“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
2. THE EUROCONTROL EXPERIENCE Resilience Engineering and Safety-II 2 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
4. www.bit.ly/HindSightMagazine 4 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
5. Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
6. 6 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
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)
9. ZOOMING OUT: HEALTHCARE, SOFTWARE, AVIATION Resilience Engineering and Safety-II 9 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
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
12. THEORETICAL & COMMUNICATION CHALLENGES Resilience Engineering and Safety-II Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 12
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
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
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
16. APPLICATION CHALLENGES Resilience Engineering and Safety-II Resilience Engineering and Safety-II – Challenges and Opportunities for Practice 16
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)
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
19. PARADIGMATIC & METHODOLOGICAL CHALLENGES Resilience Engineering and Safety-II 19 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
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
22. ORGANISATIONAL & SECTORAL CHALLENGES Resilience Engineering and Safety-II 22 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
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
25. OPPORTUNITIES FOR UNDERSTANDING Resilience Engineering and Safety-II 25 Resilience Engineering and Safety-II – Challenges and Opportunities for Practice
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
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
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
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
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
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
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