Health & Safety System Approaches

Health & Safety System Approaches Systems are deeply embedded in the way an organisation manages health and safety (H&S). Over the last century there are recognizable shifts in the approaches taken toward H&S systems. Four Health and Safety System Approaches are identified and covered showing how the perspective taken by each of H&S and related accident analysis differ. These Health and Safety System Approaches are not substitutable options, rather they can be viewed as progressively adding to ways in which H&S is improved by organisations, in a sense reflecting a progression in the level of maturity of organisational H&S. The multi-level perspectives reflected in Health & Safety System Approaches can be similarly reflected in the law of tort and in Commissions of Inquiry into H&S failures. David Alman Version 3. November 2013

Health & Safety System Approaches David Alman

Proventive Solutions Page 2

Contents

Acknowledgements ................................................................................................................................. 3

1. Systems of Work a basis for improved Health and Safety .................................................................. 4

2. What is meant by the terms Hazard and Risk in a systems context ................................................... 6

3. Four Health &Safety System Approaches ........................................................................................... 9

4. Health & Safety System Approaches Explored ................................................................................. 14

4.1 Transactional System Approach: Compliance based ................................................................. 14

4.2 Governance System Approach: Resilience based ...................................................................... 17

4.3 Referential System Approach: “Drift” affected systems ............................................................ 21

4.4 Interpretive System Approach: “Dissonance” and crisis............................................................ 26

5. Maturity of Health and Safely Systems, and Tort. ............................................................................ 29

Conclusion ............................................................................................................................................. 30

Notations............................................................................................................................................... 31

References ............................................................................................................................................ 35

About the author .................................................................................................................................. 38



Acknowledgements

This article arose from a LinkedIn Systems Thinking World (STW) Thread discussion. My thanks to

Gene Bellinger for encouraging such discussions on, and learning in, Systems Thinking, and through

the way he has managed and supported this LinkedIn Group. My Thanks to Frank Wood who raised

a Thread covering systems thinking in relation to the field of Health & Safety and, through the

Thread’s postings, for highlighting the lack of public information linking Systems Thinking to Health &

Safety.

My thanks to T.A. Balasubramanian who referenced Nancy Leveson and her e-book Engineering a

Safer World. This is not the first time that Tabby has referenced Leveson’s publications and from a

previous discussion and reference to Leveson I found online elsewhere that excellent article by Zahid

Qureshi A Review of accident modelling approaches for complex socio-technical systems. This article

highlights how the approach to Health & Safety has shifted over time; introduces the concept of

Complex Sociotechnical Systems; and leads to exploring the more recent authors in the field such as

Erik Hollnagel, Jens Rasmussen, Anthony Hopkins, and Peter Ladkin. In this respect my thanks too

to Frank Verschueren for his enthusiasm for Health & Safety and its link to Systems Thinking.

Through his interests I have picked up and included the work of Sydney Dekker.

My thanks also to Sanjiv Bhamre for referencing Karl Weick’s work in Health & Safety that

subsequently led me to a particular Karl Weick article which helped finalise the four Health & Safety

System Approaches applied in this article.

My thanks to all those who post on STW that helped develop my interests and musings; to others

across the world who I share my drafts with and who kindly review and offer comment; and, more

close to home, those who not only take the time to read, review, and offer feedback but who also sit

down with me and share and discuss their views such as my wife, Donna, and good friend Peter

Wojciechowski.

Non, in my view, receive the acknowledged appreciation they deserve.

http://www.linkedin.com/groups?viewMemberFeed=&gid=2639211&memberID=8365646





1. Systems of Work a basis for improved Health and Safety

According to the International Labour Organization (ILO) and the World Health Organization (WHO),

health and safety at work is aimed at the promotion and maintenance of the highest degree of

physical, mental and social well-being of workers in all occupations; the prevention among workers

of leaving work due to health problems caused by their working conditions; the protection of workers

in their employment from risks resulting from factors adverse to health; the placing and maintenance

of the worker in an occupational environment adapted to his or her physiological and psychological

capabilities; and, to summarise, the adaptation of work to the person and of each person to their job.

[1].

Health and Safety (H&S) at work is influenced by “hard” legislation that provides directives and

regulation about what is to be complied with by organisations and accountable persons, as well as

covering the means of its legal enforcement. In addition there is “soft” legislation that provides

unenforceable guidelines. It should be noted, however, in H&S matters before a court an

employer’s actual practices, for example when considering what are the causes of an accident, can

be compared to such published legislative guidelines and this is taken into account in a court’s

decision.

H&S is viewed as improved by considering H&S issues within a systems approach, and this is

confirmed as there is health & safety legislation where safety in a systems sense is specifically

referred to for employer application. This may be through “hard” legislation as in Australia and the

UK where “safe systems of work” are sought [2].

A safe system of work is a framework resulting from a systematic examination of work to identify

hazards and design specific work methods to eliminate or minimise hazards. A safe system of work

therefore refers to systems of work that have been assessed for safety and where hazards have been

identified and addressed. What is involved in making a system of work safe is based on Risk

Assessments [3], unless specifically a matter to be addressed in a manner covered by regulation.

Safe systems of work can be further supported, as in Australia, by “soft” legislation that provides

guidance through, for example, reference to the use of H&S Management Systems [4].

Despite some countries H&S legislation not referencing the application of safety in a systems context

there are large organisations in such countries that voluntarily set up and apply H & S Management



Systems [5]. The voluntary implementation and application of Health and Safety systems at work

can also extend to and include, for example, the establishment of behavioural based safety systems.

Traditionally there has been a separate practice by some large organisations to focus on behavioural

based safety systems, however behavioural based safety systems can also be integrated with

procedurally based H&S Management systems [6].

Whether through procedurally based H&S Management Systems; behavioural based systems; or safe

systems of work, the intention is to better address risk of injury from hazard sources.

What is meant generically by an H&S system should be explained before proceeding further so there

is a common understanding of how the term is used in this article.

A system can be generally and broadly described as:

A purposeful organisation of its component parts, each with varying attributes, that results in intended (and unintended) consequences resulting from its interactions. [7]

Within this context H&S systems can include, for example [8]:

A purpose such as to develop, maintain, and improve safe ways of working by identifying hazards and addressing risks to the health and safety of employees and others <why>.

Components such as materials, people, plant, equipment, process(es), tasks and environment <what>.

H&S influences and constraints that address system component hazards and the risks in their interactions <how>.

What an H&S system is and what its component parts are, along with their interactions and

attributes, can be viewed in different ways. These different ways, or perspectives, are grouped

under the four H&S System Approaches described in this article.



