Barriers Trilogy - final installment

The third part of our Barrier Trilogy can now be read on SafetyCary's blog.

Please keep coming with your feedback!

Gerd Gigerenzer – Reckoning With Risk, Learning To Live With Uncertainity

A quite interesting and enjoyable book that I accidently picked up while strolling through the University book store at NTNU. Most books on risk in my bookshelf are either safety or finance oriented, Gigerenzer takes his examples from the medical (mammography, HIV testing) and justice (DNA finger printing, court evidence) worlds, which is interesting and nice for a change.

While I don’t subscribe to Gigerenzer’s very strict (and in my opinion limited) definition of ‘risk’ as uncertainty that can be expressed as a number (a probability or frequency), it’s very worthwhile to read the book and I support his statement that people have to overcome their illusion of certainty and gain proper insight in uncertainty and risk. The book may be an eye opener to many. I have always been sceptical about a lot of statistics, but after reading “Reckoning With Risk” I will be even more so. I guess concepts like base rate frequency, false positives and natural frequencies are now glued to my brain forever.

On a critical note – safety experts may want to comment the DASA example on pages 28/29 (both views about measuring safety mentioned here are due for criticism) and the “Why most drivers are better than average” chapter  (page 214-217) where the author oddly replaces the question of “who is the better driver” with “who has less accidents” without noticing (or explaining) himself. There may be a connection between “better” and “less accidents”, but that relations goes one way (better, thus less accidents), not backwards from (less accidents, thus better).

In connection to this book I’d recommend one also checks out Paulos’ “Innumeracy”.

I’ve read the Penguin paperback edition ISBN 978-0-14-029786-7

Note: In the USA this book has been published as “Calculated Risk”

Barrier Trilogy - Part 2

Proudly presenting the second part of our Barrier Trilogy. Feedback of any kind is HIGHLY appreciated since it only can help to improve the method.

Missing something?

Me too. But some recommendations aren't meant to be. Such is life.

Risk Perception

A Barrier Trilogy, part 1

Read it on Safety Cary's blog. Comments and discussion is highly welcomed!

Working at height in the middle of Oslo

Looking out the window, preparing a course... when a subject for an exercise in risk assessment present itself.

Willem Top: How To Build A Management System That Works

Willem Top is kind of a legend in safety - at least in The Netherlands and Belgium. When I started in the safety profession in 1992, my first major course was Safety Auditing and an induction in the International Safety Rating System (ISRS) from DNV. At the course I was given two books, “Risk/Loss Control Management” and “Safety Auditing”, both written by Willem Top and both of which have been used from one time to another during the past 20 years of my professional career.

Now Willem has collected some of the knowledge and experience he has gathered in his long career as a professional and bundled it in this e-book. I’m no particular fan of e-books (love to read from paper and highlight/comment on the printed version) but at least this saves some space in the bookshelf.

On 200 pages Willem delivers an easy to read, practical and rather unpretentious view on how a management system (regardless the scope, even though he comes from a safety background the book is rather holistic) can be built with the help of a number of basic elements/principles. Willem himself calls it a “travel guide” rather than a “cook book”.

At first one may get a perception that Top concentrates very much on avoidance of losses, reading on in the book one discovers that he very much promotes the use of positive drivers, call it leading indicators if you want, in order to reach this goal.

Some people will criticize the culture-as-system approach that seems to be promoted on page 29, but Top is quick to apply an important nuance. He knows his limitations, being a chemical engineer and no psychologist and he stresses some of these limitations throughout the e-book.

The proposed elements for the management system sound sensible. Sure, I would have made a slightly different cluster than Top’s 17 steps, but that’s quibling over details in definitions. The elements discussed are essential. On a critical note, the PLAN, TRAIN, DO model that Top promotes does in fact contain check/evaluate and improve steps, but these are a bit hidden in the model. I would propose to follow Deming’s PDC(S)A.

What I like is that Top stresses the fact that a management system can be written down, but in some instances also done orally, or just through actions and giving the example. This might be an eye opener for quite a few. Especially with the ISRS in the back of my mind which I always perceived as very solid and complete, but also as very bureaucratic. Willem Top addresses another drawback of the ISRS (without actually naming the ISRS) namely the rating, which may become a goal in itself, thereby prioritizing elements that gain points and neglecting essential elements that create control. He does propose an alternative rating for his 17 step approach as a measure for implementation.

