The Two Towers of Safety: Be Safe, Act Safe

When it comes to safety there are two schools of thought. The oldest one is focused on behavior and its by-line is, "Act Safe." This is the domain of Behavior Based Safety or BBS and has been around for many years and has contributed significantly to improving occupational safety. However, a major problem with this approach is the tendency to blame the person should an incident or mishap occur. This results in workers not wanting to report incidents or even near-misses, and who would blame them for not wanting to under a climate of fault finding.

The second school of thought focuses on systems and processes and its by-line is "Be Safe." This is the realm of Human and Organizational Performance or HOP. This is relatively new and parallels the work in process safety management. The goal is to use systems and processes to create the conditions for people to be safe. In a manner of speaking, this approach reduces risk so that individual behaviors are less likely to cause an incident. This approach is also not without its problems as it can sometimes lead to "blaming" the system and loss of accountability for human action. Nevertheless, HOP has helped to address systemic safety issues that would otherwise not be addressed by human behavior alone.

There has been much debate in recent years as to whether HOP will replace BBS or whether they will merge into one approach, or even turn into something new altogether. It is my belief that both are needed as they deal with two different aspects of safety and here is why.

Root Cause Analysis

Dean Gano, the creator of the Apollo Root Cause Analysis method [2][3], goes back to St. Thomas Aquinas (13th Century Philosopher) to help us to understand the nature of cause and effect. Aquinas writes that the existence of potency (i.e. capability) cannot reduce itself to act. As an example, "the copper cannot become a statue by its own existence." For that to happen you need a sculptor to act on the copper to make it into a statue. In other words,

for an effect you need both a condition and an action.

In fact, an effect needs a prior cause and that cause needs both a condition and an action and so on. This leads to the conclusion that a cause and an effect are the same thing. This distinction is an important one and one that is often lost when using other methods for attempting to discover the "rootiness" of a cause.

Rationale mapping and functional modelling enhanced root cause analysis [1]

The point that I would like to highlight is that at every branch (see previous Figure) in the analysis you always have at least one condition and one action. A condition by itself is not enough and neither is an action. This is where the two schools of safety come in.

Without the presence of a risky condition (the focus of HOP) an adverse effect is less likely to occur no matter what the action might be (of course there are exceptions). Similarly, risky actions will not be a problem if there are no risky conditions. You cannot have an explosion without bringing an ignition source (the action) into the presence of a flammable gas (the condition).

The consideration of both actions and conditions is helpful to understand why we might need both the benefits of an effective BBS based program to address behavior as well as a HOP based approach using systems and processes to create safer conditions.

However, we cannot so neatly put everything into one of the camps or the other. The two towers need to work together. The Apollo Root Cause Analysis would have us look for a prior condition and action for every behavior and a prior condition and action for every condition. To put it another way, each camp needs to be resident in both towers.

Perhaps, this might suggest that the two towers might indeed become one and using methods like the Apollo Root Cause Analysis might help to integrate the two schools of thought.

Until then, no matter what approach you choose,