Promoting safety as an emergent property of a resilient system
The problem addressed
Resilience has been defined as the reactive ability of a system to recover after a shock but also as its capacity to be proactive. We stress the proactive nature of resilience as the ability to develop the requisite imagination for anticipating future outcomes, to provide strong responses to weak signals (i.e. uncertain information, embedded in normal operations, that could be read as a warning of future changes, both mishaps and opportunities). We propose a study based on the Resilience Matrix model (RM), which provides the system with the frame of reference to manage safety involving the three main actors: single workers, teams and the organization. Each actor could be a proactive promoter of the safety culture and safety could become an emergent property of the system by means of the Non-Technical Skills (NTS) like stress and workload management, situation awareness, communication, decision making and problem solving, leadership, and teamwork. According to this approach, the Resilience Matrix Questionnaire (RMQ) will be validated, in order to highlight the key elements of individuals, teams and organizations to handle complexity, enhance performance and improve safety. A training and tutoring project will be provided to a group of managers and operators of an Italian energy distribution company. It will be based on the enhancement of the NTS, and it will be aimed at increasing the safety of the organization without reducing its productivity and promoting operator's well-being. The project will enhance proactive behaviors towards weak signals, promote group-based mutual support of practitioners, helping them to cope with stress, workload and lack of motivation and improve communication skills. A retest of the RMQ will be performed and the development of the NTS will monitored over a period of two years. The outcomes of the project will be the development of a tool to assess the resilience attitudes of an organization, and the training and tutoring package to enhance them for safety’s sake.
This study has two main goals. First, we propose a new model to understand how resilient organizations operate (T2): the Resilience Matrix. According to this model, we will develop and validate the Resilience Matrix Questionnaire. This instrument should show which are the relevant indicators at the three levels of operation (individual, group and organization) a resilient system should have to be able to detect risks and prevent accidents, highlighting weakness and strengths of the system. The study will be repeated on different samples to demonstrate its validity in a different context (T1.3). The second goal is to demonstrate the validity of this model by acting on the main weakness points evaluated in the system and addressing its safety-related performance before and after the intervention (number of accidents, incidents, reports, etc.). We adopt a research-intervention method based on the enhancement of the NTS in groups and operators, intended as the keystones for the system’s safety and resilience. Finally we want to demonstrate that a proactive approach to safety is a gain, not a cost, showing how the utilitarian ethics and duty ethics viewpoints on safety could be not in contrast, but in agreement. Operators’ well-being and commitment towards weak
signals will enhance both safety and work performance (T1.1).
Scientific disciplines: psychology
The project will provide a resilience engineering approach based on the empowerment of the NTS. It will be based on an assessment tool, the RMQ, and on the training/tutoring package of the NTS. The stakeholders of this methodology will be companies whose activities cold be defined as complex (e.g., transports, health, industry), where it is important to pay attention to weak signals for a proactive safety. The project will enhance the perceived well-being of the workers: on the one hand, they will be able to cope with stress and workload relying on effective teamwork and communication skills and, on the other hand, decreasing their organizational cynicism helping them to understand goals, policies and values of the management. The organization as a whole will be safer thanks to the improved circulation of information, ability to change and to learn from experience.
Phase 1: the RMQ development
The cultural change could be accomplished after an early assessment of the system's resilience characteristics. According to the current literature about resilience engineering (RE) we developed the RM taking into account the three main actors that could cope with complexity during normal operations: individuals, team, and organizations. Each of them is in charge of noticing and dealing with weak signals and only their harmonic relationship could
afford the emergency of resilience and therefore system's safety.
Following the rationale of the RM the RMQ has been developed and is currently under validation (Phase 1.a). This tool addresses the main factors promoting resilience in a complex system which could be summarized in four dimensions:
- Mindfulness: the ability to notice weak signals embedded in normal operations, avoiding the over-simplification of the work activities.
- Communication: the ability to share at the group and organizational level the information avoiding the blame culture.
- Dynamic Adaptation: the ability to cope with the potential threats hidden in the weak signals, implementing technological or organizational barriers.
- Solution Implementation: the ability to put in practice new procedures and barriers and monitor their efficacy.
The above mentioned dimensions are peculiar of complex systems and are the fundamental ground for the development of resilience and safety. The abilities required to accomplish these factors are profoundly non-technical, since relying on technologies norms and procedures is not enough to get safety. The complex nature of the work environment exceeds the containment capacity of traditional approaches to safety; it is necessary to develop a global and coherent commitment of the three main actors of the system: individuals, groups and the organization. This is accomplished by means of the NTS, which become a trigger for the technical skills.
One of the main issues in RE literature is the incongruence between the work as imagined by the management and the work actually performed by the operators. The RMQ aims at investigating both the management and the front-line operator's points of view in order to assess this mismatch. Moreover an other incongruence could be assessed concerning the safety culture as attitudes and ideal values versus what is actually performed in everyday operations. Therefore we developed two versions of the questionnaire one addressed to the managers (RMQ-M) and the other one to the operators (RMQ-W). Both of them were composed by a group of items assessing resilient behaviours and a second group of items assessing resilient attitudes.Phase 2: the training/tutoring package
After the measurement of the resilient characteristics of the system we aim at developing a training/tutoring package that could help the organization to fill in the gaps observed between ideal and actual behaviours and planned and performed work.
At the individual level we will train operators to notice and report weak signals in their operational context, discussing human performance variability, the effectiveness of procedures and barriers and developing the requisite imagination to foresee possible risks, looking at the variability from the sharp-end point of view. Moreover, we will highlight the
importance of an internal locus of control about safety and we will link the increase of responsibility with the increase of power of action of every practitioner. We will work on the NTS involved in these processes such as situation awareness, communication and ability to manage with stress and workload.
At the group level we will focus on reporting procedures and shared tutoring, we will provide tools and contexts for information sharing, group’s problem solving and decision-making skills. We will aim at improving teamwork and leadership skills, showing the biases of hindsight analyses of accidents and discussing about the nature and effects of a blame culture. In addition, we will promote a group-based mutual support of practitioners, helping them to cope with stress and lack of motivation.
At the organizational level, a Resilience Engineering Program will be planned in cooperation with the top management to implement responses for the most relevant warnings. In addition, we will link safety and well-being, providing the organizational level with some hints about the development of a safety culture ad the decrease of the organizational cynicism among workers.Phase 3: the retest and monitoring
The last phase of the project will be devoted to the retest of the resilient attitudes and behaviours of workers assessing whether a significant change has occurred after the training/tutoring intervention. Moreover we take into account the improvement of objective safety indicators such as the number of accidents, incidents and the increase of reporting (Phase 3.a).
The second part of this phase (3.b) will be developed according with the outcome of the training/tutoring project and its monitoring. It will aim at supporting and following the increasing development of the NTS among the workers. The cultural change is a slow and long process since it is based on the shaping of new attitudes about safety. It requires a
constant monitoring process where the workers will be helped in the assessment of their confidence in the application of the NTS. We will help the workers to design and implement new organizational devices aimed at the emergence of resilience, such as significant event audits, reporting systems, methods for the tracking and enhancement of the best practices.
A presentation made of project progress at the 2018 SAF€RA symposium held in Bilthoven, the Netherlands.
(Disfor, University of Genova,
— project coordinator
(Department of Education, University of Genova,
||2014-01 to 2016-04
Information last updated on 2017-02-02.
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