the organizations' condition as overregulation, since the internal regulation is detailed and overachieving on the limit to contradict its objectives. ...
... Still, it is common that safety management systems do not lead to procedures designed for an organization's operations (Hale and Borys, 2013b). Many practitioners and researchers consider safety management systems in general as too extensive, bureaucratic, and focused on documentation, thus creating a risk rather than ensuring safety (Antonsen et al., 2012;Bieder and Bourrier, 2013;Dekker, 2014;Rae et al., 2018;Walters et al., 2011). And indeed, the time-period after introduction of safety management regulation coincided with a time of more accidents (for example Le Coze, 2013;Maritime Authority, 2015;Oltedal, 2011). ...
Over the past decades, government safety management regulation has been driven by deregulation, simplification and organization-level regimes of inspection. So-called functional rule-making requires organizations to implement safety management systems appropriate for their operations. The paradox that seems to have arisen is that overregulation is common in many organizations. Research has found over-proceduralization, safety clutter, bureaucratic overload, and procedures not at the service of safety. To explore the paradoxical relationship between governmental deregulatory measures and organizational overregulation, we analyze empirical data from Norwegian fish farming and coastal transport. The data confirms that practitioners experience a rapidly grown abundance of internal rules and protocols, ill-fitting procedures, and pervasive, exaggerated safety management. We trace three mechanisms that have driven internal overregulation: work auditability; managerial insecurity and liability; and audit practices. These mechanisms show how functional regulation can have unintended consequences when it meets other accountability expectations. Expectations of market doctrine, bureaucratic entrepreneurism and control can lead a company transforming simple governmental regulations into vastly overcomplicated safety management systems. We conclude our study with prescriptions of how this aspect of safety could be done differently.
... Safety management often is talked about as one black-boxed activity, even though it consists of a line of tasks that consume time and reduce focus in most jobs (cf. [7]). These tasks should be recognized when developing operations. ...
... However, procedures in many industries have been reported as overly complicated and demanding extensive documentation, potentially contributing to accidents [21,22,26,27]. Ironically, accidents and incidents often lead to more procedures being added to the already massive safety management systems [7,28]. Safety management is often understood as secondary tasks adding work load and a parallel system on the side of core tasks [27]. ...
Safety management is a topic of engagement and frustration among seafarers. Safety management can reduce accidents, but it also can reduce the focus and flexibility needed to perform safe operations. In operations, core tasks ideally should be supported by safety management tasks (working according to procedures, harmonizing procedures to other professions, and documenting operations). Instead, safety management sometimes displace core tasks. Even though previous research on future vessel operations seek to create a situation where core tasks have full attention, safety management is rarely mentioned. Therefore, this study explores how safety management can support core tasks in remotely controlled vessel operations. Since such operations are still at the trial stage, this study relies on previous theoretical or small-scale empirical studies to find examples of conditions relevant for safety management. Future conditions may include fragmented organizational structures, new role interdependencies, and a heavy burden on shore-control centers. The findings suggest that the present safety management weaknesses – reduced focus and flexibility – are probably enhanced by the expected future conditions. The recommendations from this study should be considered and implemented before remotely controlled vessels are launched.
... This study highlights the extent of the: separation, fragmentation, and standardization of safety professional work, through the growth of demonstrated, social, and administration safety work disconnected from operational safety. Safety professionals spent considerable time engaged in demonstrated and administrative safety work which appeared significantly distant from operational safety outcomes ( Rae and Provan et al., 2018). These activities included: managing messages, participating in tokenistic activities, developing generic safety processes and practices, and compiling safety information, etc. ...
... Personality and authority will prevail over absent, or poorly presented empirical evidence ( Peters and Peters, 2006). Empirical safety findings help reduce the institutionalization of the safety professional role and reduce safety work that does not contribute to operational safety -safety clutter ( Rae and Provan et al., 2018). ...
The safety profession has grown and evolved over recent decades, and despite the prominence of the role within organisations, there is limited research about the current state of safety professional practice. The objective of a safety professional’s role is often stated as ‘preventing incidents and harm to people', although the existing research fails to demonstrate a compelling link between safety professional practice and worker safety. More recently, a model of safety work in organisations proposed that safety activities fulfill broader social and political needs, in addition to the physical reduction of safety risk. In this paper, we report a study that investigated the underlying objectives of individual safety professional tasks, then performed thematic analysis to explore the contemporary role of safety professionals in organisations. 12 mid-level and senior-level safety professionals were interviewed at monthly intervals for six months regarding their work activities, in addition to an embedded researcher performing more than 240 h of field observations. Four categories of safety work in organisations – demonstrated, social, administrative, and physical – were used as priori themes to deductively analyze the data. The findings demonstrate strength of alignment between the safety professional role and line management, the increasing institutionalization of safety professional work, an absence of safety professional work directed at reducing safety risks to workers, and the lack of a clear connection between safety professional practice and safety science research.
... Meanwhile, Rae and Provan [26] put forward the concept of safety clutter, which refers to the random accumulation of safety procedures, documents, roles, and activities under the banner of safety but not conducive to the safety of work because of the opportunity cost of ineffective activities. The bureaucracy of safety is also accelerating, which has led to some drawbacks of safety work, including complicating the links between institutions, relationships, and individuals, reducing the marginal benefits of safety measures, and limiting the diversity of safety work and the creativity of personnel, hindering the innovative development of safety work [27,28]. ...
