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What constitutes a healthy & safe system?
Risks are well understood by the individuals in the organisation, who are well equipped to manage them.

What are the characteristics of a ‘surprisingly safe’ operation? A ‘surprisingly safe’ operation is one that has a high-risk potential but apparently does not receive its ‘fair share’ of accidents. In other words, looking at what the operation is, one is surprised to find out that there are few serious accidents. I would like to list some of the characteristics one may find in such an operation:

It is assumed that every day will be a dangerous day: always expect the worst, never relax your guard, maintain a state of chronic unease at all times.
Encouragement of system-wide safety awareness of the high risks for all members of the organisation, even those who may not be in a high-risk area. Nobody can be expected to help solve a system’s safety problems if they do not understand what those problems are.

Encouragement of and reward of personal autonomy in the safety sphere. Encouragement of creative and critical thought for all members of the organisation.

Linking the parts of the system whose work is interdependent. The members of a sub-system must understand each other’s work if they are to co-operate in solving shared safety problems.

Reward of communications and activities that show a desire to contribute to overall system safety. Recognise and acknowledge, even though they may not provide the answers. ‘Good try’ is always better than ‘no good’.
Examination of mistakes honestly. Deal with them as system problems. Importance of identifying source of an error, not to punish the person who made it. The ability of a system to rectify problems is directly related to openness to criticism.

Creation of facilities for bypassing standard communications channels, if these are blocked. The organisation should encourage inquiry, critique and advocacy by promoting the free flow of information. The organisation should legitimise reasoned and constructive dissent.

If that all sounds a little over-the-top, I can assure you that there are high-risk organisations that operate like this, and, as a result, do so with surprisingly good levels of safety performance.

Examining a couple of these characteristics in more detail - assuming every day will be a dangerous day – you may say that this sounds a little grim and life is never that bad, but if it is part of the culture it is no different to defensive driving. How many consider that they are defensive drivers? It just means that you assume every other driver is incompetent and around every corner there is a tree across the road!

Examine mistakes honestly – obvious really, and many enlightened organisations are moving towards this, but it does seem to be a hard wired human characteristic not to be completely open about mistakes. Without that, any remedy is likely to be inadequate, as it does not address all the facts.

© 2007 A & K Ross Associates Pty Ltd