We can then distinguish three broad approaches to the management of risk each with its own characteristic approach. Each one has given rise to an authentic way of organising safety with its own characteristic approach and its own possibilities for improvement (Grote 2012; Amalberti 2013). In practice the distinctions may not be that clear cut but the division into three models serves to illustrate the principal dimensions and factors in play (Box 3.1).
Box 3.1 A Note on Terminology
We have chosen three terms to describe contrasting approaches to safety: ‘ultra-adaptive’, high reliability and ‘ultra-safe’. All of these terms, particularly the first two, are associated with a number of theories and concepts. In this book we use these terms in a more descriptive sense. ‘Ultra-adaptive’ simply means that this approach relies heavily on the judgement, adaptability and resilience of individuals; ‘high reliability’ does indeed reflect the literature on high reliability organisations (HROs), but here is mainly meant to indicate a flexible but prepared response of teams in the management of risk; ‘ultra-safe’ refers to the absolute priority safety has in those environments and to the means of achieving such safety.
Embracing Risk: The Ultra-adaptive Model
This approach is associated with professions in which seeking exposure to risk is inherent in the activity and often also embedded in the economic model of that profession. Skilled professionals sell their services on the basis of their expertise and willingness to embrace risk, master new contexts, cope and win through, reaping benefits where others fail or are afraid to go. This is the culture of champions and winners, and there are of course those who fail to meet the challenges or who are injured or die in the attempt. This tends to be explained in personal terms; they did not have the knowledge or skill of the champions; they did not have the ‘right stuff’ to be part of these elite groups (Wolfe 1979). Deep sea fishing skippers, for example, are willing to seek out the riskiest conditions in order to catch the most profitable fish at the best times. Such professions are very dangerous and have appalling accident statistics. They are not, however, insensitive to the risks they run. They have safety and training strategies which are very well thought-out, but they are highly reliant on individual skills and strongly influenced by their own particular culture.
Within the ultra-adaptive model individual autonomy and expertise take precedence over the hierarchical organisation of the group. In many cases the group is very small (consisting of two to eight individuals) and works in a highly competitive environment. The leader is recognised for technical ability, past performance and charisma more than his official status. Everyone involved has to use a high degree of initiative. Skill, courage and accumulated experience combined with a clear-eyed awareness of personal strengths and limitations are the keys to recognition as a good professional. Success is seen in terms of winning and surviving, and only winners have a chance to communicate their safety expertise in the form of champions’ stories.
To summarise, there are a small number of procedures, a very high level of autonomy and a very large number of accidents. Becoming more effective and learning to manage risk are achieved by working alongside experts, learning from experience and increasing one’s own capacity to adapt and respond to even the most difficult situations. The differences between the least safe and the safest operators within a single resilient, skilled trade are of the order of a factor of 10; for instance the rate of fatal accidents in professional deep-sea fishing varies by a factor of 4 between ship owners in France and by a factor of 9 at the global level (Morel et al. 2009). This suggests that that it is certainly possible to make progress through safety interventions within this particular model of safety; there may however be a limit to what can be achieved without moving to a different model of safety which in turn would require a radically different approach to the activities concerned (Amalberti 2013).
Managing Risk: The High Reliability Approach
The term high reliability or high reliability organisation (HRO) is most associated with a series of studies of industries in which highly hazardous activities, such as nuclear power and aircraft carriers, were managed safely and reliably. A very wide variety of characteristics were identified as characterising high reliability organisations but all were underpinned by a disciplined but flexible approach to teamwork (Vincent et al. 2010). This approach also relies heavily on personal skill and resilience but in a more prepared and organized way; individual initiative must not come at the expense of the safety and success of the wider team (Weick and Sutcliffe 2007).
This approach is also associated with hazardous environments but the risks, while not entirely predictable, are known and understood. In these professions risk management is a daily affair, though the primary aim is to manage risk and avoid unnecessary exposure to it. Firefighters, the merchant navy, operating theatre teams, and those operating chemical factories all face hazards and uncertainty on a daily basis and typically rely on a high reliability model.
The HRO approach relies on leadership and an experienced professional team, which usually incorporates several different roles and types of expertise. All members of the group play a part in detecting and monitoring hazards (sense making), bringing them to the attention of the group, adapting procedures if necessary, but only when this makes sense within the group and is communicated to everyone. The HRO model is in fact relatively averse to individual exploits that are outside the usual repertoire of the team. The resilience and flexibility of approach employed is that of a dynamic and well-coordinated team rather than that of an individual acting on their own. All members of the group show solidarity in terms of safety objectives and the team promotes prudent collective decision-making.
The teams who work within this model place great importance on analysing failures and seeking to understand the reasons behind them. The lessons drawn from these analyses primarily concern ways in which similar scenarios could be managed better in future. This is therefore a model which relies firstly on improving detection and recovery from hazardous situations, and secondly on improving prevention – which means avoiding exposure to difficult situations when possible. Training is based on collective acquisition of experience. Once again, the differences between the best operators and those that are less good within a single trade are of the order of a factor of 10.
Avoiding Risk: The Ultra-safe Approach
With this approach we turn radically away from reliance on human skills and ingenuity towards a reliance on standardization, automation and avoidance of risk wherever possible. Professionalism in these contexts still requires very high levels of skill but the skills consists primarily in the execution of known and practiced routines, covering both routine operations and emergencies. Ideally, there is no need to rely on exceptional expertise even when dealing with emergencies, such as an engine fire on a commercial aircraft. Instead comprehensive preparation and training allows all operators to meet the required standards of performance and be skilled to the point that they are interchangeable within their respective roles. This approach relies heavily on external oversight and the control of hazards which makes it possible to avoid situations in which frontline staff are exposed to exceptional risks. By limiting the exposure to a finite list of breakdowns and difficult situations, the industry can become almost completely procedural, both when working under normal conditions and under more difficult conditions. Airlines, the nuclear industry, medical laboratories and radiotherapy are all excellent examples of this category. Accidents are analysed to find and eliminate the causes so that exposure to these risky conditions can be reduced or eliminated in the future. Training of front-line operators is focused on respect for their various roles, the way they work together to implement procedures and how to respond in a prepared manner to any emergency, so that there is minimal need for improvised ad hoc procedures. Once again, the best and the least good operators within a single profession differ by about a factor of 10.Footnote 1