This document discusses relationship-based safety and challenges some common myths about safety. It argues that human error is a symptom of deeper issues within complex systems, not a cause of failures. Investigating accidents focuses more on understanding why actions made sense at the time rather than finding mistakes. The document also questions whether safety is really a science and whether current safety education reinforces the wrong paradigm. It advocates for an evolutionary approach to safety that focuses on critical thinking, action, feedback and reconciling goals rather than providing answers or constraints.

1. Relationship Based Safety
David Bond – 21st February 2013

2. Relationships
Systemic
• Complex Systems
• Layers
• Interactions
• Emergence
Personal
• Motivation
• Accountability
• Consequences
• Just Culture

3. Some Persistent Myths
• That systems are inherently safe, it is the behaviors of
unreliable individuals that create unsafe conditions
• More than 80% of accidents are the result of errors or unsafe
behaviours
• Safety rules and procedures are there to correct or control
unreliable human behaviour
• Accidents are the result of someone not paying enough
attention – ‘they lost situational awareness’

4. New View of Human Error
• Human error is a symptom of trouble deeper inside a
system
• We can never explain failure by finding mistakes.
• Find why peoples actions made sense at the time, given
the circumstances that surrounded them.
• Complex systems are not inherently safe
• Complex systems are trade-offs between conflicting
goals
• People create safety through practice
Dekker, Sydney (2006) The Field Guide to Understanding Human Error

5. Complexity & Failure - Before
• Normal Accidents
• Drift into Failure
• Incompatible Goals
• Adaptation
Practices do not follow rules; rather, rules
follow evolving practices.
Brian Wynne

6. Complexity & Failure - After
• Oversimplification
• Hindsight bias
• Outcome bias
• Local rationality
Looking for cause or control?
“There is almost no human action or decision that
cannot be made to look flawed and less sensible in
the misleading light of hindsight.
Lord Anthony Hidden

7. Is there really a ‘cause’
anyway?
• The identification, after the fact, of a limited set of aspects of
the situation that are seen as necessary and sufficient
conditions for the observed effects to have occurred.
The cause, in other words, is constructed rather than found .
• Erik Hollnagel,
• The cause of an accident is not found in the rubble, it is
constructed in the mind of the investigator.
- Sydney Dekker,

8. Is there a need for change?
• Is safety a science?
• Rote answers
• Pre-packaged solutions
• Safety education - Are we
reinforcing the paradigm?
The point is not a set of answers, but
making possible a different practice.
Susanne Kappeler

9. Where to from here…
Evolution, not Revolution
• Focus on critical thinking, not answers.
• Promote action rather than constraint.
• Faster feedback loops.
• Minimise irreconcilable goals.
• People (not systems) create safety
Declarations of the real operate as conversation
stoppers; they establish the limits of what others
can say, who can be heard.
Kenneth Gergen

10. Thank You