Now we can do the following question: Why things go right?
Think about it. We can try to draw a model of why things go right
and why things go wrong.
First, we can say that something functions when it works as suspected.
In general people tend to think that the success is
when everything worked as designed.
That means that there are no malfunctions, there are no mistakes,
there are no errors,
everybody involved followed the procedures.
Basically, that everything led or lead, to success.
Here we have the success that is the only acceptable outcome.
It's what Safety I wants to achieve.
But sometimes that's not possible.
We have to be open to the malfunctions.
Malfunctions means that the system is not working properly.
And with malfunctions we can say a lot of things.
Like, non-compliance with the procedures,
somebody made a mistake, like closing a valve that should be left open,
errors, latent or active errors, that we have already mentioned
and we will mention in the future.
But remember that the active errors are the ones that produce events.
And the latent ones are the ones that are there and you only see them
when there is an error.
So all this just can lead
to failure
in form of accidents or incidents, basically.
What we don't say is that somebody made something
or something happened that led us to an accident.
This is really an unacceptable outcome.
And if we look here, this is a binominal logic.
Something is successful when everything works.
And there is nothing to do with that.
And something fails when something goes wrong
and then it's when you act.
So if we look here, we see that there are a lot of works
like accidents, failures, malfunctions, non-compliances, harm, fatalities,
injuries, whatever.
This, if you think about it, is a really negative vocabulary.
And what we are trying to do is define something that is positive.
Because safety is positive.
It's what we want to achieve.
It is our goal.
So basically, since the beginning of the human factors,
the actions are always to wait until there is a failure.
and then, to investigate what happened in order to discover
why things went wrong.
So it's negative.
Once again, we are trying to define
something that is positive.
Because all this, at the end, provokes that people are defensive
against safety.
They are not going to be cooperative.
In order to change all those negative terms,
or all those negative consequences or actions,
we have said a lot of protections. As we said, using the chosen models.
We have barriers, regulations, procedures, standards.
You have to comply with all the procedures and standards.
Somebody said that this is what we can call
war on error.
In fact, Safety I is something that has to go wrong
in order to be able to fix it.
If not, we wont be able to improve.
So as I said, is war on error and we are going against those things.
We have to eliminate the malfunctions and we have to eliminate the failures.
This has worked during years and years, but if we look at this graphic,
We will see that the number of incidents reduces
when you have more safety actions.
Or that the safety effort is to reduce, sorry,
you have more safety efforts and you reduce the incidents.
So we achieve lowering in time the number of cases
when the system goes wrong.
So the lower the number of adverse events is,
the safer the system is.
From this point of view, we don't start working
until there's not a negative outcome,
until there is not an absence of safety.
A higher measure of safety is a lower number of adverse events.
It is not good from the point of view of control,
real time control, for example.
Because any control needs to have a feedback.
Any control needs to know if things are going well or not.
If we have to accommodate, somehow, or not.
But here we don't have control,
because, basically, we are eliminating all the feedback.
So Safety I is not good from the control perspective.
Also we can say that it is increasingly slow, sorry.
Why? Because as we have a safest system, we have less events.
So when we have few events to fix,
we are not going to be ready to anticipate,
or to fix things.
Another thing is that it's reactive.
That means that we are trying to fix our future success
based on past models and past events.
Not in things that are happening all the time.
Also, what I said before.
We have a really negative vocabulary when defining safety.
And this is going to create defensiveness in everybody
who otherwise, would be involved in safety.
Workers have to be proactive in order to improve safety.
And what we are going to do with all this,
is to push them away.
And finally, we can define safety or according to Safety I,
safety is precisely the absence of positive outcomes,
it is somehow the opposite
of what people think is safety.
People think something is safe, when you go well to your places
on your car. Not like having an accident. That's not safe.
So it's not a really good philosophy to use only this.
So we can recap. And the question is:
Why do we need to change?
So the premises for safety management in todays industrial world
can be summarized as you can see here.
First, Safety I is based on systems cannot be decomposed
in a meaningful way.
That means that we can divide all the different parts of a system
analyze them, and then, we'll understand how that system works.
This philosophy worked pretty well
at the beginning of the age of technology.
Because in general, systems were, or machinery was less complex.
But now we have a lot of different and complex systems,
like a nuclear power plant with all the operation systems, etc.
Or if you think, air traffic management, you have a lot of different levels
a lot of planes, you have to have a special safety.
Also in oil drilling activities, you have to have a lot of protections.
People have to be involved, etc.
Now the systems are more and more complex.
So that's the first thing that we can call weakness.
Also system functions are not bimodal.
As we have said before,
Safety I is based on success and failures.
So both of them come from human performance variability.
Sometimes it's the key to have one or two.
So, as we have said,
outcomes emerge from human performance variability,
while some adverse outcomes can be attributed
to failures and malfunctions, others are best understood
as human variability.
And finally, we have to have all those things in mind.
And we are going to try to build something more positive,
something different.
As I have said before, not opposing to this,
but complementing Safety I.
And that's what professor Hollnagel defines as Safety II.
And he started using it in health care.
So let's go with that now.