A benefit of this rating system is that Top listed the desired state properties of the various steps (at least some of them) which guides the assessment further than just a simple yes/no tick-list-of-requirements. And whether you use the rating or not, it is a fine (check)list of points to consider when building and implementing your management system.

You can order this e-book directly from the author. Check Willem Top’s website:

http://www.topves.nl/contact.htm

Rob Long: For The Love Of Zero

The second book by Rob Long is mainly dedicated to dismantling the “Zero Harm Cult”, its language, its way of thinking and possibly negative effects. The book has a lesser degree of “hopping through” than the first and (I think that) it’s rather meant to read from start to end. While the book is divided in three sections, there are two main parts, the first concentrating on the “zero” phenomenon while the second part (chapters 7 onwards) deals with alternative strategies.

The book opens with a discussion of the fascination with ‘zero’ in general. One may dispute the relevance of several examples, but at least it’s amusing. The second chapter discusses some of the arguments pro and contra ‘zero harm’ and also shows some of the more extreme forms of use of ‘zero harm’ language, where ‘zero harm’ has begun to replace central and essential safety terminology like ‘risk’. A dubious trend, to say the least.

An interesting twist to some already known arguments against ‘zero harm’ is that Rob Long discusses it in relation to psychological disorders and fundamentalism. The entire chapter 6 is dedicated to the latter and one may criticize Rob mildly for the fact that he goes slightly overboard here and provokes a comment that he’s a bit of a fundamentalist himself (an anti-fundamentalist-fundamentalist, so to speak). Rob also spends ample time on the (negative) consequences of ‘zero harm’ language.

While the discussion of ‘zero harm’ is very thorough, other themes are treated a bit shallow, like Rasmussen/Reason’s SRK-model of human error and Heinrich’s pyramid (and in that case entirely missing the value of that metaphor, i.c. learning from weak signals). The discussion of HRO and Risk and Safety Maturity on the other hand is most interesting.

Very worthwhile are pages 48 and 49 with the essentials of motivation that elaborate on themes discussed in “Risk Makes Sense”. Most valuable in my opinion are the parts on good goal setting which are found in chapter 5, 7 and 8, especially underlining the importance of positive goals.

One drawback of the book is that there is a certain degree of repetition from “Risk Makes Sense”, some parts are even literally copied. So I wouldn’t recommend reading them too closely after each other (unless you want to save some time and are able to skip/skim some sections).

A third book in the series, “Real Risk”, is in the making. Regarding the contents of the first two books that should be one to watch out for!

ISBN 978-0-646-58765-3

Available from: http://www.humandymensions.com/

Dr. Robert Long and Joshua Long: Risk Makes Sense

The last few days were usefully spent on reading the Long’s first book “Risk Makes Sense”. Already the title appealed a lot to me as I’m (like the authors) convinced that a life without risk is impossible - and really boring too.

The book is handy, about 150 pages and rather accessible and easy readable. The book aims at a wider audience than just HSEQ experts, and deviates from a typical text book build-up too because instead of building up to one major conclusion, the chapters can be read separately and learning points picked up all over the place. One should be able to hop through the book like one surfs the net.

On a critical note – at some moments the text feels a bit fragmentary, or hopping between subjects. I think some things could have been explained a bit better or more extensive for the un-initiated. I had no problem following the book, but then, I’ve read quite a lot literature which makes it easy to place various references in context. Not everyone has this backing when reading the book and I think that might give a few minor hurdles for some readers.

One of these instances is where the idea of one brain and three minds is posed. I understand what the writers say, but I would like to see in greater depth where it comes from. I would also like to see this concept discussed in relation to Rasmussen’s/Reason’s SRK-model and Kahneman’s two systems. Robert informed me that several subjects will return in later books where more will be explained.

One thing that makes it easier to read the book for un-initiated is a brief glossary found at the start of the book. This gives a good and quick framework for what is about to come. Another thing that makes the book easy accessible are the transitional paragraphs between the various chapters. Each chapter is concluded with some questions for workshop use (or reflection and further ‘home’work). Excellent idea to give a bit extra to the book.

