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Abstract. Australian general aviation accident data show pilots who conduct operations into adverse weather, when against the rules, remain as a significant cause of fatal accidents. This paper presents the background, methodology, and results of a theory of planned behavior (TPB) elicitation study, which extracted key psychological beliefs of aircraft pilots in such circumstances. The present study established a psychometric survey instrument with items that are valid and reliable, to then further explore the TPB psychological constructs concerning the intentions of pilots when presented with adverse weather. Given the principled deliberations associated with rule-related behavior, the project explores an extension of the TPB by investigating the addition of two psychological constructs – personal norms and anticipated affect and their power to provide a discrete contribution and improved explanation of variance.

Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent ‘inconvenient truths’ that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture–based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

Objective: Matching safety and quality improvements to the complexity of healthcare, Gold Coast Mental Health and Specialist Services implemented a new response to clinical incidents: the Gold Coast Clinical Incident Response Framework (GC-CIRF). It utilises a Restorative Just Culture (RJC) framework and Safety II principles. This paper evaluates its impact.Methods: Staff surveys measured perceptions of just culture and second victim experiences. Quality of recommendations were compared before and after implementation. For the 19 incidents that occurred after the implementation of GC-CIRF, audits of the review processes were undertaken, measuring several components.Results: Results show significant improvement in staff perceptions of just culture and second victim experiences. Review of incident review data showed several shifts in line with Safety II and RJC. The process audit demonstrated inclusion of a broad range of stakeholders, and significant improvements in the quality and strength of recommendations.Conclusions: Embedding RJC and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels.

The safety profession has grown and evolved over recent decades, and despite the prominence of the role within organisations, there is limited research about the current state of safety professional practice. The objective of a safety professional’s role is often stated as ‘preventing incidents and harm to people', although the existing research fails to demonstrate a compelling link between safety professional practice and worker safety. More recently, a model of safety work in organisations proposed that safety activities fulfill broader social and political needs, in addition to the physical reduction of safety risk. In this paper, we report a study that investigated the underlying objectives of individual safety professional tasks, then performed thematic analysis to explore the contemporary role of safety professionals in organisations. 12 mid-level and senior-level safety professionals were interviewed at monthly intervals for six months regarding their work activities, in addition to an embedded researcher performing more than 240 h of field observations. Four categories of safety work in organisations – demonstrated, social, administrative, and physical – were used as priori themes to deductively analyze the data. The findings demonstrate strength of alignment between the safety professional role and line management, the increasing institutionalization of safety professional work, an absence of safety professional work directed at reducing safety risks to workers, and the lack of a clear connection between safety professional practice and safety science research.

More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by operators when managing abnormal and emergency situations in highly complex sociotechnical systems. The model was reviewed a decade later and only a few studies have applied it to aviation. This paper proposes adjustments to the original model, based on recent theoretical developments and empirical evidence on the anomaly management activity in aviation. The model was divided into five components; three of which—activity, types of reasoning involved, and resources—were revisited and further developed. The two other components—fault behaviour and unit of analysis—were not updated and only discussed in the aviation context. As a result, the revisited model descriptively clarifies how the activity of anomaly management emerges from the use of a wide repertoire of strategies, involving a spectrum of types of reasoning and a set of resources for action, which are not limited to those anticipated by designers, such as checklists and the warning system. An instantiation of the revisited model highlights the implications of false alarms, which trigger a cascade of disturbances that, in turn, requires adaptive strategies based on heuristics and analogies and supported by pilot’s experience. The revisited model can support a more accurate analysis of anomalous situations and the redesign of work systems to achieve a better performance.

This paper presents a conceptual framework for learning from investigations of work-related musculoskeletal disorders based on the literature. The framework is used to identify the strengths and weaknesses of current practices in 19 large Australian organisations, in comparison to recommended practice in the literature. The study involved semi-structured interviews with 34 employees responsible for investigating reports of WMSDs. The findings show that current practices are highly variable both within and across organisations, and that reports of minor injuries due to work tasks (i.e. pain, discomfort) are unlikely to be investigated. While some practices that may enhance opportunities for learning were identified, they tended to occur based on individual skills and experience. Participants also reported significant challenges in implementing recommendations to address WMSDs following investigations. Overall, the findings suggest that in large Australian organisations, investigation processes for WMSDs are not aligned with recommended practice in the literature, and that insufficient resources are available to translate any potential lessons into effective prevention activities.

