Promoting safety as an emergent property of a resilient system

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.