Trapping Safety Into Rules

In the picture below you'll find a scan of the review I wrote of this book for the magazine of the Dutch Society of Safety Science, NVVK Info. This was published there in the May 2014 issue.

The English translation goes roughly like this:

Trapping Safety Into Rules

edited by Corinne Bieder and Mathilde Bourrier (ISBN 978-1-4094-5226-3)

My current employer has a very fine internal library that contains a decent selection of books on safety. The fine ladies in the library also alert professionals to new releases that aren’t in the collection yet, but may be wanted in future. The title of this book immediately caught my attention when it was mentioned in a newsletter and that very day an order for a personal copy went out.

On 278 pages the book presents a collection of 15 articles, plus an introduction and epilogue by the editors. The contributions are based upon experiences within various branches: (mainly Norwegian) offshore, air traffic control, railways and patient safety, and there are also some more theoretically oriented contributions. The fact that the book is a collection of articles slightly affects the coherence and flow (even though I’m pleasantly surprised by the fact that the contributors refer to each other’s contributions quite frequently) and in some cases also the readability suffers. Some authors just seem to have a hard time ditching the academic approach to writing that they forget that books should be easy to read. A listing of references that fills an entire paragraph is just nonsense and should have been caught and removed by the editors.

The book’s title might suggest that the book has a critical stance with regard to (safety)rules, but as the subtitle ‘How desirable or avoidable is proceduralization?’ indicates the book highlights both sides and discusses both the pros and cons of safety rules in four different parts with the following headers:

1: Where do we stand on the bureaucratic path towards safety?

2: Contrasting approaches to safety rules

3: Practical attempts to reach beyond proceduralization: The magic tools illusion

4: standing back to move forward

The subjects discussed in the book are too varied to cover in a full overview here, so let me pick out some highlights. In part 1 we find among others an interesting discussion of ‘No rule, no use’. This is an attitude that almost any safety professional will have met at some time (or even regularly). A safety measure may be wise to implement, but never the less the question arises: “Where does it say that we have to do this?”. Ergo, quite often without a rule saying so, one does not implement a safety measure.

In the second part especially Kenneth Pettersen’s discussion about abductive thinking appealed to me. Me discusses this from a background in airplane maintenance. Mechanics often manage in doing their jobs and dealing with unexpected situations because they deviate from rules. The standard rules often aren’t helpful to solve unique problems, so one has to deviate. This is one of the most interesting contributions in the collection and more or less mandatory reading.

Part 3 is the most voluminous part of the book. It discusses a number of attempts and experiences with possible alternatives to traditional rules and regulations. The first two contributions are from medical care and are about the use of checklists in operation rooms -what I’m missing here is the nuance that a (good) checklist in fact is little more than a very smartly written procedure - and about crew resource management in hospitals. After that we get two little exciting articles about safety management (systems) and their influence on procedures in air traffic and railways.

Much more exciting are no less than three articles about regulations and safety culture with a background in Norwegian offshore where elements of safety culture are implemented in laws and regulations over the last decades. This phenomenon is regarded with a critical eye amd among other things the authors discuss how far it is possible to steer and regulate safety culture. Especially chapter 13 is interesting with its argumentation why regulators should leave safety culture alone and rather stick to rules.

The final part contains only two articles of which the first deals with the paradox role that procedures apparently have in safety management, because they on one side are a means to transfer knowledge and prescribe a safe way of doing a job, but on the other hand they may also cause rigidity and ‘auto pilot behaviour’. The final article by Todd La Porte has some interesting view on the differences between administrative and operational safety rules. Of special interest is the anecdote about the aborted exercise on an aircraft carrier and the praise that the “culprit” (the sailor who had made a mistake, but reported this immediately upon discovery) received from the highest ranking officer.

In the epilogue both editors stress once more that rules are affected by the way they are created (preferably bottom-up, although also this is no guarantee for a good rule) and that one before creating a new rule must ask oneself the question what the added value of a rule will be. One of the leasons to be learned from this book.

Published by Ashgate (www.ashgate.com)

Antifragile - a review (or two, sort of)

In the picture below you'll find a scan of the review I wrote of Taleb's latest book, Antifragile, for the magazine of the Dutch Society of Safety Experts, NVVK Info and was published there in this month's issue.

The English translation goes roughly like this:

Antifragile - Things That Gain from Disorder, by Nassim Nicholas Taleb 

(ISBN 9780141038223)

While I was reading this book - during the days around Christmas 2013 - a major storm ravaged northern and western Europe. At one point my wife asked “What is that book about, anyway” and the perfect illustration of my answer presented itself in all newspapers the next morning: hundreds of thousands of households in Norway, Sweden, The Netherlands, Germany, France and The United Kingdom were without electricity. How much easier could you want for an example to explain the concept of a fragile system? Some systems are so much optimalised that they work smoothly in the normal situation (in Taleb’s vocabulary ‘mediocristan’), but as soon as an event of certain impact (unexpectedly, or dismissed as not probable) manifests itself, the vulnerable system collapses as a house of cards. The system is fragile and breaks, often with catastrophic consequences.