2. What is meant by the terms Hazard and Risk in a systems context

There are two common terms used when considering hazard sources and their effects on H&S:

Hazard and Risk [9].

A Hazard is a direct or indirect source of potential, harm. A hazard consequence is personal

injury or death resulting from a hazard.

A risk is a measure of the likelihood of personal injury or death.

Sources of hazards can come from three types of systems: Human Designed systems; Psychosocial

systems, and Natural Environment systems, as illustrated in Diagram 1.

Diagram 1. Types of Systems encompassing Health & Safety Hazards

Human Designed Systems

Process & practice systems

Built environment

Management Systems

Natural Environment Systems

Physical

Biological

Chemical

PsychoSocial Systems

Interpersonal

Intrapersonal



Examples of hazards arising from these three systems types are provided in Table 1.

SYSTEM TYPE HAZARD AREA HAZARD EXAMPLES

Human Designed

Process & practice systems

Dangerous processes & practices.

Built Environment

Plant & Equipment layout & condition

Mechanical & electrical exposure; excessive heat or noise.

Work area design Poor lighting; slippery surfaces; entrapment – no exit.

Management System

H&S Management System status Unaddressed identified risks.

Communication system condition Inadequate network support issues.

Accountability structure design Lack of accountability or delegation, or overlapping authority.

Psychosocial

Interpersonal relations

Harassment/bullying, interpersonal conflict & relationship breakdowns

Intrapersonal values & priorities Emotional stressors, belief conflicts in values and priorities.

Natural Environment

Biological contamination

Exposure to infection from bacteria and viruses.

Chemical containment Acid, heavy metal, vapour exposure.

Physical environment Extreme weather, unsafe landscape.

Table 1. Examples of hazards that can arise within the three System Types.

These three System Types are not separate in a work environment but interlinked along with their

potential hazards. The subsequent integration of these System Types results in another form of

System Type termed a Human Activity System (HAS) [10].

Diagram 2 illustrates how the three System Types merge within a Human Activity System (HAS)

Type. It is within this Human Activity System Type that all Health & Safety related systems discussed

on this article are considered.



Diagram 2. The Human Activity System (HAS) Type as an integration of three other System Types

Human Designed

• Process & practice systems

•Built environment

•Management Systems

Psychosocial •Interpersonal

•Intrapersonal

Natural Environment

•Biological

•Chemical

• Physical

Human Activity System (HAS)



3. Four Health &Safety System Approaches

The approach taken to assessing and solving a problem situation, in systems terms - the” Systems

Approach” -is based on the paradigms of reality (the perspective) taken.

System approaches (also referred to as Systems Thinking Approaches) therefore reflect different

perspectives of reality applied to problem situations, in systems terms.

Within this context four Health & Safety System Approaches are explained in this article:

Transactional System Approach;

Governance System Approach;

Referential System Approach; and

Interpretive System Approach.

The following Diagram 3, Table 2, and Diagram 4 illustrate and outline these four distinct Health &

Safety System Approaches.

In Diagram 3 the four Health & Safety System Approaches (Transactional; Governance; Referential,

and Interpretive) are very briefly explained and also shown as interconnected yet separated by

considering them along two dimensions:

The Work Level where the Health & Safety System Approach is either more focused at the

organisational level or more focused on specifics at the Workplace Level.

The Socio-technical where the Health & Safety System Approach is either more focused on

(technical) issues, such as legislation, regulations, policies, and procedures to address health and

safety, or more focused on the specific (socio) needs of individuals and groups [12].



Diagram 3. The four H&S System Approaches compared though two dimensions.

In Table 2 the four Health & Safety System Approaches are briefly explained, with a matching

column that highlights the H&S System Approach (i.e. Compliance; Reliability; Drift; and Dissonance).

The four H&S System Approaches are also aligned to the key H&S issue addressed; and each H&S

System Approach in the table is provided with further Descriptions of hazards identified and relevant

supporting methodologies.

The four Health &Safety System Approaches are more fully explained in the subsections of Section 4

of this article.

Governance Approach

Plan, implement, and review content reliability to a given

context.

For example, develop and improve reliability management control

systems, and rules. (Analyse and Act)

Referential Approach

Identify and apply content values and priorities in a context.

For example, appreciate and apply what is valued and of priority to a

given situation. (Probe and Act)

Transactional Approach

Ensure compliance within a given context and content.

For example, compliance with

prescribed work practices. (Categorise and Act)

Interpretive Approach

Address dissonance in context and content.

For example, decide how to manage

issues in an unanticipated emergency or injustice cases. (Sense and Act)

Organisational

Workplace

Regulatory Needs

Socio-technical

Work Level



H&S System Approach Characteristics

H&S System Approaches

H&S Issue addressed

Descriptions

Hazards Identified Methodologies

Transactional. Risk manage at the event and process activity level

Compliance to H&S

requirements in Workplace Systems

The “System of work” either works as required, or fails to meet preset standards. Stop the direct “Domino” cause and effect chain that results in accidents.

Check and control through linear “Root cause” Analysis at the workplace.

Check and investigate against standards using direct root cause analysis methods.

Standards of H&S practice tightened through procedural rule changes, and through behavioural based programs.

Governance. Manage by “structuring’ depth in defences through an H&S Management system.

Reliability in

H&S Management Systems

Accidents and risks cannot be managed at the workplace without greater policy and planning to handle “variation”. More “defences” in a much wider range of direct (“sharp end”) and support policies, processes and practices (“blunt end”) to stop accidents from getting through a “Swiss Cheese” of holes in H&S defences that end in accidents.

Variations in risk exposures and accidents require greater planning and preparation to identify hazards and improve the management of risks.

A “Swiss Cheese” approach used through additional OH&S defences in both direct and indirect support areas by anticipating hazards and risks and developing and improving a “resilient” OH&S Management System.

Check and investigate using audits and non linear root cause analysis.

Reengineer for High Reliability in system processes and behaviours.

Referential. Manage culturally influenced issues to improve H&S

Drift in H&S

Culture. Planning and preparation of

H&S Management System still leaves risk exposures and serious accidents.

Whatever is organised, there can be a “drift” and lack of recognition of how priorities and values are influencing H&S.

Resolution of conflicting emergent influences.

Systems can be dynamic and unpredictable where what was safe one day is now unsafe. Hazards and risks are “emergent” from “drift” in processes and practices due to competing priorities.

Influence of values and priorities to be checked and investigated through multiple perspective root cause analysis.

Interpretive Manage and address personal experiences of hazards beyond those addressed by existing H&S systems.

Dissonance in H&S environment

Crises caused by exposure to hazards that are not covered by previous experience, or prescribed processes and practices.