In China, safety policies interfere with the occurrence of work accidents in the form of guidance and restrictions. In this study, the impact of types of safety policies on work accident prevention is quantitatively analyzed. Based on a statistical analysis of China’s safety policies and work-related accidents from 2000 to 2020, the following four policy indexes that reflect the impact of safety policies are identified: the stringency level of the policy; the scope; its technical content; and its industrial target. A vector autoregressive model (VAR) is used, and a dynamic analysis of the model is conducted with an impulse response function. The model’s degree of fit is 92.9%, the number of deaths and the number of safety policies are linearly related, and the relative error between the fitted values and the real values is approximately 5%. The negative correlation between the death rate per 100 million yuan and the stringency level, scope, technical content, and industrial targets of safety policies is first weak, then strengthened, and then weakens again over time. This study finds that the importance of safety policy indicators is different; especially, the strict safety policy has a long-term negative impact on mortality. For developing countries such as China, where the safety policy system is not yet perfect, increasing the number and implementation of safety policies can significantly improve the situation of production safety.
... The introduction of PSPs may also contribute to the problem of "safety clutter," which is the accumulation of safety procedures, checklists, and activities performed in the name of safety that do not actually contribute to safety. 14 To improve the quality of care and create more sustainable health services, it is necessary to consider the deimplementation of low-value PSPs. While there has been research to identify those PSPs ready for adoption and so by default those that are not, 15 evidence exploring removal of ineffective PSPs is lacking. ...
Objectives: Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of ‘safety clutter’ in organisations, it is important to consider de-implementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centred and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low-value.
Methods: Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (UK) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analysed using content and thematic analysis.
Results: A total of 1,394 responses from 1,041 participants were analysed. 663 responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included ‘paperwork’, ‘duplication’ and ‘intentional rounding’. Five cross-cutting themes (e.g. covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low-value.
Conclusions: Staff identified safety practices that they perceived to be low-value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for de-implementation and, if not, to explore how to better support healthcare workers to perform them.
... Another potential negative consequence of QI for staff occurs when local teams focus on making something happen more reliably without stepping back and asking what is the evidence that change will result in improvement; or more simply expressed-doing a QI project on a whim. For example, Rae and colleagues 9 argue that there is asymmetry between the ease and the opportunity for adding new safety activities and the difficulty or lack of opportunity to remove them. A recent article in Nature 10 provides experimental evidence for this human default to additive, rather than subtractive, change. ...
... We make an evidence-based argument that Take 5 is a form of "safety clutter" [8]work performed in the name of safety, which does not provide safety benefit. Safety clutter accumulates and persists because of workplace structural and social pressures rather than well-reasoned decisions about how best to improve safety. ...
This paper describes and analyses a particular safety practice, the written pre-task risk assessment, commonly referred to as a “Take 5”. The paper draws on data from a trial at a major infrastructure construction project. We conducted interviews and field observations during alternating periods of enforced Take 5 usage, optional Take 5 usage, and banned Take 5 usage. These data, along with evidence from other field studies, were analysed using the method of Functional Interrogation. We found no evidence to support any of the purported mechanisms by which Take 5 might be effective in reducing the risk of workplace accidents. Take 5 does not improve the planning of work, enhance worker heedfulness while conducting work, educate workers about hazards, or assist with organisational awareness and management of hazards. Whilst some workers believe that Take 5 may sometimes be effective, this belief is subject to the “Not for Me” effect, where Take 5 is always believed to be helpful for someone else, at some other time. The adoption and use of Take 5 is most likely to be an adaptive response by individuals and organisations to existing structural pressures. Take 5 provides a social defence, creating an auditable trail of safety work that may reduce anxiety in the present, and deflect blame in the future. Take 5 also serves a signalling function, allowing workers and companies to appear diligent about safety.
... In other examples, a focus on formalised processes widened the gap by being seen to limit the autonomy, participation, experience and tactic knowledge of workers in managing safety, such as in workers of a contract maintenance organisation (Borys, 2009), offshore workers following a large process of standardising the safety system and practices (Antonsen et al., 2012) and for reducing "common sense" in the case of seafarers (Knudsen, 2009). Rae et al. (2018) more recently highlight the problem of safety clutter. Safety clutter is the accumulation of safety artefacts, roles and activities performed for safety purposes but do not actually improve operational safety Problematically, clutter tends to resist removal and, in some cases, propagate further, due to the relative challenge of removing documents once they are implemented . ...
Safety Management Systems are developed to help manage occupational risk, but they can also increase an organisation’s exposure to risk. This contradictory effect may happen when written artefacts (plans, risk assessments etc.) enable work to happen by encouraging a belief that the risks have been managed, when in reality they have not been. In this paper we introduce the term “enabling device” to cover the situation where a written artefact facilitates the commencement of work. We explore how enabling devices can become excessively symbolic, where they facilitate work to commence even when they may be decoupled from the issues they were designed to manage. We argue that highly symbolic artefacts acting in their enabling function: a) become more speculative than functional, b) make assumptions and beliefs “appear more real” by giving them an observable form, c) fill a need for people to solve issues without actually having to solve the issue, and d) increasingly become the unit of management instead of the issues and then take on a life of their own. This work suggests that practitioners should more critically evaluate the often invisible and potentially pervasive symbolism vested in safety artefacts to direct effective and sustainable risk interventions.
