“So what should we do?” Challenges and opportunities for Resilience Engineering and Safety-II in practice

Resilience engineering and Safety-II have emerged as credible perspectives and approaches to tackle some of the fundamental problems faced by societies, organisations and teams. Building on complexity science, systems theory, human factors engineering, and other established disciplines, the approaches have both strong theoretical and practical validity. But - as with prior disciplines - both come with particular challenges for practitioners, who act in a milieu that is not always conducive to straightforward practical application. This talk will explore some of these challenges - and opportunities - with experiences from practitioners in aviation, healthcare and WebOps, at different levels, from intergovernmental organisations to team activity.

Shorrock, S. (2021, June). Invited Keynote: So what should we do? Challenges for resilience engineering and safety-II in practice. Joint initiative – 15th Conference on Naturalistic Decision Making and 9th Symposium on Resilience Engineering. 21-24th June 2021.

Transcript

1. Supporting
   European
   Aviation
   “So what should we do?”
   Challenges and Opportunities for Resilience
   Engineering and Safety-II in Practice
   Dr Steven Shorrock
   CPsychol CErgHF
   EUROCONTROL Network Manager Safety
   Senior Specialist Safety & Human Factors
   

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2. THE EUROCONTROL
   EXPERIENCE
   Resilience Engineering and Safety-II
   2
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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3. Conferences
   CEO & Director events
   Prosecutor workshops
   Systems thinking training
   Webinars
   Theatre plays
   TRAINING & EVENTS
   White papers
   • S-II
   • Systems Thinking
   • RE
   • Patterns
   • Weak Signals
   HindSight magazine
   Just culture manifesto
   Also with: ICAO, FSF
   PUBLICATIONS
   Discussion & learning cards
   Safety culture programme
   Investigation support
   Asset-based learning teams
   Weak signals
   APPROACHES
   SOCIAL MEDIA
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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4. www.bit.ly/HindSightMagazine
   4
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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5. Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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6. 6
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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7. Government Public
   Judiciary
   Media
   Comms
   Design, Engineering
   Management
   Operational
   Staff
   Researchers Training, Procedures
   Safety, Health,
   Quality, Env.
   Regulators
   Suppliers
   Shorrock (2021)
   COMPANY
   INDUSTRY
   SOCIETY
   Unions &
   Associations
   Competitors
   HR
   Legal
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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8. Government Public
   Judiciary
   Media
   Comms
   Design, Engineering
   Management, Planning
   Operational
   Staff
   Researchers Training, Procedures
   Safety, Health,
   Quality, Env.
   Regulators
   Suppliers
   COMPANY
   INDUSTRY
   SOCIETY
   Unions &
   Associations
   Competitors
   HR
   Legal
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   Shorrock (2021)
   

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9. ZOOMING OUT:
   HEALTHCARE, SOFTWARE,
   AVIATION
   Resilience Engineering and Safety-II
   9
   Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
   

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10. Challenges and Opportunities
    “What are your experiences of the
    key challenges and opportunities
    for Resilience Engineering or
    Safety-II as a practitioner?”
    10
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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11. Evidence Base
    • Suzette Woodward
    • Ken Catchpole
    • Tracey Herlihey
    • Mark Sujan
    • Manoj Kumar
    • Carl Horsley
    • Matt Scanlon
    • Satyan Chari
    • Shelly Jeffcott
    • Alison Leary
    • Alastair Williamson
    • Neil Spenceley
    • Ben Tipney
    • Dominic Furniss
    11
    • John Allspaw
    • Lorin Hockstein
    • J Paul Reed
    • Jessica DeVita
    • Chad Todd
    • Thomas Depierre
    • Ryan Kitchens
    • Amy Tobey
    • Jessica Joy Kerr
    • Sarah Flaherty
    • Anders Ellerstrand
    • Adam Johns
    • Christina Heuerding
    • Tom Laursen
    • Tony Licu
    • Bogomir Glavan
    • Raquel Mercedes Martinez
    • Phil Bonner
    • Joerg Leonhardt
    • Steven Shorrock
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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12. THEORETICAL &
    COMMUNICATION
    CHALLENGES
    Resilience Engineering and Safety-II
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 12
    

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13. The term ‘resilience’ is often seen as an
    individual trait (5)
    • “This frustrates people as it makes it all
    about them” Suzette Woodward
    • ”Resilience … is used as the antithesis of
    'burnout’ (i.e., the individual ability to put up
    with terrible systems) and the Orwellian
    "Resilience Training” Ken Catchpole
    • “The focus on "personal resilience" during
    COVID now means that we are almost
    unable to use anything which uses the
    concept of ‘resilience’” Carl Horsley
    13
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Chris Blakeley https://flic.kr/p/TobkBG CC BY-NC-ND 2.0
    

