The New View is fundamentally the application of systems thinking to workplace health and safety. It considers safety an emergent property of the system (see graphic 1). So what does that jargon mean? It means that instead of focusing on an individual condition, action, procedure, near miss or incident, the organization steps back and takes a broader view, by considering the many factors that interact to produce the incident or near miss.
Understanding how work gets done
Front-line workers are always trying to adapt work and balance a number of often conflicting goals such as productivity, efficiency, quality, and safety in an ever-changing workplace frequently burdened by resource constraints. They inherit the output of many organizational processes. Some of the processes are excellent while others may be deficient for a variety of reasons. Front-line workers generally make the system work despite process shortcomings. This adaptive behavior and unique expertise is an essential resource for safety as well for the success of the organization.
The graphic helps to clarify the distinction between how work is planned and how it is actually performed. The way work is planned or imagined is represented as the straight black line. But is this the way work is performed?
When asked, workers normally shake their heads and respond “no” because they are constantly adapting to make the system work as mentioned above. Understanding how work is actually performed - the blue line - is critical to operational and organizational learning, successful work and workplace safety. Organizations accomplish this by implementing learning teams, no-fault incident and near miss reporting systems, pre-task planning, post-task debriefs and discussions with workers.
How the New View adapts to risk assessments
These fundamental concepts influence how risk assessments are performed as well as how audits, inspections and investigations are conducted. The emphasis is on learning how the system and processes work - the interaction of the parts in graphic #1.
With respect to risk assessment specifically, each organization should consider graphic #2 and ask the question, are our risk assessments based on the black line or blue line? If they are based on the black line they may be extremely deficient because context factors like goal conflict, production pressure, staffing and other factors are not taken into account.
Risk assessments conducted under the New View are based on a much deeper understanding of work systems and produce much more robust controls or defenses.
Similarly inspections, audits and investigations are transformed from “safety police” activities to learning processes. The scope is broadened beyond safety because those doing the work are always trying to balance a variety of factors that occasionally may be in conflict such as safety, quality, productivity and schedule.
New View concepts are not just safety concepts but rather system and process concepts that apply universally to all aspects of the organization. As such, implementation of the New View automatically builds collaboration between departments - between those doing the work and those managing and leading the organization.
Sustainable organizations of the future will be those that best learn from both success and failure and understand their processes. The New View is a great foundation for achieving these goals.
How the New View applies to system improvement
The new view is the best among available approaches because the concepts and methods apply universally to system improvement rather than only to safety. Almost every learning team convened to address a “safety” problem results in a broad array of improvements. We need to transition from a mental model that considers safety separate from the overall system to one this recognizes safety is just a part of the overall system and influenced by many factors.
That’s why driving out fear, responding to failure in a positive and constructive manner, stepping back and understanding the context of normal work and the organizational factors that influence it are so fundamental to building this holistic understanding of our organizations.
How the New View applies incident analysis
Under the New View, incident investigation is transformed to incident learning by:
- Beginning incident learning around understanding “normal work” (the blue line) -- how the work is typically performed -- and then in a sense “recreating” events as they unfolded moving toward the event to offset the impact of hindsight bias. This contrasts with traditional approaches that start with the event and work backward looking for the root cause that accentuates hindsight bias.
- Recognizing that how the organization responds to failure matters – a lot!
- Emphasizing learning and not blame.
- Focusing on “how” rather than “‘why.”
- Applying a systems view and considering all of the factors that influenced the event rather than a single person’s action, component or condition.
- Recognizing that human error is not intentional but rather a symptom of error likely situations that must be addressed.
- Identifying performance modes to ensure that the appropriate category of defense is selected.
Applying the New View to regulatory compliance
Thoughts contributed by Bill Hoyle, Retired, Senior Investigator, U.S. Chemical Safety Board
Prescriptive regulations such as those used by OSHA can never keep pace with ever-changing workplaces and increasing complexity. Some advanced countries use rule-making approaches that focus on the duty to evaluate changes in the understanding of hazards with the goal of continuously lowering risks. Use of safety management systems and New View thinking is essential for use both in company good practices and by regulators.
Reducing serious injuries and fatalities
The New View has grown out of and has been successfully implemented in several high-risk sectors such as energy, the military, wild land firefighting and health care. These sectors and many others have recognized the importance of learning about processes by taking advantage of collective knowledge in a blame-free environment.