... Sedang untuk proses POOH CT pada sumur Y merupakan Pelanggaran yang benar (correct violation), kinerja yang benar/sukses didapat melalui penyimpangan dari peraturan atau prosedur yang tidak tepat. Semakin berkembangnya birokrasi atau safety clutter (Rae dkk., [18]) membuat minim keuntungan yang dihasilkan inisiatif/program K3, berkembangnya usaha-usaha birokrasi, ketidakmampuan untuk memprediksi kejadian yang tidak diduga, kerahasiaan dalam struktur organisasi, permainan/manipulasi angka statistik cidera, semua itu menghasilkan masalah baru dan menghambat kebebasan, keragaman, kreativitas, dan inovasi pekerja. (Dekker,[3]) ...
Bekerja di lapangan migas lepas pantai/offshore memiliki risiko yang tinggi. Beberapa aktifitas pekerjaan terkait siklus sumur migas terdiri atas persiapan lokasi, pengeboran, penyelesaian sumur, perawatan atau perbaikan, dan penutupan atau peninggalan sumur. Studi kasus pada pekerjaan perawatan sumur menunjukkan bahwa pelanggaran yang benar/correct violation akan menghasilkan kesuksesan operasional, sedang ketaatan yang tidak sesuai/mispliance justru menghasilkan kejadian yang tidak diinginkan. Pada pekerjaan dimana ada volatilitas, ketidakpastian, kompleksitas, dan ambiguitas yang tinggi, diperlukan keseimbangan antara menaati prosedur tertulis dan keberanian untuk menyimpang, mengambil risiko, dan pertimbangan profesional untuk menyesuaikan keterbatasan sumber daya yang ada dengan konteks atau kondisi di lokasi kerja untuk mencapai kesuksesan operasional dan keselamatan kerja.
... In recent years, although China's economy has made great progress, it is also faced with the problem of high number of accidents and deaths in production safety [1]. Although the government has taken many measures, including the reorganization of the General Administration of Safety Supervision, multiple rounds of amendments to the production Safety Law, and the continuous introduction of local and industrial safety standards [2], these simple administrative measures only alleviate the severe situation of production safety to a certain extent, and are not enough to completely solve the problem of production safety [3]. To investigate the reason, in addition to administrative means, the level of economic development is also one of the important factors affecting production safety. ...
One of the important factors affecting the production safety of a country or region is the level of economic development. Avoiding accidents under the condition of ensuring economic development is a problem that needs in-depth research. On the basis of collecting the data of occupational accidents and economic development indicators in China from 2000 to 2020, this paper studies the relationship between occupational accidents and five economic indicators, such as resident consumption, energy consumption, education funds, wage level and research input. The grey working accident model of Gaussian function is established, the occurrence trend of occupational accidents is quantitatively analyzed, and the accident reduction measures are suggested based on the relationship between accidents and economy. The results show that there is a strong correlation between accident and economic indicators, and the comprehensive correlation coefficient among scientific research investment, education funds and accident indicators is significantly higher than that of other economic indicators. Increasing investment in scientific research and education is conducive to improving the quality of workers and training safety professionals and can effectively reduce workplace accidents.
... The statements about following ordinary WAP routines in a situation where most ordinary work routines theoretically and technically cannot guide actions [44,47,49,51,68,69] spark curiosity about the drivers behind these statements. The pattern of references to ordinary standard procedures was also present in the two official review reports [59,60]. ...
During the autumn of 2015, Europe experienced a sharp increase in refugee influx, and many refugees arrived in the European Øresund Region. Refugees travelled through Denmark and over the Øresund Bridge, arriving in the third largest city in Sweden, Malmö. Private, public and voluntary organizations in Malmö had to change the way they worked to meet the new entry demands. Flexible adaptations to changing circumstances can be described as resilient performance and are supported or hindered by societal and organizational drivers and barriers. Qualitative interview data from Swedish organizations managing the refugee reception in Malmö were analyzed through the theoretical lens of Resilience Engineering (RE). The analysis results showed that necessary adaptations were not supported by the managerial design of the responsible public organizations. The analysis also showed that preconditions created from societal steering hinders value responsiveness at the public management level, i.e., the public management level has barriers towards becoming familiar with the organization’s value structures. Familiarity with the system value and goal structure is essential for an efficient prioritizing of conflicting goals, which is why it is suggested that this aspect be explicitly included in RE principles.
... Unsurprisingly, firms with null commitment to a management system show the poorest safety performance (Arocena and Núñez, 2010). While some proponents of SMS almost take it for granted that its implementation will automatically lead to better safety performance (Cianfrani, 2014;Galotti et al., 2006;Gamauf, 2014;George, 2014;ICAO, 2006a), many researchers relentlessly probe and question its usefulness, value, ease, cost, practicality, flexibility and relevance (ATSB, 2011;Almklov, 2018;Almklov et al., 2014;Anthony, 2009;Antonsen et al., 2012;Bragatto et al., 2015;Dekker, 2018;Frick, 2014;Gallagher et al., 2001;Hohnen et al., 2014;Hunter, 2015;Lacagnina, 2010a;Le Coze, 2017;Niskanen et al., 2014;Rae et al., 2019;Størkersen et al., 2020;Valluru et al., 2020;Walker and Tait, 2004;Walter, 2017;Werfelman, 2009Werfelman, , 2015. ...