Social justice issues are outside the cultural values and priorities in the workplace.

The two above points create crisis and/or conflict: mental Dissonance between individuals and group experience of work environment hazards.

Reframe work practices and values (Transactional, Governance, Referential Levels) to address the issues that Dissonance raises.

This involves organisations being open to changing existing H&S systems to accommodate experiences viewed as inadequately coped with through existing processes, practices, values, and priorities.

Table 2. The four Health & Safety System Approach characteristics compared.



In Diagram 4 the four Health & Safety System Approaches that influence the way H&S is practiced

are aligned to the “ages of work”, reflecting an evolution of both in Western Society [13]:

An Industrial Age going back to the 18th Century where mechanical equipment and mechanistic

systems of work in manufacturing were common, and at a workplace level health and safety and

accident investigations fitted in by comparing “compliance” failures to preset standards.

A Technological Age going back to the mid 20th Century where industries sought to coordinate

and organise safe systems of work at an organisational level, where H&S Management Systems

built incompliance defences to improve “reliability” against accidents and incidents;

An Information Age, or knowledge based age, starting in the latter part of the 20th Century

sought team or individual flexibility in responding quickly and effectively to emergent situations.

In a Referential Systems Approach ‘drifts” in priority and values have overridden laid down

prescribed H&S practices. Where “drifts”, because of hazards and accidents, have caused a

difference, and discretion, between “what ought to be done” (as prescribed) and “what needs to

be done” to address current work pressures and influences (Referential System Approach

issues).

Also in certain situations, such as where there is a health & safety crisis faces a team or

individual, a difference between “what ought to be done” and “what needs to be done” can

result. Where, for example, emergent emergency issues cause personal “dissonance” between

inadequacies in what (prescriptively) ought to be done compared to “what needs to be done” to

survive and be safe (Interpretive Systems Approach issues).



Diagram 4. An evolution in “Ages of work” and H&S System Approaches

Industrial Age Technological Age Information Age

Transactional System Approach Addressing “compliance” issues

e.g. physical equipment, human failure

Governance System Approach Addressing “Reliability” issues e.g. H&S Management Systems

Referential System Approach Addressing “Drift” issues

e.g. Priority & value influenced

Interpretive System Approach Addressing “Dissonance” issues

e.g. Personal distressors

Need Focus

Regulatory Focus

H&S System Approaches

“Ages of work” aligned to the start of certain H&S System Approaches



4. Health & Safety System Approaches Explored

4.1 Transactional System Approach: Compliance based

A “Transactional” System Approach refers to linked and interrelated activities (procedural, technical,

behavioural) at the workplace where the focus is on producing something providing a service, or

building something, or making something. Within this Transactional System Approach, H&S

workplace practices are identified and built into the way activities are carried out to develop “safe

systems of work”.

Diagram 5 illustrates a three stepped process for identifying and addressing workplace hazards [14].

Diagram 5. Three Stepped Risk Management Process

Within this Transactional Systems Approach, hazards are identified, for example, through a Job

Safety Analysis; inspection checks on compliance to standards; and through incident and accident

reports. Incident and accident reporting, as shown in Diagram 6, can include a “root cause” analysis

of an accident/incidence that has occurred, and is carried out by asking, for example, a number of

“why” questions of the cause of the accident or incident. Through this Root Cause Analysis levels of

direct cause and effect are established.

Diagram 6. Root Cause Analysis of a Safe System of Work Failure.

Root Cause Analysis of accident

Identify Hazards Assess the risks Control the risk

Service or production Transactional System based on employee & technical interactions



In the Transactional System Approach once hazards are identified the level of H&S risk can be

assessed (based on Consequences and Likelihood of harm), as exampled in Table 3.

Likelihood Consequences

Insignificant Minor Moderate Major Critical

Almost certain Medium Medium High Extreme Extreme

Likely Low Medium High High Extreme

Possible Low Medium High High High

Unlikely Low Low Medium Medium High

Rare Low Low Low Low Medium

Table 3. A H&S Risk Assessment Matrix Example [15]

Having identified hazards, and assessed their risks, the means of controlling those risks are then

considered and actioned.

Both hazard management and accident analysis in a Transactional System Approach take a common

view based on compliance. That is, safe systems of work provide preset standards of safe work

activity that are to be complied with, where causes of accidents can be a failure to comply with

preset safe systems of work.

Whether a single event or a chain of events causes an incident or accident, the relationship between

an event’s cause and effect is direct (linear) within workplace (Transactional) systems of work. Root

Cause analyses can indicate multiple direct chains of causes, as illustrated in Diagram 6. In Diagram

7 a single sequential chain of direct events causing an accident or incident is visually shown and

described as the “Domino Effect” [16].

Diagram 7. Domino Effect



In reality, however, accidents and incident have more than one contributing factor and have

multiple root causes.

To support safe systems of work based on compliance two different methods can be taken and

integrated:

Compliance of work practices to a system of work, as discussed above.

Compliance of work practices to a Behaviour Based Safety program. Behaviour Based Safety

programs focus on identifying “at risk” behaviours and developing ways to encourage safe

behaviours, and include using behaviour observation checklists [17].

A limitation of the Transactional System Approach to health & safety is that an accident or incident

investigation based on direct (linear) causes and effects at the workplace level can be an incomplete

analysis by excluding relevant additional causal factors influencing and affecting work level practices,

for example from an established Health & Safety Management System; from management decisions;

and an organisation’s culture that are identifiable through other Health and Safety System

Approaches [18].



4.2 Governance System Approach: Resilience based

The Transactional System Approach refers to “safe systems of work” based on risk assessed pre-

planned and pre-set activities along with associated compliance standards that work together to

safely produce some output and outcome. Safe systems of work based on the Transactional System

Approach may stand alone at the workplace level, or may be part of larger Governance System

Approach to H&S that covers a wide range of issues that support the safety of a transactional system

of activities, such as training, incentive schemes, IT support, life cycle maintenance, replacement of

plant etc.

The Governance System Approach to H&S can include established Health & Safety Management

System frameworks such as ISO 18001, AS/NZS 4801, SafetyMap, 5 Star.

Health & Safety Management System frameworks tend to cover similar areas, the performances of

which are auditable (by internal or external Auditors) which assess compliance [19]. Table 4

examples areas that can be covered.

Example Elements found in Health & Safety Management Systems

Responsibility and accountability

Consultation, communication and reporting

Hazard identification, risk assessment and control measures

Safe work practices, including in normal and abnormal circumstances

Training and competency

Managing contractors

Equipment integrity

Reporting and investigating incidents – internal systems

Emergency planning

Procurement

Management of change and its affect on the Health & Safety System

Documentation and data control



Table 4. Example of elements of a Health & Safety Management System

In addition Health & Safety Management Systems are designed to apply a concept of a continuous

improvement cycle (from Policy & objective through to Review), as exampled in Diagram 8.