Explorations of everyday work involve the study of work-as-done. A framework for such explorations, developed empirically in various industries (resources, energy, explosives), is presented in this chapter. It consists of four modes that relate to work as it is “described,” “generalised,” “assumed” and “desired” by different groups of relevant stakeholders. This takes it beyond current characterisations of work-as-imagined versus work-as-done. This chapter briefly discusses the development and use of the framework, offers examples of the types of insights the framework provides, and discusses opportunities for applying the framework and exploring everyday work.

As safety practitioners we often struggle with how to interpret and apply safety research into our environments, how to truly engage our workers, and how to positively influence our safety culture. This session shows how shifting focus from safety culture to developing a learning culture may provide a better pathway. We show how realigning our investigation processes to Learning Reviews is moving us away from assumptions of human error and blame and is developing a new language and shared understanding toward a safety differently approach. Since people create safety, we show how we engage the front line to identify what works and what doesn’t, using focus groups and influence mapping as a guide to the creation of cultural interventions.

A strong prevention bias in safety thinking doesn’t offer a robust understanding of the complexity of high consequence events. Despite the best risk assessments, procedures, and people, we simply cannot prevent all incidents. We must instead balance prevention efforts with capacity to respond and recover when things go badly. But how do we promote this concept within our operations? This session offers a model we are using as a simple visual framework to stimulate dialogue and promote learning, shared understanding and safety differently language. The model is an adaptation of the bow-tie as a propeller. It includes preventive, operational and recovery elements placed in a dynamic mode, represented by turning blades – within a margin of manoeuvre sphere. On one side of the bow-tie, prevention efforts deter threats, while on the other side capacity to respond to events reduces impact. The centre represents operational activity and an event moment. This is also the moment when workers recognize anomaly and make sense of the information, learn in the moment, and innovate a change to the system. The bow-tie is depicted inside a sphere of influence representing margin of manoeuvre. Positive influences create outward force, maintaining a buoyant sphere. Negative influences put pressure on the system, reduce its size, robustness and even collapse it. An unbalanced bow-tie can also collapse the system. When we conceptually shift from bow-tie to propeller, the model becomes dynamic, demonstrating how learning creates a feedback loop to improve the entire system- including preventive, operational and response/recovery components.

Over the past decades, government safety management regulation has been driven by deregulation, simplification and organization-level regimes of inspection. So-called functional rule-making requires organizations to implement safety management systems appropriate for their operations. The paradox that seems to have arisen is that overregulation is common in many organizations. Research has found over-proceduralization, safety clutter, bureaucratic overload, and procedures not at the service of safety. To explore the paradoxical relationship between governmental deregulatory measures and organizational overregulation, we analyze empirical data from Norwegian fish farming and coastal transport. The data confirms that practitioners experience a rapidly grown abundance of internal rules and protocols, ill-fitting procedures, and pervasive, exaggerated safety management. We trace three mechanisms that have driven internal overregulation: work auditability; managerial insecurity and liability; and audit practices. These mechanisms show how functional regulation can have unintended consequences when it meets other accountability expectations. Expectations of market doctrine, bureaucratic entrepreneurism and control can lead a company transforming simple governmental regulations into vastly overcomplicated safety management systems. We conclude our study with prescriptions of how this aspect of safety could be done differently. Available online 21 April 2020 0925-7535/ © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/)

In this paper, we provide a description of a previously unlabelled and under-theorised problem in safety management – ‘safety clutter’. Safety clutter is the accumulation of safety procedures, docu...

When an accident occurs, the treatment of workers afterwards can have a significant impact on learning within the organisation. This in turn is a key influence on the organisation’s capacity to deal with future risk. The style of the accident analysis process chosen can have a considerable influence on the outcomes of the analysis and the treatment of those involved. In this paper, we report on a study into the design, introduction, and eventual sun-setting of a restorative justice process. The study found that restorative justice mechanisms can improve honesty, engagement and learning. However, the study also found that factors external to the formal accident response process have a considerable influence over the perception and execution of restorative justice. Successful management of these factors is important for realising the benefits of restorative justice for workplace accidents.