This thesis explores the rationality, completeness and functioning of Safety Management Systems (SMS) amongst micro- and small-sized air operators in business aviation. In the absence of thorough literature in this sector of aviation, a survey of prior research on OHS(MS) and on non-aviation micro/small enterprises (MSE) provided a collection of factors contributing to their safety performance. Using a sociotechnical system perspective, this ‘generic’ profile served as basis for two surveys: one amongst veteran business aviation professionals and leaders, and the other amongst air operator personnel. To complement the industry’s self-portrait, neo-institutional theory is also utilised and further explains the strategies and tactics used by many stakeholders. Its validity in business aviation and usefulness for further research is underlined in the process. The results support the existing distinctions between the three main types of business aviation air operators and provide a ‘generic’ profile for each one of them from socioeconomic and safety perspectives. Similarities and contrasts across all industries are also highlighted. Moreover, the responses to the online survey suggest that neither the micro/small air operators nor the civil aviation authorities could create, even jointly, the conditions of possibility for SMS implementations to be complete, and therefore for air operators’ SMS to be fully functional. Although further research is needed, this initial foray into business aviation safety management fuels the argument that the current, hegemonic SMS framework designed by and for large organisations is a misfit to the micro/small air operators, including their ‘safety champions’ who are best placed to implement it, i.e., corporate flight departments.
... Eliminating waste, or decluttering BCM, is necessary to ensure that resources are invested to all those BCM activities that add (business) value. Decluttering is a concept adopted from the safety literature, 16 and when applied to BCM can be defined as reducing artefacts and activities that are conducted in the name of BCM but contribute little or nothing to the organisation's resilience. To identify clutter, the safety literature suggests three dimensions: ...
As unpredictable major-impact events are on the rise, many organisations have adopted an organisational resilience (OR) approach for dealing with these so-called 'black swan events. What OR comprises is subject to ambiguity and multiple interpretations. This article presents a perspective that makes a distinction between predictable risks and unpredictable major-impact events. The article argues that predictable risks would benefit from an adaptive and efficient business continuity management (BCM) capability. Using several cases, the article demonstrates how the adaptability and efficiency of BCM can be improved in practice. For unpredictable events, this article calls for a strategy of anticipated improvisation. Both strategies necessitate executives and regulators to accept less planning and to put more trust in the expertise of specialists and managers.
... Another reason why procedures are overly detailed and complicated, is linked to bureaucracy (Dekker, 2014). It is common to add procedures after accidents or audits (Hale & Borys, 2013;Provan, Dekker, & Rae, 2017;Rae, Provan, Weber, & Dekker, 2018). Independent decisionmaking and improvisation are undervalued or even disparaged in audits, so even when practical procedures are created, they may be accompanied by impractical and theoretical procedures to ensure auditability (Størkersen et al., 2020). ...
Safety management regulation was introduced almost twenty years earlier for Norwegian seafarers than coastal fishers, although both groups work in industries with high accident frequencies. In this study, seafarers and fishers' perspectives on safety management requirements is studied, through empirical data from interviews and observation conducted over several years, with the aim of informing the future development of safety management , especially in fishing. Results show that the fishers have practical skills and an operational orientation, while the seafarers experience ill-fitting procedures, extensive documentation, and shore management that the coastal fishers lack. The suggestions for future safety management are related to development of procedures, a safe working environment, safeguards and safety management skills.
... • Should we run process plants as if they were nuclear submarines (Bierly and Spender, 1995)? • Would safety clutter be the first problem to solve (Rae et al., 2018)? ...
A significant gap exists between accident scenarios as foreseen by company safety management systems and actual scenarios observed in major accidents.
The mere fact that this gap exists is pointing at flawed risk assessments, is leaving hazards unmitigated, threatening worker safety, putting the environment at risk and endangering company continuity. This scoping review gathers perspectives reported in scientific literature about how to address these problems.
Safety managers and regulators, attempting to reduce and eventually close this gap, not only encounter the pitfalls of poor safety studies, but also the acceptance of ‘unknown risk’ as a phenomenon, companies being numbed by inadequate process safety indicators, unsettled debates between paradigms on improving process safety, and inflexible recording systems in a dynamic industrial environment.
The immediacy of the stagnating long term downward major accident rate trend in the Netherlands underlines the need to address these pitfalls. A method to identify and systematically reduce unknown risks is proposed. The main conclusion is that safety management can never be ready with hazard identification and risk assessment.
... This paper focuses on these principal constituents of a systems approach to OHSMS, namely systematic management and systems thinking, and through a literature review and the reasoning of the authors, explores avenues through which these two paradigms could co-exist and presents a mapping of their intersections. Within the broader OHS context, this paper contributes to the discussion about the safety clutter recently introduced by Rae, Provan, Weber and Dekker (2018) and connected with the duplication, generalisation, and over-specification of safety activities that might result in cynicism and superficial compliance with standards. ...
