Coordination of European Research on Industrial Safety towards Smart and Sustainable Growth
Promoting safety as an emergent property of a resilient system
Promoting safety as an emergent property of a resilient system
Resilience has been defined as the reactive ability of asystem to recover after a shock but also as its capacity to beproactive. We stress the proactive nature of resilience as theability to develop the requisite imagination for anticipatingfuture outcomes, to provide strong responses to weaksignals (i.e. uncertain information, embedded in normaloperations, that could be read as a warning of futurechanges, both mishaps and opportunities). We propose astudy based on the Resilience Matrix model (RM), whichprovides the system with the frame of reference to managesafety involving the three main actors: single workers,teams and the organization. Each actor could be a proactivepromoter of the safety culture and safety could become anemergent property of the system by means of the Non-Technical Skills (NTS) like stress and workloadmanagement, situation awareness, communication,decision making and problem solving, leadership, and teamwork. According to this approach, the ResilienceMatrix Questionnaire (RMQ) will be validated, in order tohighlight the key elements of individuals, teams andorganizations to handle complexity, enhance performanceand improve safety. A training and tutoring project will beprovided to a group of managers and operators of an Italianenergy distribution company. It will be based on theenhancement of the NTS, and it will be aimed at increasingthe safety of the organization without reducing itsproductivity and promoting operator's well-being. Theproject will enhance proactive behaviors towards weaksignals, promote group-based mutual support ofpractitioners, helping them to cope with stress, workloadand lack of motivation and improve communication skills.A retest of the RMQ will be performed and the developmentof the NTS will monitored over a period of two years. Theoutcomes of the project will be the development of a tool toassess the resilience attitudes of an organization, and thetraining and tutoring package to enhance them for safety’ssake.
This study has two main goals. First, we propose a newmodel to understand how resilient organizations operate(T2): the Resilience Matrix. According to this model, we willdevelop and validate the Resilience Matrix Questionnaire.This instrument should show which are the relevantindicators at the three levels of operation (individual, groupand organization) a resilient system should have to be ableto detect risks and prevent accidents, highlightingweakness and strengths of the system. The study will berepeated on different samples to demonstrate its validity in a different context (T1.3). The second goal is to demonstratethe validity of this model by acting on the main weaknesspoints evaluated in the system and addressing its safety-related performance before and after the intervention(number of accidents, incidents, reports, etc.). We adopt aresearch-intervention method based on the enhancementof the NTS in groups and operators, intended as thekeystones for the system’s safety and resilience. Finally wewant to demonstrate that a proactive approach to safety is again, not a cost, showing how the utilitarian ethics andduty ethics viewpoints on safety could be not in contrast,but in agreement. Operators’ well-being and commitmenttowards weak
signals will enhance both safety and work performance(T1.1).
The project will provide a resilience engineering approachbased on the empowerment of the NTS. It will be based onan assessment tool, the RMQ, and on the training/tutoringpackage of the NTS. The stakeholders of this methodologywill be companies whose activities cold be defined ascomplex (e.g., transports, health, industry), where it isimportant to pay attention to weak signals for a proactivesafety. The project will enhance the perceived well-being ofthe workers: on the one hand, they will be able to cope withstress and workload relying on effective teamwork andcommunication skills and, on the other hand, decreasingtheir organizational cynicism helping them to understandgoals, policies and values of the management. Theorganization as a whole will be safer thanks to the improved circulation of information, ability to change andto learn from experience.
Phase 1: the RMQ development
The cultural change could be accomplished after an earlyassessment of the system's resilience characteristics.According to the current literature about resilienceengineering (RE) we developed the RM taking into accountthe three main actors that could cope with complexityduring normal operations: individuals, team, andorganizations. Each of them is in charge of noticing anddealing with weak signals and only their harmonicrelationship could
afford the emergency of resilience and therefore system'ssafety.
