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How to Proactively Reduce Risk When Nothing Goes Wrong
AS IMPORTANT AS IT IS TO LEARN FROM FAILURE, it is too late. High-risk industries constantly strive to improve safety by learning from past incidents (Lindberg et al, 2010). However, companies that have successfully reduced incidents face a new set of challenges. The small injury rate can no longer accurately reflect safety performance (Cadieux et al., 2006), and simply focusing on behaviors and unsafe conditions is not enough to further reduce risk (Hendricks & Peres, 2021).
A fresh approach is needed to learn and improve in the absence of unintended events. The concepts presented in this article are based on safety science but are not limited to any field or school of thought. The text draws from a range of sources, including Safety-II, human and organizational performance, human performance improvement, human factors, engineering psychology, systems thinking, resilience engineering and cognitive psychology.
It is commonly assumed that completing a task without incident is a success, but this does not necessarily mean that the task was executed perfectly. The majority of activities are completed without an event, leading to the belief that no further improvement is needed (Hollnagel, 2002; Hollnagel et al, 2013). However, little attention is paid to how activities are completed and what the potential was for future incidents.
When an incident occurs, it feels natural to believe that it was a result of something going wrong, such as a failure to follow a procedure. On the other hand, when a job is completed without an incident, it is often assumed that all procedures were followed and all necessary controls were implemented (Hollnagel et al, 2013).
However, researchers who study work performed without incidents (i.e., normal work) find the same factors that are identified in incident investigation reports (Gerhart & Rynes, 2003). Steps in procedures may be skipped, there may not be enough time available or the correct tools may not be available. These challenges change over time, and they constrain the choices available at the time (Staddon, 1979), leading to people adapting and finding ways to overcome these challenges. These adaptations allow for the jobs to be completed without issues, and very rarely do they contribute to events. In other words, things go wrong...