A systems approach to Occupational Health & Safety Management (OHSM) acknowledges that entities of people, equipment, tools, processes and policies are all interconnected and interrelated, and in conjunction affect the outcomes and achievements of any business undertaking. Although several internationally recognised standards for OHSM systems draw on the synergy between systematic management, which reflects the degree of system control, and systems thinking, which represents the degree of system knowledge, the different levels of application of these two approaches during their symbiosis within a given system has not been visibly articulated. In our work, we reviewed relevant literature and reflected on the possible combinations of systematic management practice with the knowledge generated through systems thinking from a sociotechnical perspective. Based on the degree to which any variability is seen as inevitable and the extent to which the organisation aims to control it, we translated the various blends of the two paradigms into the ways an organisation generates and establishes objectives and procedures. Our premise is that there is no golden rule and that systems thinking and systematic management must be combined with caution and an understanding of the inherent limitations of each approach and the context in which they are introduced.
... This is necessary to help organisations and line managers understand the way that the OHS professional role can be performed most effectively within organisations to contribute to OHS risk reduction. It will prevent OHS professionals and their organisations from creating safety clutter, defined as safety work tasks that do not contribute to operational safety ( Rae et al., 2018;Rae and Provan, 2019). ...
Strategically unlearning specific knowledge, behaviors, and practices facilitates product and process innovation, business model evolution, and new market opportunities and is essential to meet emergent supply chain and customer requirements. Indeed, addressing societal concerns such as climate change and net zero means elements of contemporary practice in food supply chains need to be unlearned to ensure new practices are adopted. However, unlearning is a risky process if crucial knowledge is lost, for example, if knowledge is situated in the supply base not the organization itself, or there is insufficient organizational food safety knowledge generation, curation, and management when new practices/processes are designed and implemented. An exploratory, critical review of management and food safety academic and gray literature is undertaken that aims to consider the cycle of unlearning, learning, and relearning in food organizations and supply chains with particular emphasis on organizational innovation, inertia, and the impact on food safety management systems and food safety performance. Findings demonstrate it is critical with food safety practices, such as duration date coding or refrigeration practices, that organizations "unlearn" in a way that does not increase organizational, food safety, or public health risk. This paper contributes to extant literature by highlighting the organizational vulnerabilities that can arise when strategically unlearning to promote sustainability in a food supply context. Mitigating such organizational, food safety, and public health risk means organizations must simultaneously drive unlearning, learning, and relearning as a dynamic integrated knowledge acquisition and management approach. The research implications are of value to academics, business managers, and wider industry.
Las métricas de la seguridad laboral basadas en la accidentabilidad, como la tasa total de frecuencia de accidentes registrables, presentan deficiencias bien documentadas. Un bajo nivel de siniestralidad no exime de responsabilidades jurídicas. La seguridad, entendida como presencia de capacidades para que las cosas salgan bien, concuerda con el concepto jurisprudencial de diligencia debida del empleador. Los autores de este artículo proponen un índice que engloba ambos elementos, midiendo las capacidades de adquirir y mantener conocimientos sobre seguridad, comprender la naturaleza de las operaciones, destinar recursos para la seguridad, responder a los riesgos, demostrar la colaboración y la conformidad, y ofrecer garantías.
Face aux limites, bien documentées, des indices de sécurité au travail habituels, axés sur la fréquence des incidents, et alors que la jurisprudence a fait valoir une obligation de diligence raisonnable de l'employeur, de nombreux chercheurs préconisent de mesurer, plutôt que les échecs, les ressources – ou capacités – qui font que tout se déroule de façon harmonieuse en temps ordinaire. Les auteurs proposent dans cet esprit un indice des capacités qui englobe six dimensions: la connaissance des enjeux de sécurité, celle des processus opérationnels, les moyens alloués, le suivi des risques, la mise en conformité et les garanties de sécurité.
The academic literature presents hazard reporting as an extension of incident reporting. Hazards are presented as more safety data to collect, data that allows for proactive actions, but feeds into a similar learning process. In this paper, we use ethnographic data to examine whether either view holds up both critically and empirically. Based on both literature and data, five possible functions for hazard reporting systems were identified; sharing experiences, organisational learning, extending organisational memory, performance monitoring, and coordinating remedial actions. The data was then explored to test whether the hazard reporting system was facilitating these functions in practice. It was found that in practice, hazard reporting mostly fulfilled the role of coordinating remedial action, and pertained less to any of the learning and memory-related functions. Hazard reporting was found to be unsuitable for performance monitoring. From these findings follow general takeaways - that hazard reporting is, in practice, different from incident reporting; the word hazard is a poor choice to structure learning effort around; trying to increase reporting can be counterproductive for learning efforts, and reporting is valued for its ability to reach out to others within an organisation.
Stopping work when work becomes unsafe is universally considered to be a positive safety behaviour. Safety interventions aimed at building the capability to stop unsafe work have focussed on assertiveness training and creating authority to stop work policies. A recent focus group-based study found that these interventions do not necessarily capture the most common factors influencing stop work decisions, and found that stop-work decisions can be enacted in different forms. Inspired by this work, we used an ethnographic study in a water utility provider to understand how decisions to stop work were made, and how they were influenced by procedures. In this organisation, crews frequently made decisions to stop work, usually by handing over the job to another crew. The decisions were easy to make if they could be framed as finding the best way to complete the job. Operators did not view decisions framed this way as safety related decisions. Procedures could cause crews to consider stopping work, but were unlikely to actually lead to a decision to stop work. If a crew considered it impossible to comply with a procedure, the crew who would pick up the cancelled job would likely encounter the same situation. As such, stopping work for procedural requirements was not perceived as improving safety. These findings challenge the idea that stop-work decisions are best supported through procedures, assertiveness training, and authority to stop work policies. As an alternative, the results suggest that organisations can influence workers to stop work by providing alternative methods for them to complete a job which crews themselves can arrange.