Diagram 8. Example of continuous improvement areas in a Health & Safety Management System

Through the development and application of a Health and Safety Management System two aspects

of H&S can be considered relevant beyond the idea of “compliance”: Reliability and Resilience.

While reliability and resilience are interconnected ideas their emphasis is different:

Reliability relates to increasing the reliability in parts of, and the whole of, a Health & Safety

Management System so accidents do not occur.

Resilience relates to improving the depth of defences built (through multiple layers of defences,

barriers, and safeguards) into a Health & Safety Management System against incidents and

accidents occurring.

Continuous improvement

Policy & objectives

Planning & prioritising

Standards & targets

Implementation

Monitoring

Corrective action

Audit

Review



Diagram 9 illustrates this idea of defences against accidents and incidents [20]. First it shows that

defences can be forms of “sharp end” health and safety protection such as equipment used, human

practices, procedural processes, workplace conditions. ThIs also shows that defences can have

depth in terms of “blunt end” support factors, such as policies, purchasing practices, training

programs.

Accidents can occur at a point in time where potential hazards slip through “gaps” in these layered

defences, analogous to the holes in a “Swiss Cheese”.

Diagram 9. Adaptation of a “Swiss Cheese” Model developed by Reason

Improved reliability is therefore by adding defences that fill “gaps”.

DEFENCES

A Governance System Approach H&S Management System

Organisational Level Safety factors e.g. OSH 18001, AS/NZS 4801, SafetyMap, 5 Star

(includes “Blunt end” factors)

Workplace Level H&S factors e.g. workplace conditions and practices

(“Sharp end” factors)

Accidents

CAUSES INVESTIGATIONS

Accident



A limitation with focusing on reliability and “High Reliability” is that health and safety is not

necessarily improved by increasing reliability of, for example, Health & Safety Management Systems.

Nor by improving their resilience by improving the defences built into Health & Safety Management

Systems. This is because accidents can result from unanticipated interactions. So whilst a Health &

Safety Management System can continue to satisfy auditable safe performance requirements, as a

Governance System Approach, it is system interactions and not system elements/system parts that

can also fail [21].

To further improve H&S a move toward identifying and addressing “emergent” and “emerging”

hazards and risks is beneficial. This involves applying a Referential System Approach.



4.3 Referential System Approach: “Drift” affected systems

There are three aspects about a Referential System Approach that can be recognised in their

application:

They are based on an organisation’s cultural values and priorities; group “norms”; and individual

values and priorities, and assumptions, in decision making.

They involve the influence of values and priorities on, and through, perspectives that are

common and consistent within other Health & Safety System Approaches.

They include and combine the “multi-level” perspectives found in different Health & Safety

System Approaches. This multi perspective level, and how they interrelate within the

Referential System Approach, is shown in Diagram 10.

Diagram 10. Multi-level perspectives of the Referential System Approach

Diagram 11 shows an accident investigation, based on a Referential System Approach, using a

Human Activity System (HAS) Map. The HAS Map highlights the application of multi-level

perspectives (Referential, Governance, Transactional) [22].

Outcomes

Referential Perspective Level

Values and priorities that give “meaning” to what is

decided.

Governance Perspective Level

Organisation of “rules” to manage, control, and

coordinate what is done

Transactional Perspective Level

Technical & social activities &

Physical conditions such as equipment and work layout



+

Diagram 11. HAS Map of an Accident Investigation.

Human Activity System (HAS) Map

Purpose: Accident investigation

Outcomes

Transactional Level

Governance Level

Referential Level

Priority on efficiency & cost cutting

H&S risk management practices not reinforced

Management priority on production

outcomes

Machine maintenance schedules affected by cost

cutting decisions H&S checks not carried out

Delays in routine machine maintenance

schedules

Machine guard sensor not operating

Machine guard not functioning

Employee rushing to complete job

Slip on oil leak on machine platform

Press operator injured by machine

Time off on Workers

Compensation

Injury subject to external

investigation and penalty



In terms of a Referential System Approach Diagram 12 also illustrates the analysis of multi-level

perspective relationships to incidences occurring at a workplace level [23].

Diagram 12. Workplace Level Example of a Referential System Approach

Referential Level (values & intentions)

Supervisor & certain team members

Transactional Level (role activities and behaviours)

Governance Level (organisation structure)

METHODOLOGICAL

CONSIDERATIONS IN

USING ACCIMAPS AND

THE RISK

MANAGEMENT

FRAMEWORK TO

ANALYSE

LARGE

-

SCALE SYSTEMIC

FAILURES

P.E. Waterson

Team

Team

Team

Contributory Factors

Supervisor and certain team

members coercive and

disrespectful to female staff.

Female employees part of set

work teams and affected by

attitudes of certain other

team members and by

Supervisor style and attitudes.

Female employees ostracised

and belittled, with

breakdowns in relationships

and loss of coordination of

work.

Loss of attendance of female

staff, poor resulting

performance, drop in

workplace productivity.



On a broader sense the Referential System Approach highlights the importance of checking for

“emergent” issues and emerging shifts in H&S that can expose organisations and humans to hazards

and risks. A way of exampling these shifts, or Drifts, as it relates to the Referential System Approach

with its multi-level perspectives is exampled in Diagram 13.

Diagram 13. Example of a “drift” in work practices beyond pre planned safety nets.

A key concept inherent in Diagram 13 is one of “drift” toward increased incidents and accidents.

Referential

Referential

Multi-Levels

Governance

Governance

Transactional

Multi-Levels

Transactional

Increasing organisational Performance

Supporting Employee wellbeing

Past work processes and role requirements based on balancing performance & H&S

requirements (“What ought to be done”)

Current work & role processes and practices based on an emphasis on improving

performance needs yet affecting H&S wellbeing (“What needs to be done”)

Current Safety Net

Past Safety Net

Legend

= Safety Net

= Accidents & Incidents

DRIFT

DRIFT



The concept of “drift” and the “emergence” of incidents and accidents from apparently safe work

systems can be discussed in terms of four associated concepts:

1. Hollnagle’s “ETTO” Principle”;

2. The term “Drift” coined by Dekker;

3. Rasmussen’s shift through influencing constraints in his Dynamic Safety model; and

4. Hopkins AcciMap examples:

The insights that can be gained from these four associated concepts are:

1. The ETTO Principle relates to “Efficiency- Thoroughness Trade Off”. If thoroughness dominates,

there may be too little time to carry out the actions efficiently. If efficiency dominates, actions

may be badly prepared or wrong for lack of thoroughness. Making an efficiency – thoroughness

trade-off is never wrong in itself. Employees are expected to be both efficient and thorough at

the same time – or rather to be thorough, when with hindsight it was wrong to be efficient and

where the consequence was an accident. The greater the need of performance adjustments is,

the less thorough they are likely to be as demands to increase efficiency may overrule

thoroughness and health and safety [24].