The book draws (among others) a lot of inspiration from Weick’s work on HRO and the concept of mindfulness he proposes. Since I’m a major fan of this approach it’s a big thumbs up there!

The first chapter concentrates on myth busting. Quite an interesting take on some widely entrenched beliefs here. Throughout much of the book you’ll find a well-founded and well-reasoned trashing of the zero cult. I’m looking forward to read more of that in the second book (which seems to promise to do that, judging from the title). I also love the phrase ‘safety cosmetics’. This describes very well some things of what I see around in safety practioning!

In that regard it is interesting to see that the writers connect themes to religion and fundamentalism. Too much of that which is done and decided is rather based on dogma than on reason.

I like the way the writers stress learning throughout the book. That’s something we are struggling with/working on all of the time in the company I work. We had about 30.000 registrations of big and small cases (incidents, complaints, proposals for improvement etc) last year. We are relatively good at handling these, but how do you get the learning points from essential cases into as many heads/minds as possible? Challenging! Some thoughts found in this book.

I found also the angle about language very interesting. Language is one of our most powerful tools. As such it can be easily misused. I also read with interest what has been written about the art and importance of dialogue. This reminds me very much of the work and writings of my Belgian friend Johan Roels. His book on crucial dialogues (alas only in Dutch, check here) elaborates on some of the themes touched upon in “Risk Makes Sense”.

There is quite some space spent on conscious and subconscious actions in the book. Of these I find especially the argument about the counterproductive effect of a rationalist approach in the non-rational setting intriguing. I truly hope that the writers will come back to that in the two follow-up books, since I’m more than just a bit interested in the ambiguous relationship between rules and safety that has some of its origin in this phenomenon.

Off to the second book now. 

 

I've read the second edition, ISBN: 978-0-646-57094-5

P.S. One thing I appreciated a lot: the book does mention what the writer’s company does, the tools that they have developed, but the book never tends towards sheer marketing. Good job! I’ve seen many books which are mainly the vehicle to sell and I’m no fan of that practice, to say things mildly.

Meanwhile, feel free to check them out on the web:

http://www.humandymensions.com/

May The Force Be With Us!

At times I'm pleasantly surprised by the US government... Sense of humour too! Check here.

Malcolm Gladwell: What The Dog Saw (2009)

I’m a major fan of Malcolm Gladwell’s writing but this book was a slow starter for me, and at least I was a bit disappointed. Stories about chicken grills, hair dying products and the birth control pill are mildly interesting or amusing, but not the mind-tickling stuff that I have started to expect from Gladwell. This book revolves not, like his previous works, around a central theme, but rather it’s a collection of stories and articles written previously. All do have in common, however, that they are all about what goes on inside people’s minds.

The book is in three parts in which the first part, “Obsessives, Pioneers, and Other Varieties of Minor Genius” is mainly interesting because of two stories. Firstly, I finally find out about the qualities of ketchup, and more importantly why Coca Cola tastes good, and a generic supermarket cola horrible. Secondly, there’s a chapter about Nassim Taleb and black swans, which obviously had my professional interest.

Part Two is titled “Theories, Predictions and Diagnoses” and finally picks up pace and interest. Here we find stories about Enron and how it’s not a problem of disguising information, but rather how too much information makes it difficult to see the signs. Also discussed is the dilemma of tackling power-law distribution problems, seeing patterns that predict bad events in the future (which turns out to be very easy in hindsight, but is often impossible at the time), the art of failure (and the difference between choking/over-thinking and panicking) and there is even a chapter on ‘normal accidents’. The only not all that HSEQ-related story is the one about intellectual property, but that one is also very thought-provoking and not quite predictable at all!

The third part deals with “Personality, Character and Itelligence”.  Highly relevant questions are treated here. How do we know that we hire the right people if formal qualifications alone are not enough to determine if one will do a great job. And do we actually use the right method selecting them anyway – what is the value of a job interview, and how could it be done better? Criminal profiling gets a very critical treament and the ‘talent myth’ even more (Enron and their consultants McKinsey get it heavily here).

So, after initial disappointment, I believe this is a book that I will return to at some point in the future. At least to the last two thirds which are recommended reading.

I've read the Penguin paperback, ISBN 9780141047980.