Following the rationale of the RM the RMQ has beendeveloped and is currently under validation (Phase 1.a).This tool addresses the main factors promoting resiliencein a complex system which could be summarized in fourdimensions:
Mindfulness: the ability to notice weak signalsembedded in normal operations, avoiding the over-simplification of the work activities.
Communication: the ability to share at the groupand organizational level the information avoidingthe blame culture.
Dynamic Adaptation: the ability to cope with thepotential threats hidden in the weak signals,implementing technological or organizationalbarriers.
Solution Implementation: the ability to put inpractice new procedures and barriers and monitortheir efficacy.
The above mentioned dimensions are peculiar of complexsystems and are the fundamental ground for thedevelopment of resilience and safety. The abilities requiredto accomplish these factors are profoundly non-technical,since relying on technologies norms and procedures is notenough to get safety. The complex nature of the workenvironment exceeds the containment capacity oftraditional approaches to safety; it is necessary to develop aglobal and coherent commitment of the three main actorsof the system: individuals, groups and the organization.This is accomplished by means of the NTS, which become atrigger for the technical skills.
One of the main issues in RE literature is the incongruencebetween the work as imagined by the management and thework actually performed by the operators. The RMQ aimsat investigating both the management and the front-lineoperator's points of view in order to assess this mismatch.Moreover an other incongruence could be assessedconcerning the safety culture as attitudes and ideal valuesversus what is actually performed in everyday operations.Therefore we developed two versions of the questionnaireone addressed to the managers (RMQ-M) and the other oneto the operators (RMQ-W). Both of them were composed bya group of items assessing resilient behaviours and asecond group of items assessing resilient attitudes.
Phase 2: the training/tutoring package
After the measurement of the resilient characteristics ofthe system we aim at developing a training/tutoringpackage that could help the organization to fill in the gapsobserved between ideal and actual behaviours and plannedand performed work.
At the individual level we will train operators to notice andreport weak signals in their operational context, discussinghuman performance variability, the effectiveness ofprocedures and barriers and developing the requisite imagination to foresee possible risks, looking at thevariability from the sharp-end point of view. Moreover, wewill highlight the importance of an internal locus of control about safety andwe will link the increase of responsibility with the increaseof power of action of every practitioner. We will work onthe NTS involved in these processes such as situationawareness, communication and ability to manage withstress and workload.
At the group level we will focus on reporting proceduresand shared tutoring, we will provide tools and contexts forinformation sharing, group’s problem solving anddecision-making skills. We will aim at improvingteamwork and leadership skills, showing the biases ofhindsight analyses of accidents and discussing about thenature and effects of a blame culture. In addition, we willpromote a group-based mutual support of practitioners,helping them to cope with stress and lack of motivation.
At the organizational level, a Resilience EngineeringProgram will be planned in cooperation with the topmanagement to implement responses for the most relevantwarnings. In addition, we will link safety and well-being,providing the organizational level with some hints aboutthe development of a safety culture ad the decrease of theorganizational cynicism among workers.
Phase 3: the retest and monitoring
The last phase of the project will be devoted to the retest ofthe resilient attitudes and behaviours of workers assessingwhether a significant change has occurred after thetraining/tutoring intervention. Moreover we take intoaccount the improvement of objective safety indicatorssuch as the number of accidents, incidents and the increaseof reporting (Phase 3.a).
The second part of this phase (3.b) will be developedaccording with the outcome of the training/tutoring project and its monitoring. It will aim at supporting and followingthe increasing development of the NTS among the workers.The cultural change is a slow and long process since it isbased on the shaping of new attitudes about safety. Itrequires a
constant monitoring process where the workers will behelped in the assessment of their confidence in theapplication of the NTS. We will help the workers to designand implement new organizational devices aimed at theemergence of resilience, such as significant event audits,reporting systems, methods for the tracking andenhancement of the best practices.
Dounia Tazy
ICSI
France
Tommaso Piccinno
University of Genova
Italy
Fabrizio Bracco
University of Genova
Italy
FonCSI
France