We reluctantly present a comparison between the new and old view.  Comparisons can be thought-provoking, providing an opportunity to reconsider long-held assumptions about how the world will unfold.  On the other hand, comparisons can be misleading.  They can suggest a binary relationship, black or white, either one way or the other.  The truth is that the world is shades of grey and in this case, there is no safety program that is entirely new or old view.  So use the comparison to stimulate thought, to question assumptions and mental models and challenge thinking.  

The new view builds on many of the accomplishments of the old view and replaces many outdated assumptions and mental models based on the latest research and practice.  No one is suggesting that all old view concepts were completely wrong or that all old view activity should be eliminated or replaced.  Progress is always the result of building on the knowledge and experience of those that preceded us.  You know, we stand on the shoulders of those that preceded us.

1) What is safety?

Old View:  Safety is the absence of injuries and illnesses, so the emphasis is on OSHA recordables and other lagging indicators usually based on injury and illness reporting.  This understanding implies that if an organization can remove enough injuries, illnesses, violations and non-conformances, the result will be a safe system or organization.

New View:  Safety is an emergent system property.  Safety is not found in a single device, procedure, training program, person or policy.  Safety emerges or arises from the complex interactions of leadership, organizational and operational processes, culture, reward systems, etc.  Because the new view emphasizes making sure that things go right as much as preventing things from going wrong, efforts are not limited to taking undesirable results out of the system but also putting into the system processes and capacities that lead to success such as emphasis on learning, open and unfiltered information and communication flow, continual process and management system improvement, etc. 

2) Focus of activity

Old View:  Most activity is directed at improving the parts of the program individually by conducting inspections, incident investigations and audits that identify specific physical hazards - conditions and behaviors that are thought of to be deficient.  Again, the underlying assumption is that if the organization can find and fix enough conditions and practices, the system will be safe.  That is, the performance of the system is the sum of individual parts of the program taken separately.  The problem is not with inspections, investigations and audits.  These methods are used in both the old view and new view organizations.  The difference between the old and new view is the assumptions and mental models held by the organization and particularly the leaders carrying out the activities.

New View:  Conditions, actions/behaviors, compliance violations are symptoms of operational and organizational processes and should not be thought of in isolation of their context.  When an incident, violations, non-conformance is identified it is necessary to step back and think and understand the containing whole.  Many health and safety professionals have been doing this to some extent for a long time.  On the other hand, it is not unusual for organizations to develop lists of hazards and recommended corrective actions that seldom include system deficiencies that guarantee continued hazards, incidents and failure.  Activity is directed at improving the whole system based on the understanding that performance improvement results from improving the interactions of the parts rather than improving the parts taken separately.

3) Root cause

Old View:  Almost all incidents have a single root cause.

incident complexity model.png

New View: Incidents seldom have only one 'root cause'.  The new view discourages the use of the term 'root cause' because often when the 'root cause' is identified during an investigation learning and the investigation ends.  Logically every 'root cause' has a single or multiple causes.  Most new view advocates identify multiple influencers or contributing factors or identify local and system deficiencies rather than a 'root cause'.  This approach is consistent with the understanding that injuries and illnesses are caused by failures of the control structure which often are the result of multiple factors that take place within an organizational and operational context.

4) Behavior and Bad Apples

Old View:  Systems are basically safe as long as workers follow procedures and work safely.  "If we can only get rid of the 'bad apples' everything would be fine.  This assumption is somewhat addressed in numbers 1 and 2.

New View:  Processes are typically a patchwork of methods, incomplete controls, limited procedures, resource constraints and goal conflicts.  While some processes are much better designed and maintained than others - all processes operate degraded.  In every process, workers attempt to get the work done and be safe.  This results is real-time decisions being made that are almost always successful.  Infrequently, failures occur which should be treated as an opportunity to learn and improve rather than blame and punishment.  Workers should be regarded as a rich resource of information for process improvement rather than the cause of process failures.

5) Procedures

Old View:  If we write enough procedures and make sure everyone follows them - the workplace will be safe.

New View:  Well written procedures developed by knowledgeable and experienced personnel are an essential part of every safety control structure.  However, even the best procedures cannot take into consideration all of the circumstances workers will experience.  Workers should be advised to the limitation of procedures and reminded that it is always the blending of worker knowledge and experience, procedures or similar performance support tools, the physical tools needed to do the technical work and the context/environment that leads to successful work.  One of the space shuttle astronauts became well known for saying, "The best way to get yourself killed is to not follow the procedures.  The second best way to get yourself killed is to always follow the procedures." 

6) OSHA Incident Rates

Old View:  The OSHA incident rates are the primary measure used to assess health and safety performance.

New View : The OSHA incident rates do not accurately reflect health and safety performance. Many catastrophic incidents have taken place at workplaces with award-winning low incident rates. Safety measures and metrics should be based on the organization's assumption about factors that lead to successful work.  As the organization's understanding of the critical organizational and operational factors matures, metrics and measures should be updated.  The organization should continually strive to improve its knowledge of systems and processes which leads to refining assumptions and measuring factors most critical to success.

7) Safety Activity

Old View:  Safety and health activity is primarily driven by the safety department.

New View:  Recall the discussion in #1 - safety is a system property that emerges from the interaction of many elements such as leadership, culture, processes, procedures, training, supervision, design, etc.  This understanding has important implications the most significant being the fundamental need to insure that safety and health is integrated into almost all areas of the organization such as procurement, contractors, maintenance, operations, engineering, senior leadership, etc.