Safety professionals have been working within organizations since the early 1900s. During the past 25 years, societal pressure and political intervention concerning the management of safety risks in organizations has driven dramatic change in safety professional practice. What are the factors that influence the role of safety professionals? This paper reviews more than 100 publications. Thematic analysis identified 25 factors in three categories: institutional, relational, and individual. The review highlights a dearth of empirical research into the practice and role of safety professionals, which may result in some ineffectiveness. Practical implications and an empirical research agenda regarding safety professional practice are proposed.

In high-risk industries such as construction, mining and energy, subcontractors play an increasingly significant role. A typical arrangement is for the site owner to hire a principal contractor who in turn hires multiple subcontractors. This means that multiple subcontractors from multiple companies can be working on the same site at the same time. There is evidence that the use of subcontractors is not only increasing, but that the accident rates for subcontractor employees are higher than those of operator/site owner employees. Existing research on subcontractors, which focuses on the role of the prime contractor in selecting and managing subcontractors, fails to explain why subcontractors continue to experience higher rates of serious injury even where subcontractor management systems are in place. The purpose of this paper is to understand how and why employees of subcontractors’ experience safety differently from employees of principal contractors. The paper does so by extensively reviewing the applicable literature and reporting on a cross-industry focus group study.

A key theme in safety is the investigation and improvement of work processes and conditions. This is built on a tradition of studying accidents, but there is growing interest in the investigation of everyday work. Researchers have started using terms such as success, normal and everyday work investigations, but behind these can be different activities. This paper makes explicit some considerations behind investigations of everyday work, how these considerations shape an investigation, and how they reflect different schools of thought. These considerations can be used as an aid for designing everyday work investigations for safety and serve as a first step towards critical reflection on investigating everyday work.

This paper discusses the literature that shows that declaring a zero vision for everything bad (including unsafe behaviours, incidents, injuries) does not prevent fatalities or major accidents. In ...

This paper traces Zero Vision as a product both of Enlightenment thinking (particularly in its aim to perfect humanity and society through measurement, science and rationality) and a continuation of traditionally religious promises that deliverance from suffering is achievable and morally desirable. It then explores how a Zero Vision might look in the twenty-first century, focusing on a limitation on top-down, rule-driven, centrally governed control over safety outcomes in the pursuit of zero; a switch to looking for and understanding our successes, rather than our shrinking number of failures; and a suggestion that secular organizations can commit to an alleviation of suffering as a morally acceptable and practically doable substitute for its eradication.

Chapter 10 continues the focus on the sorts of things that can be found and fixed in an organization before they can create or contribute to an accident. Encouraging organizations to build a ‘good’ safety culture is the logical continuation of this trend. Safety culture has given organizations an aspiration, getting leaders and others to think about what they want to have rather than what they want to avoid. Researchers and practitioners became concerned with specifying what is necessary inside an organization and its people to enhance safety. A functionalist approach to safety culture sees and measures it as something that an organization ‘has.’ A culture can be taken apart, redesigned, and formed. Management can ‘work’ on parts of that culture (e.g., hazard reporting, procedural compliance). It assumes that values drive people’s attitudes and beliefs, which in turn determine their behavior. The interpretivist, or qualitative, approach defines culture as something that an organization ‘does.’ It considers culture as a bottom-up, complex, emergent phenomenon; greater than the sum of its parts; resistant to reductionist analysis, measurement, and engineering. For this reason, it cannot be trained and injected into individual minds. Critiques of ‘safety culture,’ discussed in the chapter, have been targeted at (1) the normative idea that some cultures are ‘better’ than others, (2) the implication that cultures are consistent and coherent rather than full of conflict and contradiction, (3) the avoidance of any mention of power in most models of safety culture, (4) the methodological individualism that sees culture as the aggregate of measurable individual attitudes, beliefs, and values, (5) the lack of usefulness of the concept in safety regulation and investigations, (6) the lack of predictive value, and (7) the fact that the ‘container term’ of ‘safety culture’ tries to say so much that it ends up saying very little.

Resilience engineering has changed the value of expertise from meeting required standards, to how it helps organizations to adapt. This chapter discusses the origin of the concept of resilience and how it has been applied to sociotechnical systems within the safety domain. From there we review the current literature to explore how to manage expertise, considering both its possible good and bad effects, to engineer resilience into organizations. For this, the chapter looks at how this applies separately to frontline workers, teams and management, and on a systems level. While expertise generally has a positive relation to resilience on all levels, how to two relate to each other does change. This affects how expertise is best managed at different levels of an organization.