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14. There is limited understanding of the
    concepts of RE and S-II (7)
    • “A lot of Safety II data is talked about as
    ‘soft intelligence’ … as randomly
    collected, anecdotal, and so not
    actionable, or ultimately meaningful to us”
    Shelly Jeffcott
    • ”RE and Safety-II have concepts that my
    peer groups and executive
    leadership/management will consider
    jargon unless they've read about
    RE/Safety-II” Chad Todd
    • “I often have to translate and frame things
    into terms that people want to hear" Ryan
    Kitchens
    14
    Robert McGoldrick https://flic.kr/p/bhgZbx CC BY-ND 2.0
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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15. Theoretical writings aren’t always helpful (5)
    • “There are multiple models/names/
    approaches that pretty much describe the
    same thing or at least have the same
    outcome” Sarah Flaherty
    • ”The terminology Safety-I/II is ambiguous
    and may have contributed to some
    misunderstandings, with Safety-I often
    being seen negatively” Tracey Herlihey
    • “A lot of the narrative and leadership in this
    area is also fairly vague, theoretical and
    somewhat ‘ivory tower’" Ken Catchpole
    15
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Markus Lütkemeyer https://flic.kr/p/5N5RAk CC BY-NC-SA 2.0
    

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16. APPLICATION
    CHALLENGES
    Resilience Engineering and Safety-II
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 16
    

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17. The practical application of RE and S-II is
    opaque or difficult (11)
    • “There is as yet little practical guidance
    for how to move from description to
    intervention” Mark Sujan
    • “Many academic theories are not easily
    understood or easily applied in an
    operational context” Sarah Flaherty
    • ”How can we determine flexible (human)
    behaviours that help the system bounce
    back to the expected performance …
    apart from those which are genuinely
    unwanted?” Raquel Mercedes Martinez
    17
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    clement127 https://flic.kr/p/qfcreF CC BY-NC-ND 2.0)
    

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18. There is a lack of evidence of
    effectiveness (6)
    • “I know of no study that suggests adopting
    resilience approaches would help” Ken
    Catchpole
    • “I am worried that both terms (S-II and RE) will
    become tainted in healthcare as they do not
    follow the scientific mindset of the medical
    view” Alastair Williamson
    • ”Academia lacks access to industry operations
    to test and validate RE/S-II methods and
    practices” Tony Licu
    18
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Pablo Gonzalez https://flic.kr/p/WfCzmV CC BY-NC-ND 2.0
    

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19. PARADIGMATIC &
    METHODOLOGICAL
    CHALLENGES
    Resilience Engineering and Safety-II
    19
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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20. The dominant paradigm, collective mindset
    or common focus is a barrier (18)
    • “We are still very firmly embedded in
    Safety-I, counting harms, root cause
    analysis, linear cause and effect”
    Alison Leary
    • “It remains difficult to direct people’s
    attention to how normal work is done; if
    there is no “incident” to mark activities
    for deeper exploration, why look at it?”
    John Allspaw
    • “We invest lots of time in investigating
    incidents and doing bureaucratic work,
    from many incidents there is nothing to
    learn but they have to be investigated”
    Christina Heuerding
    20
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Andreas https://flic.kr/p/97GrxU CC BY-NC-ND 2.0
    

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21. There are entrenched and conflicting legacy
    approaches (6) and newer false equivalences (2)
    • “Safety-I approaches are attractive due to
    their clear link between risk and risk control …
    for Safety-II there are no such simplistic /
    reductionist interventions” Mark Sujan
    • “There is a really strong dogma in tech to
    derive metrics from incidents. There isn’t the
    recognition how this drops context and
    intentionally narrows and filters our
    perspective” Ryan Kitchens
    • “Most safety management systems are still
    locked in the traditional approaches to safety”
    Joerg Leonhardt
    21
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Steven Shorrock https://flic.kr/p/2fMBZpK CC BY-NC-SA 2.0
    

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22. ORGANISATIONAL &
    SECTORAL CHALLENGES
    Resilience Engineering and Safety-II
    22
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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23. The need is not evident or the value is
    unclear (10)
    • “They don't know what they don't know and
    hesitate to embrace change as they do not see a
    problem” Manoj Kumar
    • “It's hard to justify resilience engineering type
    work. Many people simply don't see the value.
    You need to have a champion in management that
    ‘gets’ it” Lorin Hochstein
    • “[RE and S-II] are not regulatory requirements.
    And there is, in most cases, not a problem with
    safety. So, ANSP managers focus on what is
    actually a problem – costs and capacity” Anders
    Ellerstrand
    23
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Kristina Alexanderson https://flic.kr/p/9FkZcA CC BY-NC-SA 2.0
    