Shortcomings of incident‐based metrics such as Total Recordable Incident Frequency Rate (TRIFR) are well‐documented, including the lack of standardization, construct validity, statistical power, and predictive power. A low TRIFR is also no assurance against legal liability. There is considerable overlap between the research literature on safety as the presence of capacities to make things go well, and jurisprudence in labor and workplace safety law. In this paper we suggest an index that merges the two, measuring the capacities to acquire and maintain safety knowledge; to understand the nature of operations; to resource for safety; to respond to risks; to demonstrate engagement and compliance; and the capacity for assurance.
The process of describing human activities in procedures has been used since the beginning of the 20th century. However, it is increasingly evident that procedures understood as sets of orders and prohibitions can be counter-productive because they do not allow the proper use of employees’ knowledge and experience. Therefore, it is postulated that guidelines for practice should be co-developed by employees from the ‘sharp end’ of the organization, but there are no simple methods that can achieve this aim. In the present work, we propose a procedure based on sticky notes, inspired by how information technology teams function. We present a description of the original sticky notes method (SNM) and demonstrate its application in the railway sector. As a result of the workshops conducted with the participation of experts, we gained knowledge about practices that were not included in the documentation, but that could significantly improve the process under research. The primary purpose of the SNM is to ensure the involvement of employees in the process of creating guidelines for practice. This method is particularly useful for describing linear processes in which activities can be arranged chronologically.
Neoliberalism refers to the political, economic and social arrangements that have become globally dominant since the 1980s. It promotes privatization, free markets, and deregulation. Neoliberal governance can be linked to safety management by stifling rules developed by non-experts, bureaucratic overreach, imposition of discipline and accountability, and a hemming in of autonomy and discretion on the frontline. Using a variety of sources, this paper examines what safety and safety management can look like after neoliberalism. Centrally, it hinges on changing the belief that complex risks can be managed by rule-based uncertainty reduction, documentation-based liability management, or shrinking the bandwidth of allowable human performance. Safety after neoliberalism involves regulation on the basis of capacities to make things go right as opposed to compliance; de-bureaucratizing safety by putting safety expertise closer to the ‘messy details’ of actual practice, and instituting investigations and restorative incident responses that emphasize safe working conditions as a collective responsibility. In addition, safety after neoliberalism takes a fresh look at global supply chains, participatory equality, and workers’ compensation practices.
The safety management literature describes two distinct modes through which safety is achieved. These can be described as safety management through centralized control, or safety management through guided adaptability. Safety management through centralized control, labelled by Hollnagel as ‘Safety-I’, aims to align and control the organization and its people through the central determination of what is safe. Safety management through guided adaptability, or ‘Safety-II’, aims to enable the organization and its people to safely adapt to emergent situations and conditions. Safety-II has been presented as a paradigm shift in safety theory, but it has created practical difficulties for safety professional practice. In this paper, we define the two modes of safety management and explain the challenges in changing the role of a safety professional to support Safety-II. When should safety professionals re-enforce alignment, and when should they support frontline adaptations? We outline specific activities for safety professionals to adopt in their role to move towards a guided adaptability mode of safety management. This will move the safety professional further towards their fundamental responsibility – ‘to create foresight about the changing shape of risk, and facilitate action, before people are harmed.’
Introduction:
The professional identity of safety professionals is rife with unresolved contradictions and tensions. Are they advisor or instructor, native or independent, enforcer of rules or facilitator of front-line agency, and ultimately, a benefactor for safety or an organizational burden? Perhaps they believe that they are all of these. This study investigated professional identity through understanding what safety professionals believe about safety, their role within organizations, and their professional selves. Understanding the professional identity of safety professionals provides an important foundation for exploring their professional practice, and by extension, understanding organizational safety more broadly.
Method:
An embedded researcher interviewed 13 senior safety professionals within a single large organization. Data were analyzed using grounded theory methodology. The findings were related to a five-element professional identity model consisting of experiences, attributes, motives, beliefs, and values, and revealed deep tensions and contradictions. This research has implications for safety professionals, safety professional associations, safety educators, and organizations.
Safety professionals have been working within organizations since the early 1900s. During the past 25 years, societal pressure and political intervention concerning the management of safety risks in organizations has driven dramatic change in safety professional practice. What are the factors that influence the role of safety professionals? This paper reviews more than 100 publications. Thematic analysis identified 25 factors in three categories: institutional, relational, and individual. The review highlights a dearth of empirical research into the practice and role of safety professionals, which may result in some ineffectiveness. Practical implications and an empirical research agenda regarding safety professional practice are proposed.
Safety activities may provide assurance of safety even where such assurance is unwarranted. This phenomenon – which we will call “probative blindness” – is evident both in hindsight analysis of accidents and in the daily practice of safety work. The purpose of this paper is to describe the phenomenon of probative blindness. We achieve this by distinguishing probative blindness from other phenomena, identifying historical instances of probative blindness, and discussing characteristics and causes associated with these instances. The end product is an explanation of the features of probative blindness suitable for investigating the probative value of current safety activities, and ultimately for reducing the occurrence of probative blindness.
