Professor Sidney Dekker
Safety is an albatross around the neck of our businesses. Safety is a monster that we need to wage war against. These are not my words, these are the words of David Cameron, UK Prime Minister. Safety is a monster that we need to wage war against, safety is an albatross around the neck of our businesses? How have we sunk so low? How is it almost embarrassing to say that you are involved in occupational safety today? This is something I want to explore with you because if we don’t tackle that sort of critique and see how justified it might well be, I don’t think there is a meaningful future for what we do together in managing risk. The way I’m going to do that is I want to lay out a timeline here in front.
So I’m laying out a timeline and one image I want you to keep in mind during that journey along the timeline is the enormous reduction in harm and increased control of risk that we have been able to muster over the past century. So the graph typically starts here, pretty high, killing a lot of people, hurting a lot of people and then dramatically drops as the century wears on, and now a bit into the 21st Century we’re almost asymptotic, we’re plateauic, that is the curve is almost parallel to the horizontal, we’re no longer making a lot of progress. In fact, there is not a lot of progress to be made anymore. But there are ironies in that I will address.
So as we see that curve I want you to keep in mind a couple of ideas, in fact three central ideas that seem to animate people’s ideas about how to manage risk, how to create safety. When you listen to comments of David Cameron for example, and he’s not alone, that sort of critique is rather common particularly in some of the industries that my lab works with. They have the same sorts of complaints about the health and safety monster making their work impossible, creating extra costs, being very cumbersome and not necessarily managing their risks very well for that matter. In fact, creating extra risks, so these are common critiques. When you look at the ideological basis beneath that what you see typically is the idea that people are a problem to control. So people are the problem, and people are a problem that needs to be controlled through a variety of means. We’ll talk about some of those.
The second assumption in that ideological package is the best way to control people is to intervene at the level of their behaviour. We still call this behavioural safety, we call this engagement, winning hearts and minds - things like that, so we intervene at the level of their behaviour.
And the third portion of that ideological collective is that we measure safety as the absence of negative events. So we know we’re successful if nothing bad happens. These are the ideas. People are the problem to control. We control them by intervening at the level of their behaviour and we know whether we’re successful by measuring the absence of negatives. That seems to be the ideological package that has driven health and safety and risk management in many industries including academia. When you throw that on its head, I think we can simultaneously paint a picture of the future, of a different era in thinking about safety, and I think there are good reasons to start to do that, which I’ll get into. Instead of people seeing people as a problem to control, people are a resource to harness. They are the solution, without them we won’t get anywhere. They are the ones who know the work, they know the messy details, they know the risk typically and with a good conversation we can get quite far. So they’re not a problem to control, they’re a resource to harness. The intervention shouldn’t happen at the level of their behaviour telling them to try a little harder, telling them to watch out more carefully. I saw a notice the other day that said safety is as simple as A, B, C, always be careful. When treated like that, one becomes very childish because you are treated like a child, and that’s exactly the sort of behaviour that we’re probably sponsoring. You don’t need to think for yourself, we’ve figured it all out, always be careful. With a three year old that might work, it might not, in fact probably not. So intervening at the level of behaviour may not be the prescription, rather you intervene in their working conditions and make sure the working environment is such that risk can be managed.
And thirdly, rather than seeing safety or measuring safety as the absence of negatives, we can actually reinvent that and say safety should be more about the presence of positives. What positives? Positive capacities, competencies and capabilities on the part of teams, people and organisations. To make things go well even in situations which are unpredicted and uncontrolled. And that’s where the word resilience comes in and that sort of thinking occurs and has some pretty strong backing in safety science today. So those are at the extremes of that curve that traces from the beginning of the 20th century into the present day. Many of the ideas that were formed here at the beginning of the 20th century still resonate very strongly with us today. Let me give you an example, in fact, let’s start there.
Concern with safety, industrial safety starts really in the late 19th century. The end of the Industrial Revolution creates safety as a public concern. It starts to cost money, insurers get involved, there is growing social consciousness that killing a lot of children and husbands at work is not a good thing to do, and we should be managing that better and somebody should pay if it does happen. This is of course consistent with a lot of movements and ideas which start brewing at the end of that long 19th century universal suffrage, and all kinds of things that lead to greater democratisation, greater voices from below and this is part of that trend.
So people start thinking about this, science starts thinking about this. And they come up with a very interesting definition of the human factor, which is considered one of the greatest sources of risk. It is these people, these people who are a problem. And what is the human factor defined as in the early 1900’s? The definition of the human factor is the physical, mental and moral shortcomings that predisposes an individual to accident. Accident was used as verb back then. To accident. So the physical, mental and moral shortcomings of an individual that predisposes him or her to an accident. Interesting. Where does that locate the source of risk? In the individual, squarely in the individual and their shortcomings. What you see is a vocabulary of deficit, of control, of constraint. We have to tell people to try harder. We have to tell people not to make errors. We have to tell people not to do these things wrong. We have to tell people to be better moral actors in order to create greater safety. That is both the psychology and the philosophy of safety thinking at that time. And then, in our present day let’s wonder into the future a little bit. What sorts of programs do we see? We see programs called hearts and minds. Now what are we saying if we say we need to win worker’s hearts and minds? We need to get these academics to be better at engagement with safety problems. What we are saying is that workers, academics, are deficient and defective moral actors. Their heart isn’t in it. We need to win your heart.