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24. There is a lack of resources (competency,
    time, money) (6)
    • “We don't even resource the adverse events
    stuff well enough, and no one seems to have
    the capacity or any real sense of how we
    should start collecting non-traditional
    information” Shelly Jeffcott
    • “Finding the capacity to apply RE practices
    against other demands around more
    traditional safety management demands”
    Adam Johns
    • “You need well educated experts to be able
    to benefit from the principles … Most
    organisations have little time for education
    and reflection” Tom Laursen
    24
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Andreas https://flic.kr/p/97GrxU CC BY-NC-ND 2.0
    

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25. OPPORTUNITIES FOR
    UNDERSTANDING
    Resilience Engineering and Safety-II
    25
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    

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26. RE and S-II ideas are understood, appreciated
    and talked about (13)
    • “Some success in taking the Safety II/RE
    'message' to a vast array of colleagues across
    clinical practice, safety, governance, and
    operations” Satyan Chari
    • “WebOps has a lot of practical growth to do
    with RE/Safety-II when it comes to
    understanding the language at the various
    layers (front-line, mid-level management, and
    executives” Chad Todd
    • “Eventually, you need to put a stake in the
    ground and move forward with your own
    language and model” Bogomir Glavan
    26
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Johnson Cameraface https://flic.kr/p/aaLgwp CC BY-NC-SA 2.0
    

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27. RE and S-II offer a better explanation of the
    world (11)
    • “Rather than introducing a ‘new view’ it seems
    much more like it is a better explanation of the
    world as found” Carl Horsley
    • “I think one of the most important questions to
    start asking in our unit is ‘Today, why did
    nothing happen..?’” Neil Spenceley
    • “We don't have the baggage of the traditional
    safety-critical fields. There's no ’Safety-I’ that
    we are reacting to” Lorin Hochstein
    • “The industry has become so complex that it
    needs it now more than in the past” Tony Licu
    27
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Steven Shorrock https://flic.kr/p/2fMsL2v CC BY-NC-SA 2.0
    

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28. Practical opportunities to learn and move
    toward a better understanding of work (9)
    • “The latest patient safety incident response
    framework … is moving away from root cause
    analysis and other linear methodologies”
    Suzette Woodward
    • “The pandemic has only amplified what data
    can be available, since teams working
    remotely with each other is mediated by
    software” John Allspaw
    • “When your manager supports you in safety-II
    / resilience there is a great chance to look at
    different ‘cases’ or non-events and get a new
    view” Christina Heuerding
    28
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Robert McGoldrick https://flic.kr/p/bhNRxZ CC BY-ND 2.0
    

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29. Opportunities for usable and practical
    methods (5)
    • “Opportunity to develop simpler models and
    tools to help think differently about patient
    safety and how we learn and improve” Tracey
    Herlihey
    • “An opportunity is to get the layers of the
    organization to measure qualitatively the skills
    and expertise within it” Chad Todd
    • “Some simple techniques have started to
    emerge (see our EUROCONTROL
    neutralisation of taxonomies etc)” Tony Licu
    29
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Steven Shorrock https://flic.kr/p/2fMsL2v CC BY-NC-SA 2.0
    

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30. Opportunities to develop expertise in RE
    and S-II (4)
    • “Some trusts are appointing psychologists and
    one is even trying to appoint a CHF specialist
    but its slow” Alison Leary
    • “Fund a Human Factors and Systems Safety
    Team or RE/Safety-II Team” Chad Todd
    • “Use RE principles and practices as a vehicle to
    expand the remit of the safety function to
    broader operational and organisational goals
    and activities” Adam Johns
    30
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
    Steven Shorrock https://flic.kr/p/2eoAKYD CC BY-NC-SA 2.0
    

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31. Some general observations
    • ‘S-II’ and ‘RE’ offer credible and useful
    insights
    • But each appeals to different sectors and
    professionals
    • And each term has unintended
    consequences
    • Both seem to be more useful for
    understanding than intervention
    • Human factors specialists and safety
    specialists seem to have more reservations
    • There are many practical barriers
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 31
    Đorđe Miladinović https://flic.kr/p/SEipqa CC BY 2.0
    

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32. So what should we do?
    • Communicate artfully, inc. via social media
    • Contextualise and translate theory in plain
    language
    • Make the ‘how to’ clearer (maybe compile
    in a handbook)
    • Gather evidence of usefulness (beyond
    safety)
    • Adapt what already exists where possible
    • More research-practice collaboration
    • Work with all stakeholders (inc. regulators,
    senior management, HR, media)
    • Keep pushing for more roles in
    organisations (see Netflix, BP,
    EUROCONTROL)
    Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 32
    Kevin Dooley https://flic.kr/p/7n2tGK CC BY-2.0
    

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