How well poised is an organization with near incident-free performance for adapting to changing risks? Is stellar incident performance indicative of adaptive capacities to the management and containment of its risks?
This upcoming 2008 study summary, including Sid Dekker as co-author, explored these questions in a chemical company; via what they called a “resilience engineering safety audit”.
Some key findings where that, despite this company having near incident-free performance:
· Was ill-equipped to handle future risks and many well-known future problems
· Constant trade-offs and sacrificing decisions were made by staff every day between production and safety
· For workers, these trade-offs resulted in workarounds (like not donning PPE in order to save time) and some incidents weren’t even considered as incidents; rather being “normal side-effects of daily work”
· Safety was often borrowed in order to meet acute production goals – these trade-offs were seen as a source of professional pride where people could “reconcile the irreconcilable”
· An “internalisation of external pressures” was found, where the multiple competing goals of production goals, economic pressures, cost goals had to be managed by people simultaneously as best they could
· A worker relayed how they would pre-fill forms to avoid non-conformances
· There was also a normalisation of daily risk – where many types of incidents weren’t reported, nor were even seen by workers as an incident. Examples included acid in the eyes or skin burn
· Moreover, the departures of procedures was also normalised, where these processes operated more as “guidelines instead of fixed and mandatory rules”
· In other instances, the “sheer number of procedures or manuals made it impossible to follow them”
· The company was observed to have a poor cycle of learning. For one, it didn’t have a structured learning process following incidents that spread across the whole company
· Operators were required to use the Intranet to find out info on events, and even then the official reports didn’t tell them all of the info that they wanted to know
· As far as how the organisation learns from failures – no active and structured way was observed, and instead people were required to remember the events and details; hence, the responsibility of corporate learning was left with individuals
· As the paper observed “Organizational learning from incidents was fragmented into small organizational or production units without a companywide learning”
Ref: Huber, S., van Wijgerden, I., de Witt, A., & Dekker, S. W. (2009). Learning from organizational incidents: Resilience engineering for high‐risk process environments. Process Safety Progress, 28(1), 90-95.
Safety & Performance Research Summaries 
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