taking the risk to think differently about hazard...
TRANSCRIPT
Viji Vijayan
Assistant Dean
Safety, Health and Emergency Management
Past President
Biorisk Association of Singapore
Taking the risk to think differently about
hazard management
• Established in 2005, first US-style graduate-entry medical
school
• Annual enrolment of over ~ 60 medical students
• Strong PhD program
• Over S$320 million in grants
• 2,000 peer-reviewed journal articles
• Four wet bench lab based programs
• Co-located – Singapore’s largest healthcare group –
augments translational research
Duke-NUS Medical School
What is safety?
basic meaning of safety is simply freedom from
harm of any nature. This cannot be absolute because
there is no such thing. Therefore, organizations and
people should find a “reasonable or acceptable”
level of harm they are willing to accept in their
respective industries and lives.
History of safety
• In the early days the starting point for safety concerns was
always an accident
• Investigation was performed, cause “found” they apply the
stop-rule
• Often human factor
• Replace humans with machines
• Then machines started to cause more severe accidents
History of safety
• Systems became very complex
• Human-machine interactions became very critical
Complex Systems
Complex Systems
Complex Systems
Complex Systems
Sociotechnical System
Sociotechnical systems (STS) in organizational development is an approach
to complex organizational work design that recognizes the interaction between
people and technology in workplaces.
• The social aspects of people and society and technical aspects of
organizational structure and processes.
• Not material technology, but procedures and related knowledge
• Sociotechnical refers to the interrelatedness of social and technical aspects
of an organization or the society as a whole. Sociotechnical theory therefore
is about joint optimization, with a shared emphasis on achievement of both
excellence in technical performance and quality in people's work lives.
(Wikipedia)
Sociotechnical System
The practice of safety is to prevent accidents and yet we
spend a lot of time analysing accidents and trying to learn
from them. Why do we do this?
“An unintended but unavoidable consequence of
associating safety with things that go wrong is a creeping
lack of attention to things that go right”.
Erik Hollnagel asked this and came up with the concept
of safety I and safety II.
Eric Hollnagel
Safety is a state where few things go wrong, and that when they
do go wrong it is due to failure or malfunctions of the socio-
technical system we work in.
Humans, who are viewed as the most unreliable component of
this socio-technical system, are considered a liability. In the
early days, the starting point for safety concerns was always an
accident, especially a major one.
When an accident occurred, an investigation was performed and
when the investigators “found” the cause(s) the stop-rule was
applied and the search ended.
Often, human error was found to be the cause!!
Safety I- old view
Why does it go right most of the time?
Because the same humans who were considered a liability in
Safety I are able to anticipate failures and adjust their daily work
such that injuries are rare.
Safety II is about supporting the people to do their work in the
right way such that accidents occur rarely
Safety II- new view
Safety II- new view
0
10
20
30
40
50
60
70
80
90
100
per man hour
99.99716
0.00284
Going Right Going Wrong
Duke-NUS:
400 researchers
44 hours a week
915,000 hours a year.
2016 - 26 cases of minor injuries.
Things that went right = 99.99716 %
Things that go wrong = 0.00284%
Safety I and II
Safety I Safety II
Aim for absence negative outcomes Aims for presence of positive outcomes
Safety management aims to prevent
negative outcome by constraining
people’s behaviour and making them
adhere strictly to standards.
Safety management aims to use the
resilience of the system
Uses the variability and diversity of the
workers and their ability to respond to
unexpected situations
People DO NOT come to work wanting to
cause an accident
How we worked with Zika virus
Researches in our Emerging Infectious disease wanted to be the first to publish
Has to be done rapidly
Not much was known about the virus
Initiated by the researchers:
• Team formed including researchers, safety team, Infectious Diseases Physicians
• Rapidly discussed the processes
• Conducted briefings
• Developed SOPs and RAs
• Where to grow the virus, where the work can be done, signage, waste
disposal
• Undertaking about pregnancy
• Provided staff access to ID physicians for counselling
• Strict oversight of the virus - from import, storage, culturing, disposal,
• Inventory control
Sociotechnical System
Is safety really First?
Productivity is first and safety is a very close second
On the other hand…
“If you think safety is expensive, then try an accident”
Efficiency-thoroughness trade-off principle (ETTO)
The efficiency–thoroughness trade-off principle (or ETTO
principle) is the principle that there is a trade-off between efficiency
or effectiveness on one hand, and thoroughness (such as safety
assurance and human reliability) on the other. In accordance with this
principle, demands for productivity tend to reduce thoroughness while
demands for safety reduce efficiency.
So…
Safety professional should constantly consult with the actual workers
to come up with regulations
Following SOPs does not guarantee that accidents will not happen
Accidents are often unexpected reactions and the resilience of the
system is what prevents it
SOPs are critical but with allowances
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