2. Dekker defines “drift” as the “slow, incremental movement of systems operations towards the

edge of their safety envelope”. Drift occurs as small deviations from accepted practice that build

upon one another to a become a huge deviation from stated (safe) practices [25]

3. Rasmussen developed a Dynamic Safety Model of which Diagram 13 is a simplified and adapted

version of his model that demonstrates how three influencing constraints cause drift into

accidents [26].

4. Hopkins has developed a number of AcciMaps that provide an easy visual description of the

causes underlying major accidents. This work is based on Jens Rasmussen’s work on AcciMap

that recognises multi-levels of perspective. Diagrams 11 and 12 are illustrative of this [27].

A limitation with using AcciMaps and HAS Maps is that it is possible to develop different multilevel

causal maps of the same accident, showing different sets of causes depending on the analyst’s focus

[28].



4.4 Interpretive System Approach: “Dissonance” and crisis.

The Interpretive System Approach is similar to the Referential Approach in that both apply a

multilevel perspective. They differ, however, as the Interpretive System Approach relates to:

Situations at the workplace level only;

Individual and group personal beliefs and assumptions in the circumstances they find themselves.

Interpretive System Approach that is separate from organisation based Health & Safety System

Approaches previously described.

Diagram 14 provides a comparison between a Referential and Interpretive System Approaches and

illustrates how they can interact.

Diagram 14. Comparison of Referential and Interpretive System Approaches

The Interpretive System Approach is relevant to employee health & safety in the areas such as:

Organisation Level

Workplace Level

Organisation focus Employee focus

Referential Perspective

Referential Governance

Transactional Perspectives

Referential System Approach

Interpretive System Approach

Governance Perspective

Transactional Perspective



An emergency where existing practices fail to address serious hazard exposures and risks to

employees. For example where in a forest firestorm, fighting equipment and practices fail to

keep employees safe and they are left to their own devices to work out survival solutions [29].

A “secondary victim” where an employee or ex-employee suicides or gives up career as a result

of being blamed as the cause of an accident, such as a nurse or doctor over a patient’s death or

an airline pilot as a result of a crash. In such instances organisations could seek a just culture

that protects people's honest mistakes from being seen as culpable [30].

A violation of valued expectations in relation to, for example, social justice as in the way an

accident is treated. For example where there is harassment or bullying of employees

unrecognised by management. Also where the workplace environment causes high levels of

employee stress.

In such cases “dissonance” and a personal crisis can occur.

An example is illustrated in the following formal employee harassment complaint that “Maps”

causes through a multi-level perspective from outcomes at the Transactional Level, to causes at

Governance Level, then the Referential Level. See Diagram 15.



Diagram 15. Human Activity System (HAS) Map of an Employee Workplace Harassment

New employee to team with history of

providing new ideas that improve services

Human Activity System Map

Purpose: Identify causes of workplace harassment complaint

Outcomes

Transactional Level

Governance Level

Referential Level

Management Employee Work Group

Long term employees in an established team, providing

consistent service

Inexperienced manager with attention on senior

management relationships

Work group rejects suggestion

Employee raises a suggested improvement to group work practices

Work group criticises employee and makes repeated fun of a

disfigurement

Improvement suggestion raised with manager in front of an

executive, who supports the idea.

New idea implemented into work group by manager

Employee informally raises harassment concerns

Manager dismisses and ignores employee

concerns

Employee raises formal harassment complaint

No regular meetings or planning meetings with work group to address work issues

New employee to team with history of providing new ideas

that improve services



5. Maturity of Health and Safely Systems, and Tort.

From Commissions of Inquiry into H&S related issues, such as accidents, it can be seen that multi-

levels of perspective are taken in examining and assessing the evidence. This is illustrated through a

number of AcciMaps and supporting publications around AcciMaps published by Hopkins [31]. In

this document those differing multi-levels of perspective found in AcciMaps are reflected in the

Referential System Approach, such as in Diagram 11 and 15 HAS Maps.

In the AcciMaps of Hopkins a “but for” approach is used to analyse serious accidents and develop

their cause and effect relationships across the different multi-levels of perspective within the

AcciMaps. The “but for” rational is that it is also applied in law to work out liability based on Tort

[32]. This “but for” legal liability for accidents can be traced through multi-level perspectives in the

Referential Approach to H&S, because both AcciMaps and HAS Mapping can apply and trace causal

relationships through a “but for” (tort) analysis. Alternatively HAS Maps can be developed using a

“why-because” analysis across the multi-level perspectives [33].

This article also proposes that the Health & Safety System Approaches applied in supporting

organisational H&S can be viewed as building up from a Transactional System Approach, with a

particular transactional perspective level, through to the Governance System Approach with a

particular governance level perspective (and also includes the Transactional System Approach

perspective), to the Referential System Approach where its perspective includes all perspectives

from the other Health and Safety System Approaches.

Beyond this is the manner in which the multi-level perspectives of the Referential System Approach

also supports employee wellbeing by identifying and addressing “dissonance” and crises issues they

face through an Interpretive System Approach.

From this it could be argued that the “maturity” of organisational H&S relates to which Health and

Safety System Approaches they apply. This highlights two points, that:

The “maturity” of an organisation’s H&S can be assessed based on what Health and Safety

System Approaches are applied;

An organisation’s potential tort liability can be tried to be addressed through the application of a

Referential System Approach or an organisation can take a higher risk by not recognising and

addressing its liability exposure by managing H&S through limited or no use of Health and Safety

System Approaches.



Conclusion

H&S is associated, historically, with the way organisations perceive and manage themselves using

one or more Health and Safety System Approaches. Different Health and Safety System Approaches

can also be viewed as developing across four “ages of work” during the last century in the western

world: From industrial; to technological; to knowledge Ages, as illustrated in Diagram 4.

Through Health and Safety System Approaches several aspects about H&S can be recognised:

Health & Safety System Approaches, progressively and systemically, extend addressing H&S from

the immediate, tangible and direct (“sharp end”) workplace H&S issues that effect people, to

include (“blunt end”) organisational Health and Safety Management support that are indirect

and intangible influences such as priorities and values on H&S;

Health and Safety System Approaches are Human Activity Systems (HAS). HAS integrate and

include three system Types: Natural Environment; Human Designed; and the Psychosocial

systems.