Now that is in 2014. I think we were just talking about 1905 right, a hundred years plus. A lot has happened in that time. Technological developments, developments in how we govern big systems, how we understand big systems and yet fundamentally it seems that our safety thinking hasn’t evolved a whole lot, if in 2014 we still believe we need to win people’s hearts and minds because they are mentally and morally deficient when it comes to this. Just think about that. Let’s step a little bit further into that 20th century.
In 1911 a very important piece of work comes out that my colleagues in the business school world will know very well, and in fact many of you might as well. Frederick Taylor and Frank Gilbreth come out with their ideas on scientific management. Scientific management was rather radical at the time and it solved, or was meant to solve, a number of rather important production efficiency and ultimately safety problems in industry. The problem that they fundamentally tried to solve was that of balancing the line. Balancing the line was a problem that afflicted all kinds of production lines. It didn’t start with Ford, it started with pigs in the slaughter houses of Chicago. Balancing the line means that, or an unbalanced line means that pigs are bunching up in some stations and then there’s no pigs in the next stations, everybody’s waiting for the pigs to arrive. So you’re paying these people to do nothing and these other people are completely overworked and get involved in accidents, start cutting off their own things and these are big problems.
Now, the normal intervention that comes out of 19th and in fact 18th century thinking is to try to tell the individual to try a little harder, to work a little harder, to pay more attention, to get these pigs going, to crack the whip. But it doesn’t work. This mode of production is insensitive to that intervention, it doesn’t respond. So the innovation that scientific management comes with in 1911 is to say that these are problems of management and planning. These are not the problems of an individual worker. If there are efficiency, safety and other issues to be observed at the level of the worker, then that’s not generated by the worker. It is generated by problems in planning and management. And this is what scientific management addresses. Let’s solve this at that level.
Here’s how you do it, you pass up your work in the most tiny deconstructed bits you can find, you find the one best method for conducting the task and then you force the worker to follow that one best method, and in order to do that you invent a whole new layer of organisational supervisor’s called the line supervisors or the direct supervisors whose task it is to monitor compliance with that one best method. To make sure that the workers follow that one best method because that is how you balance the line, that’s how you avoid problems. Make sure, scientific management tells the supervisors, that people don’t improvise, that they don’t use heuristics and rules of thumb because those things are unpredictable, unmanageable, uncontrollable and it creates problems. Make them follow that one best method, which by the way the workers haven’t figured out, no, the managers and the planners have figured out what the one best method is. The sneaky message underneath this, which is in fact not very far below the surface of scientific management, is that workers are dumb and managers are smart. It’s these smart managers and smart planners who can figure out how to do work well and all that the dumb workers need to do is execute that plan and then everything will be alright. That’s the idea. That’s the message just underneath the surface of scientific management.
1911, let me read to you a quote from a paper published in 2000 on safety culture. Here’s what is says, it says “it is now generally acknowledged” and I’m standing in 2000, I’m not standing in 1911, “it is now generally acknowledged”, by the way, when a fellow academic says that, it is now generally acknowledged, as colleagues we all know that they were too lazy to check the references right. “It is now generally acknowledged that the majority of accidents are caused by human frailties. Many of these have been anticipated in safety rules, prescriptive procedures and management treaties, but some people don’t do what they are supposed to do”, and this is italicised in the article. “Some people have negative attitudes to safety which afflict their behaviours, which then undermines the system of multiple defences that management has put in place to protect the organisation from incident”. 2000. If I were on the editorial board of that journal then, I don’t know whether it would have appeared because I don’t think it’s very innovative. 2000, what tailoristic ideas did you just hear? All of them right. Managers are smart, they figured it all out, they’ve put in place these systems of protection but then these workers undermine these systems by not doing what they are supposed to do, by not following the one best method, by not sticking to that plan, by taking their own initiatives, by violating the rules. These are deeply Tayloristic and early 20th century ideas which are imbued with the morals of the Victorian era. Yet we see them as apparently fully legitimate in 2000, so legitimate that we can publish them in the high end journal in the safety field. Again I ask you, how much progress have we made in our thinking? How far have we come in safety thinking?
Let’s walk to 1925. 1925, a very important set of ideas comes out. Both England and Germany at the same time, and when that happens historians get all excited because they can then trace the genesis of these ideas and when they see no links, that is no Germans went to England to talk about this idea it came out individually, separately in these two places, then that is an idea whose time had come. The time was right for this idea. What was the idea? The idea was that there is such a thing as the accident-prone human being. This can be statistically proven from the 1880’s onward. This will surprise no-one. The German’s have fastidiously, punctiliously collected data and more data, and their statistics show that some people are involved in more accidents proportionally than others, and what it also shows, in fact the Brit’s backed this up, they say well hang on, not only is it that some people are involved in more incidents and accidents than others, but those who are not involved or have never been involved in incidents and accidents seem statistically less likely to be involved in the future. Now if you are an insurer what do you tell Robbie, what do you tell a Corporation? Show me them. Show me your accident prone people and I will lower your premiums, right. Show them to me, get them out of the safety critical areas where they can touch stuff that can break, and then I will lower your premiums. It’s a wonderful compact. Financial and scientific.