Deming Cycle in JBV Style

This is an A3 "poster"/"placemat" that we use to explain HSEQ Management and some instruments to managers and other people. You'll find them all around our company on desks and wall.

Bug me sufficiently and I will do a translated (English) version. Temporary version of this below - I haven't had time yet to translate the various tools/documents of course...

Internal audits done efficiently

My personal translation of one of the great Lunsj comics - it's like the Norwegian Dilbert, but without the occasional silliness... Loads of HSEQ inspiration!

Problem solving 101 according to ISO 9001

It Really Says so...

Well, happy new year then...

Are We Blundering Our Way Through Safety?

A recommended read here. Will have to buy Zachary Shore's book myself soon...

Zero accidents = safe!

So... because nobody was hurt when this happened, this practice is perfectly safe.

Hmmm... something tells me that there's something fishy with that logic...



How to write an Academic Article - Quick Guide

If you ever have to write an academic article, follow the below guideline and you're safe:

Introduction

The following article describes the study into [insert theme] which is an important framework for [insert theory] which has been the [insert either: ‘leading paradigm in the field for the past years’, or ‘paradigm that has undergone a shift in latter years’]. This paper describes the study into [brief description here].

The Study

[Describe the metodology, research and results, use a lot of quotes and references, avoid as much as possible original research, but add some statistics and results. Use complicated words at will and sentences shall be combined into long complicated structures with many adjectives and commas. One or two scattergraphs are cool.]

Conclusion

This study has given us greater understanding of [insert theory]. More research is recommended.

Make sure the title is impossibly long and about some ridiculous detail of your research. Like: "The Influence of the Lovelife of the Madagarscar Blowfly on Safety Consciousness in a Postmodern Society within a Brownian Motion Model"

Follow APA rules for layout to make it additionally unappealing (you wouldn't want anybody accidently reading this, being publish should be sufficient).

Some thoughts... 'The' Cause (?)

The people who know me, know that I tend to reject the notion of ‘the’ cause. Let’s explore the concept a bit. I believe there are two main variations on ‘the’ cause.

1. A simple philosophy about causal relationships. Everything that happens has just one cause.

2. The elevation of one particular cause as the most important.
3. A very strict definition of the word cause

Re 1: Monocausality

I do believe in the existence of simple accidents with a straightforward linear causal sequence (and have experienced some), not unlike the one below where each effect is basically the cause of the next effect until we come to the final consequence. Working backwards from the final consequence we’ll have a continuous sequence of why - because relationships. E.g. I’m on my way out (context, not cause), change my mind and turn around abruptly only to bump into the door that closes behind me. Some cases might be that simple that causal chains even may be restricted to just one cause and one effect…

Often, however, the world is not quite that simple and causal paths develop more or less independently, only to join up at some point causing some outcome. Please see the example discussed elsewhere on this blog; I don’t see how that can be turned into one linear sequence without dismissing a number of essential factors.

Re 2: More important causes

Are some causes more important than others? In some sense, yes. Especially if one defines preventive and corrective actions to remove them one may want to focus more on one cause than on others. But that’s then ‘more important’ in the sense of prioritizing resources and actions, not ‘more important’ in a causal sense.

In a causal sense it’s a bit more difficult… Leaving aside the discussion if an underlying (or root) cause is more important than a direct cause (we may get back to that issue another day), I find it hard to say that cause A is more important than cause B because it caused the incident more than the other cause… If an investigation has established that both were necessary for the incident to happen I cannot maintain that one should be ranked above the other.

Take the lab example: both not wearing goggles and mixing the ingredients wrongly are needed for chemical substances hitting the eye of the victim. How can one be more important than the other? Sure one might argue that the wrong mixing is the point of loss of control, or the first barrier breached. But still, both are needed for the defined incident.

For now I remain unconvinced that some causes are more important than others. But please supply viewpoints of your own.

Re 3: Strict definitions

Some define the word cause very strictly, for example by only allowing a deliberate act, or discarding conditions as causes (see elsewhere). Or by limiting the meaning to the direct cause (which in effect boils down to option 1). The added value of this isn’t quite clear to me so far - apart from eventual legal use… or as an alternative for what I often would call a direct cause (like in the lab example). But my opinion on the value may change as discussion progresses and knowledge grows…