(c) Erik Hollnagel, 2022
The meaning of the noun synthesis (from the ancient Greek σύνθεσις) is the unification or combination of two or more entities that together results in something new; alternately, it may mean the activity of creating something out of something else that already exists. The meaning of safety synthesis is similarly the system quality needed to ensure that a system is able to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. (This is obviously a paraphrase of the definition of resilience in Resilience Engineering.) This is however not a natural and stable condition, but an artificial and potentially unstable one.1 Safety is, with a paraphrase of Weick’s terminology, a ‘dynamic event’, hence something that must be created constantly and continuously. The basis is that which makes up everyday work and everyday existence. The synthesis of that, the bringing together of what individuals and organisations do on all levels and over time, is what creates safety – at least until a better term has been adopted.2 This synthesis has two different forms, a synthesis across organisational levels and a synthesis over time.
The synthesis across levels is relatively easy to explain. It means that one must understand the dependencies or couplings between everything that happens in an organisation or when carrying out an activity, no matter which levels of the organisation or types of work are involved. And it is of course necessary that the people who do the work understand that themselves, i.e., that the synthesis is part of what everyone does or at least that it is recognised by them.
The synthesis over time is more difficult to explain, but no less essential. In many kinds of activities – probably in all – synchronisation is important. This certainly goes for industries where safety (whether as Safety-I or as Safety-II) is a concern; it goes for services; for communication; for production – not least if it is lean - and so on. Synchronisation is achieved by organising the various productive processes to avoid delays (outputs arriving too early or too late), to ensure a better use of the resources (for instance, doing things in parallel so that the same preconditions do not have to be established twice), to coordinate transportation of matter and energy between processes and sites, and so on.
But synchronisation is not the same as synthesis. A synthesis - and thereby synesis - is first achieved when we understand how things really fit together, when we understand the variability of everyday performance (the approximate adjustments), and how this variability may wax and wane, leading to outcomes that mostly are as intended, hence beneficial but sometimes are unintended and potentially detrimental. A temporal synthesis cannot be achieved by exploring pairwise combinations of functions, even if it is done exhaustively. Neither can it be achieved by a bottom-up approach. Instead it requires a genuine top-down, synthetic perspective in the sense of being able to see (perhaps by serendipity rather than by combinatorics) when something new and useful has been achieved. Safety synthesis or synesis is the constant creating and maintenance of conditions that allow work to succeed on all criteria taken together.
According to the conventional interpretation of safety, here called Safety-I, safety denotes a condition where as little as possible goes wrong, the focus of practical efforts whether in management or analysis is therefore on the occurrence of unacceptable outcomes and on how to reduce their number to an acceptable level, ideally zero and the emphasis is on how to manage safety eo ipso, as seen in the ubiquitous safety management Systems (SMS).
This approach, however leads to somewhat of a paradox since Safety in this way is defined and measured more by its absence than by its presence, as noted by Reason, (2000). According to a Safety-I perspective an accident thus represents a situation or a condition where there is or was a lack of safety. Which immediately raises the obvious question of how it is possible to learn about something if it only is studied in situations where it is not there?No known sciences can do that-- except safety science!!! And furthermore how is it possible to manage something that is not there? The simple answer is that it is impossible! THE UNACCEPTABLE OUTCOMES THAT SAFETY MANAGEMENT FOCUS ON ARE THE RESULTS OF SOMETHING THAT HAPPENED IN THE PAST,BUT DOES NOT HAPPEN ANY LONGER IT CAN THEREFORE NOT BE MANAGED!!!-- While you can manage a process you cannot manage a product.These paradox fortunately disappears in the view proposed by Safety-II, where safety is defined as a condition where as much as possible goes well. An acceptable outcome therefore represents conditions where safety is present rather than absent, and efforts are accordingly directed at understanding how this happens and how one can ensure that it will happen also in the future. Logically, if as much as possible goes well, then as little as possible goes wrong,since in practice something cannot go well and go wrong at the same time. A Safety-II approach therefore achieves the same objective as a Safety-I approach, but does so in a completely different way. In Safety-II the concern is not to manage safety as a static outcome, hence using safety as a noun but to manage system performance safely, as a dynamic process, hence safely as an adverb. There is a crucial difference between managing safety and managing safely. The former represents a cost, since the purpose is to avoid something rather than to achieve something, while the latter represents an investment that directly contributes to productivity as well as increased revenue. It is therefore clearly more important and useful for a company to manage safely than to manage safety.
Since most work and most activities in practice go well, even though we fail to pay attention to them there will also be more cases to study sand learn from. Best of all, perhaps is that there is no need to wait for something to happen, i.e., to fail or go wrong. Something is happening all the time all we need to do is to pay attention to it
Reason, J. (2000). Safety paradoxes and safety culture. Injury Control & Safety Promotion, 7(1), 3-14.