This study addressed the nature and functioning of relationships of interpersonal trust among managers and professionals in organizations, the factors influencing trust's development, and the implications of trust for behavior and performance. Theoretical foundations were drawn from the sociological literature on trust and the social-psychological literature on trust in close relationships. An initial test of the proposed theoretical framework was conducted in a field setting with 194 managers and professionals.
This paper reports an investigation into the use of evaluation as part of system safety research. Using a simple classification scheme based on the knowledge and evaluation components of research papers, we classify two years of papers at the IET System Safety conference. Our analysis indicates a significant mismatch between a small collection of observational research papers with strong evaluation, and a large body of papers providing guidance which have not been evaluated. Of particular concern is that the majority of these papers do not provide sufficient information to support future evaluation. In response to these findings we suggest a minimum set of properties which guidance research products must have in order to allow the research to be evaluated.
This article reviews the now extensive research literature addressing the impact of accountability on a wide range of social judgments and choices. It focuses on 4 issues: (a) What impact do various accountability ground rules have on thoughts, feelings, and action? (b) Under what conditions will accountability attenuate, have no effect on, or amplify cognitive biases? (c) Does accountability alter how people think or merely what people say they think? and (d) What goals do accountable decision makers seek to achieve? In addition, this review explores the broader implications of accountability research. It highlights the utility of treating thought as a process of internalized dialogue; the importance of documenting social and institutional boundary conditions on putative cognitive biases; and the potential to craft empirical answers to such applied problems as how to structure accountability relationships in organizations.
The Institute of Medicine's seminal report To Err
Is Human1 highlighted the risks of medical
care in the United States and shocked the sensibilities of many Americans.
As one element of a multipronged response, the Agency for Healthcare Research
and Quality (AHRQ) commissioned the University of California, San Francisco–Stanford
University Evidence-Based Practice Center to develop a compendium of evidence-based
patient safety practices, a resource summarizing the literature supporting
practices relevant to improving patient safety.
The paper reviews the literature from 1986 on the management of those safety rules and procedures which relate to the workplace level in organisations. It contrasts two different paradigms of how rules and their development and use are perceived and managed. The first is a top-down classical, rational approach in which rules are seen as static, comprehensive limits of freedom of choice, imposed on operators at the sharp end and violations are seen as negative behaviour to be suppressed. The second is a bottom-up constructivist view of rules as dynamic, local, situated constructions of operators as experts, where competence is seen to a great extent as the ability to adapt rules to the diversity of reality. The paper explores the research underlying and illustrating these two paradigms, drawn from psychology, sociology and ethnography, organisational studies and behavioural economics. In a separate paper following on from this review (Hale and Borys, this issue) the authors propose a framework of rule management which attempts to draw the lessons from both paradigms. It places the monitoring and adaptation of rules central to its management process.
Originally developed by Glaser and Strauss, grounded theory is a useful research method for researchers aiming to generate novel theory as it emerges from data gathered and analysed. However, this method is not utilised extensively, and when it is applied, it often leaves researchers confused as to its utility. This article addresses the origins of grounded theory while also informing readers of some of the difficulties regarding this research method. These difficulties arise as a result of the fundamental contentions presented by Glaser and Strauss in their theoretical and methodological divorce from each other and their original grounded theory approach. Illustrative examples of the issues related to the selection of a grounded theory method are presented in relation to a study that relied on the Straussian grounded theory approach to account for the meanings of HIV prophylactic Voluntary Medical Adult Male Circumcision in South Africa.
This paper examines the bureaucratization of safety, and the increase in safety as measurable bureaucratic accountability. The bureaucratization of safety—which has accelerated since the 1970s—revolves around hierarchy, specialization and division of labor, and formalized rules. Bureaucratic accountability refers to the activities expected of organization members to account for the safety performance of those they are responsible for (e.g. unit, team, site). Bureaucratization of safety has brought benefits, including a reduction of harm, standardization, transparency and control. It has been driven by regulation, liability and insurance arrangements, outsourcing and contracting, and technologies for surveillance and data storage. However, bureaucratization generates secondary effects that run counter to its original goals. These include a reduced marginal yield of safety initiatives, bureaucratic entrepreneurism and pettiness, an inability to predict unexpected events, structural secrecy, “numbers games,” the creation of new safety problems, and constraints on organization members’ personal freedom, diversity and creativity, as well as a hampering of innovation. This paper concludes with possible ideas for addressing such problems.
This paper examines how the syndrome of authoritarian high modernism, described in detail in the public policy sphere in James C Scott’s Seeing Like a State, serves as the dominant, orthodox ideology informing patient safety. We compare Scott’s conceptual framework to the currently dominant health care safety practices to surface foundational issues that would otherwise remain hidden, but which need to be revealed to make progress in safety. Although the paper focuses on safety in healthcare as a particular, specific exemplar, the elements of the syndrome are relevant to orthodox safety efforts in many hazardous activities.
The story of the patient-safety movement is one of slow progress punctuated by episodes of inspiring successes that are slow to be replicated. So it is not surprising that when promising innovations are not universally adopted, the public and policymakers are outraged and sometimes turn to regulation to ensure compliance. The surgical safety checklist is such an innovation.(1) The use of such checklists has been mandated or strongly encouraged by several governments, including those of the United Kingdom, the Netherlands, and Ontario, Canada. A study reported in this issue of the Journal by Urbach and colleagues(2) shows the limitations of ...
