(c) Erik Hollnagel, 2020
On Monolithic Explanations
The preference for single and simple explanations seems to be a common trait in the human quest to understand what goes on. This can be found in all fields of activity, politics, ethics, law, biology, history, finance, and of course in industrial safety. In this case it is easily illustrated by the well-known proposal for three stages of safety thinking. Each stage was dominated by a single type of cause – technology, human factors, and organisational culture, respectively – which throughout the stage was accepted as the likely explanation for whatever went wrong. In other words, people used a single explanation, a single cause, or a single solution to solve a host of problems. Solutions, or explanations, of this nature can be called monolithic, in the sense that the constitute a single idea, a single concept - a unitary explanation so to speak.
Monolithic explanations are attractive because they appear to solve two problems at the same time. The first problem is to find a workable solution to the current problem so that we can be safe. The second problem is to set the mind at ease so that we can feel safe. In cases where we cannot actually be – or become – safe because we do not have an articulated understanding of why things happen, we can at least try to feel safe – or try to make others feel safe – even though it may mostly be an illusion. This is not least the case for the current favourite among monolithic explanations – Complex Adaptive Systems.
Monolithic explanations are used in two different ways. One is to explain (adverse) outcomes as due to the presence of some cause. The other is to explain (adverse) outcomes as due to the absence of some cause. In each case the cause is seen as the only, or at least the dominating, reason why something has happened. Examples of the former use are human error, workload, fatigue, etc., illustrated by statements such as “the accident was due to human error”. Examples of the latter use are “situation awareness” and “safety culture”, illustrated by statements such as “the accident was due to a lack of safety culture”. (As an aside, human factors people have shown remarkable ingenuity in inventing causes where their absence could explain why something happened. In other words, a contrafactual conditional.)
Monolithic explanations represent a social convention, almost – or exactly – like an ETTO. They are efficient because they offer a single and simple solution to a problem, but they are by the same token not thorough. This leads to the idea that safety culture, much like safety itself, is a social construct. (A social construct is an idea or notion that seems obvious or even inevitable to people who accept it but which on closer inspection is essentially a mutually accepted invention of a community or social group.) Causes are clearly social constructs. This is the case for simple physical causes, since they represent first stories. And stopping after first stories is a social agreement or construct. But it is also the case for more complicated explanations, especially when they refer to something intangible such as a human error or a sociological (or organisational) phenomenon such as an 'X' culture..
Monolithic explanations are characteristic in safety thinking but can obviously be found elsewhere – if not everywhere. In relation to safety, it is necessary to keep in mind that monolithic explanations are an inextricable part of Safety-I. The focus on adverse outcomes and the practical and psychological need to find their causes naturally favour single and simple explanations. In relation to safety-II, where the focus is on understanding why and how things go well, there is little if any need of monolithic explanations. In the case of safety culture, for instance, it is clear that it does play a role in human and organisational performance – even if there is no clear understanding of how. But it is equally clear that it cannot be the only explanations or the only cause. Human and organisational performance is determined by many different factors, interests, and motives. Some of these are transient and change from moment to moment while others are more stable and may play a role across a variety of situations and conditions. Accounting for the dynamics of human and organisational performance, not least over extended periods of time, is a challenge to Safety-II and to the management of organisations in general. Resilience engineering and synesis, among others, try to answer that challenge, but not by reducing it to a question of finding yet another monolithic explanation.
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.