Those who have read Taleb’s last book, the bestseller and masterpiece “The Black Swan”, will notice that “Antifragile” picks up things where Taleb stopped the last time. The new book is the closing part of a trilogy that started about ten years ago with “Fooled By Randomness”. In “Antifragile” Taleb tries primarily to provide some strategies that enable us to cope with the fragility of systems - on one hand by assessing if something is fragile, or is made fragile by decisions that are made, and on the other side by discussing possibilities to make things (more) antifragile.

Taleb use a triad, or three different states, to illustrate the point. The first state is fragile: things break as a consequence of shocks, disorder or time. One example is an e-book that depends if your reader has enough power. The second state is robust: things are insensible to shocks (until a certain level), like an ordinary book that usually “works”. Finally there’s antifragile: things that do profit from disorder, like an oral delivery which goes from mouth to mouth and often only wins fantasy. For some this may seem strange; after all in common understanding it’s robust that is used as the opposite of fragile, but Taleb aims at another kind of opposite: not the difference between braking and not breaking, but between being harmed by and benefiting from something.

It’s likely that the reader has to get used to Taleb’s use of language and his jargon. He had a couple of specific “own” words (for example ‘fragalista’ which he uses as a label for people who advance fragility - often named, like the president of the Federal Reserve) or terms which he uses to characterize a certain phenomenon (“soccer mom”). This also applies to his style of writing. Taleb likes to stroll, and it shows in his books. This is no scientific academic report or paper (luckily it isn’t!) but a continuous discussion and reflection where the author switches from one subject to another. Sometimes he returns to a subject, sometimes he doesn’t. The contents may vary from seriously technical or mathematical stuff to fantastic or just every day reflections.

The language is flowery and at times outrageous. Taleb is erudite with a preference for the Classics and we’ll know this! All of this is coupled to an enormous waywardness and a certain arrogance (he doesn’t shy back of kicking seriously against the established order within among others economy en science). This may be a certain threshold for some readers. With that in mind it’s a relief that one doesn’t need to read everything. Some parts of the book can be skipped without any problem and without missing part of the message. In fact, on various occasion the author even indicates that a part can be skipped.

One may question how relevant this book is for safety professionals since there is only a limited discussion of ‘real’ safety subjects in the book (Fukushima as one example of fragility is a rare exception). My opnion: definitely relevant. Taleb’s books are about uncertainty and risk, about the thinking about risk and about decision making (with all kinds of consequences). This alone makes the book (and definitely its predecessor) almost mandatory reading.

Do note that this is by no means a ‘Do Book’ that will lead you to an antifragile state (presuming that this is possible and desirable) within 7 Steps. Reading the book can, however, help to create awareness and start a process. To this end it is necessary that each reader picks out relevant elements for himself and translates those to his own every day practice (domain blindness is one returning theme, by the way). Examples are fragility enhancing things like naive interventionism (the urge to implement measures that are likely to be unnecessary which may cause unwanted side-effects that in fact cause a worse situation) and agency problems (decisions taken or advocated by people who will profit in some way from that decision).

On the positive side Taleb discusses a number of tools that may help to enhance robustness or even gain antifragility. To name but a few: the principle of redundancy (preferably applied aggressively because in a time of scarcity one can gain a lot from your own abundance) even though it’s despised by economists and bean counters, optionality (making use of opportunities when they present themselves), flexibility, using heuristics (practical mental rules of thumb that make the everyday life easier) and allowing some hormensis in our lives and organizations (some disorder and stress is necessary to make things stronger, like not always washing your hands before diner can enforce your immune system and is thus healthy...).

One other thought that struck me while reading the book is that Taleb’s fragile/antifragile thinking unwillingly manages to combine two safety theories that are often regarded as opposites within the same framework. I’m obviously talking about Perrow’s Normal Accident Theory (fragile, Black Swans) and the antifragile concepts of High Reliability Organisations (Weick & co) and Resilience (Hollnagel, Woods etc.). For safety professionals it may be confusing that Taleb on several occasions says that antifragile and resilience (to him synonymous to robust) aren’t the same thing, while elements that “we” (safety professionals) range within the resilience framework are seen by Taleb as antifragile elements. A matter of definition, I think, and don’t let that stand in the way of gathering some useful lessons from this book.