Workplace safety is undergoing a process of ‘responsibilization’. While employers have traditionally been the target of health and safety law, workers are increasingly assigned greater responsibility for their own safety at work and are held accountable, judged, and sanctioned through this lens. This is illustrated through an analysis of the rationales and mentalities of a new ticketing regulatory system in Canada whereby workers are targeted for sanctions and blamed for health and safety violations. Under the responsibilization strategy of health and safety, workers are not only re-defined as both potential victims and offenders but they also find themselves forced to adopt a rights-defined identity. This is a significant albeit subtle shift that paves the way for a host of new projects that strive to reveal the discourses and techniques that define and characterize individual responsibilization in health and safety.
This paper reviews the claim that there has been an audit explosion in recent years and seeks to refine the argument in terms of its institutional and behavioral effects and its underlying causes and consequences. A framework for greater comparative sensitivity is suggested, both in cross-national and cross-sectoral terms, which focuses on variation in the knowledge base, formal organization, and operational dimensions of auditing. Finally, a preliminary framework for evaluating the design of auditing practices is developed that could inform a post-Enron critical discussion of the problems and the potential for auditing in the future.
Healthcare demonstrates the same properties of risk, complexity, uncertainty, dynamic change, and time-pressure as other high hazard sectors including aviation, nuclear power generation, the military, and transportation. Unlike those sectors, healthcare has particular traits that make it unique such as wide variability, ad hoc configuration, evanescence, resource constraints, and governmental and professional regulation. While healthcare's blunt (management) end is more easily understood, the sharp (operator) end is more difficult to research the closer one gets to the sharp end's point. Understanding sharp end practice and cognitive work can improve computer-based systems resilience, which is the ability to perform despite change and challenges. Research into actual practice at the sharp end of healthcare will provide the basis to understand how IT can support clinical practice. That understanding can be used to develop computer-based systems that will act as team players, able to support both individual and distributed cognitive work at healthcare's sharp end.
How, and to what extent, do people become involved in an organization and committed to its goals? If an organization is to survive and to function effectively, it must require not one, but several different types of behavior from most of its members, and the motivations for these different types of behavior may also differ. How does a business organization attract the kind of people it needs? How does it hold them? How does it induce both reliable performance and spontaneous innovation an the part of its members? This paper proposes an analytic framework for understanding the complexities of motivational problems in an organization.
This paper is a report of a discussion of the arguments surrounding the role of the initial literature review in grounded theory.
Researchers new to grounded theory may find themselves confused about the literature review, something we ourselves experienced, pointing to the need for clarity about use of the literature in grounded theory to help guide others about to embark on similar research journeys.
The arguments for and against the use of a substantial topic-related initial literature review in a grounded theory study are discussed, giving examples from our own studies. The use of theoretically sampled literature and the necessity for reflexivity are also discussed. Reflexivity is viewed as the explicit quest to limit researcher effects on the data by awareness of self, something seen as integral both to the process of data collection and the constant comparison method essential to grounded theory.
A researcher who is close to the field may already be theoretically sensitized and familiar with the literature on the study topic. Use of literature or any other preknowledge should not prevent a grounded theory arising from the inductive-deductive interplay which is at the heart of this method. Reflexivity is needed to prevent prior knowledge distorting the researcher's perceptions of the data.
Clinical governance emerged as one of the big ideas central to the latest round of health reforms. It places with health care managers, for the first time, a statutory duty for quality of care on an equal footing with the pre-existing duty of financial responsibility (Warden 1998). Clinical governance tries to encourage an appropriate emphasis on the quality of clinical services by locating the responsibility for that quality along defined lines of accountability. This paper explores some of the implications of clinical governance using the economic perspective of principal-agent theory. It examines the ways in which principals seek to overcome the potential for agent opportunism either by reducing asymmetries of information (for example, by using performance data) or by aligning objective functions (for example, by creation of a shared quality culture). As trust and mutuality (or their absence) underpin all principal-agent relationships these issues lie at the heart of the discussion. The analysis emphasises the need for a balance between techniques that seek to compel performance improvements (through externally applied measurement and management), and approaches that trust to intrinsic professional motivation to deliver high quality services. Of crucial importance in achieving this balance is the creation and maintenance of the right organisational culture.
The challenger launch decision: Risky technology, culture, and deviance at NASA (1 edition)
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Safety-I and safety-II
- E Hollnagel
Hollnagel, E. (2014). Safety-I and safety-II (New edition edition). Farnham, Surrey, England, UK; Burlington, VT: Ashgate.
Risky conversations: The law, social psychology and risk
- R Long
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- C Ashhurst
Long, R., Smith, G., & Ashhurst, C. (2016). Risky conversations: The law, social psychology and risk. Scotoma Press.
Leading & lagging indicators
- F A Manuele
Manuele, F.A. (2009). Leading & lagging indicators. Professional Safety, 54(12), 28-33.
Drive: The surprising truth about what motivates us
- D Pink
Pink, D. (2011). Drive: The surprising truth about what motivates us. New York: Riverhead Books.
Safety can’t be measured: An evidence-based approach to improving risk reduction)
- A S Townsend
Townsend, A.S. (2013). Safety can't be measured: An evidence-based approach to improving risk reduction). Britain: Gower
Publishing Ltd.
Striking a balance between checking and trusting (The York Series on the NHS White Paper No. Discussion Paper 165). York: Centre for Health Economics
- H T O Davies
- R Mannion