The Transactional, Governance, Referential, and Interpretive Health and Safety System

Approaches each reflect a different perspective, or paradigm, in thinking about H&S. H&S

improves by adding and integrating the different Health and Safety System Approaches, as each

adds a different level of H&S perspective until creating multi-level perspectives. In this sense an

organisation’s level of maturity in health and safety can be reflected based on which Health and

Safety System Approaches (and perspectives) are applied.

Health and Safety System Approaches, overall, include considering both a “unitary” (i.e.an

organisation focus) and a “pluristic” one to address “dissonance” and crises affecting individuals

and groups.

Because later Health and Safety System Approaches (e.g. Referential and Interpretive) are not widely

understood there is a very real question regarding the “maturity” of Health and Safety System

Approaches applied by organisations, and through this their level of risk exposure, and their ability

to manage tort liability at senior management levels: Those who are accountable for organisational

H&S.



Notations

[1] The Eurofound Dictionary provides explanations and definitions for the term Health and Safety. Ref http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety.htm [2] Safe System of Work Division 2.2 Clause 19(3)(c) Work Health & Safety Act 2011 Ref http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf and Safe Systems of Work (p2) Ref http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OF-WORK.pdf [3] An OH&S Risk Assessment can be found in How to manage work health and safety risks from Safe Work Australia. Ref http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Manage_Work_Health_and_Safety_Risks.pdf [4] A Safety Management Systems explanation is provided by Safe Work Australia. Ref http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManagementSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf [5] References to specific Health & Safety Management Systems from a Wikipedia on Safety Management Systems. Ref http://en.wikipedia.org/wiki/Safety_management_systems and OHSAS 18001 Occupational Health and Safety from the bsi group. Ref http://www.bsigroup.com.au/en-au/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS-18001/ AS/NZS 4801 Safety Management Systems. Ref http://www.ncsi.com.au/as-4801-OHS-Certification.html The 5 Star Health & Safety Management System and others are discussed in Pomfret In Occupational Health and Safety Management System Auditing. Ref http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf [6] SafeMap . Ref http://www.safemap.com/english/cb_safety.html and Beyond the behaviour-based safety plateau . Ref http://pipeliner.com.au/news/beyond_the_behaviour-based_safety_plateau/067203/ [7] Armson in Growing wings on the way: Systems Thinking for messy situations (p 134) sates “A system is a collection of elements connected together to form a purposive whole with properties that differ from those of its component parts”. Also “A system can be defined as “a set of objects together with relationships between the objects and between their attributes” (Hall & Fagen, 1969, p. 81) referenced by Hollnagel in Modelling of failures: From chains to coincidences (p 8). Ref http://www.resist-noe.org/DOC/Budapest/Keynote-Hollnagel.pdf [8] Armson in Growing wings on the way: Systems Thinking for messy situations (p 215) indicates, in simple terms, that a system can be viewed as containing three aspects, as shown in this template “A system to do < what> by means of <how> in order to contribute to achieving <why>” this template is exampled in the text. [9] In terms of Terminology covering “Hazard and Risks in the workplace”; “Hazard”, and “Hazard consequences” is provided in ref http://www.engica.com/engica-terminology.aspx

http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety.htm


http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf

http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OF-WORK.pdf


http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Manage_Work_Health_and_Safety_Risks.pdf


http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManagementSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf


http://en.wikipedia.org/wiki/Safety_management_systems

http://www.bsigroup.com.au/en-au/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS-18001/



http://www.ncsi.com.au/as-4801-OHS-Certification.html


http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf

http://www.safemap.com/english/cb_safety.html

http://pipeliner.com.au/news/beyond_the_behaviour-based_safety_plateau/067203/


http://www.resist-noe.org/DOC/Budapest/Keynote-Hollnagel.pdf


http://www.engica.com/engica-terminology.aspx



[10] In Practical Soft Systems Analysis (p8) Patching states Human Activity Systems are “systems where humans are undertaking activities that achieve some purpose. These systems would normally include other types, such as social, man-mad, natural systems.” [11] The explanation of what “Systems Approaches” means is based on, and adapted from, the Flood & Jackson book Problem solving: Total System Intervention (1991, p 32) and technically equates to the terms “Systems Thinking Approaches”. [12] In Diagram 3 the four H&S System Approaches can be variously considered as a Framework or illustrating differing perspectives or paradigms or domains, or “ways of thinking”. There is some resonance in this diagram’s explanation of the difference in H&S System Approaches to Dave Snowden’s Cynefin in that both can be viewed as different forms of sensing in that there is a brief reference to “Categorise & Act”, “Analyse & Act”; “Probe & Act’; “Sense & Act” though clearly there are differences to Cynefin’s “Sense Making” Domains, refer to The Origins of Cynefin. Ref http://cognitive-edge.com/uploads/articles/Origins_of_Cynefin.pdf . [13] Hollnagel in Resilience Health Care slide 7 outlines Three Types of Accident Models over time and the explanation within this article is intended to be consistent with this. Age or time is not necessarily the key factor, rather that certain industries arose at different times in the Western world that is reflected in the time lines and these industries have influence on H&S Approaches that are considered relevant. Ref http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf [14] There are a number of fairly typical risk assessment processes that can be accessed. Two have been drawn on in this paper as they provide additional supporting information. The Risk Management Process of the Northern Territory Government ref http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf and Safe Systems of Work of the Footwear and Leather Industries ref http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OF-WORK.pdf [15] There can be variants in the formatting of a H&S Risk Assessment Matrix. This example is from the Queensland Government, Department of Education, Training and Employment document “Health & Safety Risk Assessment Template” issued in August 2012 ref http://bit.ly/1bcCqm7 [16] The Domino Effect is described in this paper as a linear causal chain that results in an accident. The term originally has more specific causal factors based on the Domino Theory by Heinrich. Ref p5 in A Review of Accident Modelling Approaches for Complex Socio-Technical Systems by Zahid Qureshi ref http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543 [17] Behaviour Based Safety programs are broadly explained on this Wiki ref http://en.wikipedia.org/wiki/Behavior-based_safety. With more detail in terms of their effectiveness in Behavioural Safety Interventions by M.D. Cooper ref http://www.behavioral-safety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf [18] Nancy Leveson in Chapter 2 of her e-book Engineering a safer world identifies the weakness and limitation of relying on event chain models for accident investigation (p36-49). https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_Safer_World.pdf [19] COMCARE have produced a booklet that covers Safety Management Systems in major hazard facilities that can be viewed as relevant to Health and Safety Management Systems in general. Ref

http://cognitive-edge.com/uploads/articles/Origins_of_Cynefin.pdf

http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf

http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf



http://bit.ly/1bcCqm7

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543

http://en.wikipedia.org/wiki/Behavior-based_safety

http://www.behavioral-safety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf


https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_Safer_World.pdf




http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=http%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafety_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouFyAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw [20] Reason developed a “Swiss Cheese” model of accident causation where accidents emerged due to holes (failures) in barriers and safeguards. The model used in this paper is an adaptation of another adaptation of the model Reason used in his publication Managing the Risks of Organizational Accidents (1998). The “Swiss Cheese “model is drawn from URL reference found here http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html [21] Nancy Leveson in her e-book Engineering a safer world explains how safety is not increased with increased H&S system reliability (p 28-35). https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_Safer_World.pdf [22] Reference to Human Activity System (HAS) can be found in Human Activity System (HAS) Mapping article by D. Alman ref http://en.calameo.com/read/0014509349aed27553fc3. [23] Work Level Referential System example is an adaptation based on Rasmussen & Svedung publication Proactive Risk Management in a Dynamic Society (2000 p 53) figure 7.3 ref https://www.msb.se/RibData/Filer/pdf/16252.pdf . To this has been added a “Contributory Factors” table, as exampled in Figure 1 Risk Management (ActorMap) Framework in Methodological considerations in using AcciMaps and the Risk Management Framework to analyse large scale systemic failures by P.E. Waterson and D.P. Jenkins ref https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/7944?mode=full [24] The ETTO Principle -Efficiency-Thoroughness Trade-Off Or Why Things That Go Right, Sometimes Go Wrong Erik Hollnagel ref http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf [25] Modeling drift in the OR: A conceptual framework for research by Richard Severinghaus, Taryn Cuper, and C. Donald Combs. Ref http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Submission.pdf [26] ‘‘Going solid’’: a model of system dynamics and consequences for patient safety R Cook, J Rasmussen. Ref http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html and The role of error in organizing behaviour by J Rasmussen ref http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf [27] AcciMaps in use by Anthony Hopkins ref http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf [28] In Root Cause Analysis: Terms and Definitions, Ladkin (p10) explains the limitations (and strengths) of AcciMaps ref http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf by Peter Ladkin. [29] Karl E. Weick The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster ref http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Organizations_The_Mann_Gulch.pdf

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=http%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafety_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouFyAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw




http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html



http://en.calameo.com/read/0014509349aed27553fc3

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDEQFjAA&url=http%3A%2F%2Fwww.msb.se%2FRibData%2FFiler%2Fpdf%2F16252.pdf&ei=aCnVUY3sLMPhkAWCvICoBQ&usg=AFQjCNHZ4VHa2njiNw6lQwS85D_l_b4JEA&sig2=ySzvRBf3_yIesSkHS87Ygw&bvm=bv.48705608,d.dGI&cad=rja

https://www.msb.se/RibData/Filer/pdf/16252.pdf

https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/7944?mode=full


http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf

http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Submission.pdf


http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf

http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf

http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf


http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Organizations_The_Mann_Gulch.pdf




[30] Sidney Dekker identified and coined the term “secondary victim” in recognising that not only are there victims as a result of an accident, but that those blamed by organisations and others can end up consequentially as “secondary victims” and in this organisations need to seek A just culture to protect employee honest mistakes from being seen as culpable. Explained in “Just culture: Balancing safety and accountability” ref http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+Accountability.pdf [31] An AcciMap of the Esso Australia Gas Plant Explosion by Anthony Hopkins ref http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf An AcciMap overview can be found in Root Cause Analysis: Terms and Definitions by Peter Ladkin at http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf . [32] “but for” test discussed with an example ref http://www.mcmillan.ca/The-Crucial-but-for-Test-in-Determining-Causation [33] Peter Ladkin in “Why-Because Analysis of the Glenbrook, NSW Rail Accident and Comparison with Hopkins’s AcciMap”, examples the application of “Why-Because Analysis” on a “But-for” AcciMap, and provides two methodologies to cross check the accuracy and adequacy of HAS Maps. In effect this means that on a HAS Map one could:

Apply a Why-Because Analysis approach to Governance and Transactional Perspective Levels;

Apply, subsequently, a Cultural – Causal Analysis to the Referential Perspective Level. Ref Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf

http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+Accountability.pdf


http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf



http://www.mcmillan.ca/The-Crucial-but-for-Test-in-Determining-Causation





References

D. Alman 2013 Human Activity System (HAS) Mapping http://en.calameo.com/read/0014509349aed27553fc3 Armson, R. (2011). Growing wings on the way: Systems Thinking for messy situations. Axminster, UK: Triarchy Press AS/NZS 4801 Safety Management Systems. URL reference http://www.ncsi.com.au/as-4801-OHS-Certification.html Eurofound Dictionary of Health and Safety. URL reference http://www.eurofound.europa.eu/areas/industrialrelations/dictionary/definitions/healthandsafety.htm Behaviour Based Safety programs Wiki URL reference http://en.wikipedia.org/wiki/Behavior-based_safety Beyond the behaviour-based safety URL reference. plateau http://pipeliner.com.au/news/beyond_the_behaviour-based_safety_plateau/067203/ But for test http://www.mcmillan.ca/The-Crucial-but-for-Test-in-Determining-Causation COMCARE Safety Management Systems in major hazard facilities. URL reference http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CF0QFjAD&url=http%3A%2F%2Fwww.comcare.gov.au%2F__data%2Fassets%2Fword_doc%2F0003%2F39387%2FSafety_Management_System.doc&ei=AczUUdDFDdCyiQfJh4HACA&usg=AFQjCNHuCyz6RYJ9hJyzI2JSzIouFyAsOQ&sig2=5wj8vL9UGlqfOLQ4LcbfEw Cook, R. Rasmussen, J. ‘‘Going solid’’: a model of system dynamics and consequences for patient safety. URL reference http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html Cooper M.D. Behavioural Safety Interventions. URL reference http://www.behavioral-safety.com/articles/behavioral_safety_interventions_a_review_of_process_design_factors.pdf Dekker, S. (2007). Just culture: Balancing safety and accountability. URL reference http://xa.yimg.com/kq/groups/18351986/1360486422/name/Just+Culture+Balancing+Safety+and+Accountability.pdf Flood, R.L. & Jackson, M.C. (1991). Creative problem solving: Total Systems Intervention. Chichester, England: John Wiley & Sons Ltd. Hazard and Risks in the workplace; Hazard, and Hazard consequences terminologies. URL reference http://www.engica.com/engica-terminology.aspx Health & Safety Management Systems Wiki URL reference http://en.wikipedia.org/wiki/Safety_management_systems Hollnagel, E. The ETTO Principle -Efficiency-Thoroughness Trade-Off Or Why Things That Go Right, Sometimes Go Wrong. URL reference http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf














http://qualitysafety.bmj.com/content/14/2/130.full.pdf+html





http://www.engica.com/engica-terminology.aspx

http://en.wikipedia.org/wiki/Safety_management_systems

http://www.abdn.ac.uk/iprc/uploads/files/Aberdeen_ETTO.pdf



Hollnagel, E. Modelling of failures: From chains to coincidences. URL reference http://www.resist-noe.org/DOC/Budapest/Keynote-Hollnagel.pdf Hollnagel. E. Resilience Health Care. URL reference http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf Hopkins, A. AcciMaps in use. URL reference http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf Hopkins, A. An AcciMap of the Esso Australia Gas Plant Explosion. URL reference http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf How to manage work health and safety risks Safe Work Australia. URL reference http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/633/How_to_Manage_Work_Health_and_Safety_Risks.pdf Ladkin, P. Root Cause Analysis: Terms and Definitions. AcciMap overview. URL reference http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinRCAoverview20130120.pdf Leveson, N.G. (2011) Engineering a safer world: Systems Thinking applied to safety. E-book URL reference https://mitpress.mit.edu/sites/default/files/titles/free_download/9780262016629_Engineering_a_Safer_World.pdf OHSAS 18001 Occupational Health and Safety. URL reference http://www.bsigroup.com.au/en-au/Assessment-and-Certification-services/Management-systems/Standards-and-schemes/OHSAS-18001/ Patching.D. (1995). Practical Soft Systems Analysis. London: Pitman Publishing. Pomfret, W. Occupational Health and Safety Management System Auditing. URL reference http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf Queensland Government, Department of Education, Training and Employment document “Health & Safety Risk Assessment Template” issued in August 2012 URL ref http://bit.ly/1bcCqm7 Qureshi.Z, H. (2008) A Review of Accident Modelling Approaches for Complex Socio-Technical Systems. URL reference http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543 Rasmussen, J. The role of error in organizing behaviour. URL reference http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf Rasmussen, J & Svedung, I. Proactive Risk Management in a Dynamic Society (2000) URL reference https://www.msb.se/RibData/Filer/pdf/16252.pdf The Risk Management Process Northern Territory Government. URL reference http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf Safety Management Systems from Safe Work Australia. URL reference http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/127/OHSManagementSystems_ReviewOfEffectiveness_NOHSC_2001_ArchivePDF.pdf



http://www.resilienthealthcare.net/RHCN_2012_materials/Tutorial.pdf

http://www.efcog.org/wg/ism_pmi/docs/Safety_Culture/Hopkins_ACCIMAPS_in_use.pdf

http://www.qrc.org.au/conference/_dbase_upl/03_spk003_Hopkins.pdf









http://www.ccohs.ca/hscanada/contributions/ohs_auditing_pomfret.pdf

http://bit.ly/1bcCqm7

http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA482543

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743771/pdf/v012p00377.pdf

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDEQFjAA&url=http%3A%2F%2Fwww.msb.se%2FRibData%2FFiler%2Fpdf%2F16252.pdf&ei=aCnVUY3sLMPhkAWCvICoBQ&usg=AFQjCNHZ4VHa2njiNw6lQwS85D_l_b4JEA&sig2=ySzvRBf3_yIesSkHS87Ygw&bvm=bv.48705608,d.dGI&cad=rja

https://www.msb.se/RibData/Filer/pdf/16252.pdf

http://www.education.nt.gov.au/__data/assets/pdf_file/0011/4106/risk_management_process.pdf





SafeMap. URL reference http://www.safemap.com/english/cb_safety.html Safe Systems of Work Footwear and Leather Industries. URL reference http://www.britishfootwearassociation.co.uk/wp-content/uploads/2011/10/SAFE-SYSTEMS-OF-WORK.pdf Severinghaus, R. Cuper, T. & C. Combs, D. Modeling drift in the OR: A conceptual framework for research . URL reference http://scs.org/upload/documents/conferences/autumnsim/2012/presentations/mpms/4_Final_Submission.pdf Snowden, D. The Origins of Cynefin. URL reference http://cognitive-edge.com/uploads/articles/Origins_of_Cynefin.pdf Swiss Cheese model. URL reference http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html Waterson , P.E. & Jenkin D.P. Risk Management (ActorMap) Framework in Methodological considerations in using AcciMaps and the Risk Management Framework to analyse large scale systemic failures. URL reference https://dspace.lboro.ac.uk/dspace-jspui/handle/2134/7944?mode=full Weick, K E. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. URL reference http://www.nifc.gov/safety/mann_gulch/suggested_reading/The_Collapse_of_Sensemaking_in_Organizations_The_Mann_Gulch.pdf Work Health & Safety Act 2011 Division 2.2 Clause 19(3)(c). URL reference http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf

http://www.safemap.com/english/cb_safety.html







http://dkv.columbia.edu/demo/medical_errors_reporting/site/module2/swiss-cheese-model.html





http://www.legislation.act.gov.au/a/2011-35/current/pdf/2011-35.pdf



About the author

David Alman lives in Brisbane, Queensland, Australia, and is the business owner of Proventive Solutions, which offers services in Organisational Health. Organisational Health is a broad overview term that refers to assessing and improving performance and well being of both an organisation and its employees, recognising there is a nexus between the two.

Further explanation through various articles, blogs, slides, on different subjects can be found on Proventive Solutions at WordPress, along with contact details. Please refer to: http://proventivesolutions.wordpress.com/2012/07/13/about-proventive-solutions/ This article is part of a body of work on Systems Thinking with a common base around the idea of looking at, and addressing, situations through different “Perspective Levels”. Other articles in this body of work include: Multilevel System Analysis: An introduction to Systems Thinking at http://www.slideshare.net/davidalman/multilevel-system-analysis and http://en.calameo.com/read/001450934d8a5a5d9b090 Human Activity Systems (HAS) Mapping at http://www.slideshare.net/davidalman/human-activity-system-has-mapping and http://en.calameo.com/read/0014509349aed27553fc3

http://proventivesolutions.wordpress.com/2012/07/13/about-proventive-solutions/

http://www.slideshare.net/davidalman/multilevel-system-analysis

http://en.calameo.com/read/001450934d8a5a5d9b090

http://www.slideshare.net/davidalman/human-activity-system-has-mapping

http://www.slideshare.net/davidalman/human-activity-system-has-mapping


Business

Health & Safety System Approaches