Workshop on Safety-II in Practice

Florida, February 25-27, 2019

Sunday, February 24
5:00 – 7:30 PM Welcome Reception and Registration
Lobby - Ground Floor Hyatt Place Downtown Saint Petersburg
Monday, February 25
Main Conference Room Level 5 Hyatt Place
6:30 – 8:30 AM Breakfast Main Lobby for Hotel Guests
7:30 – 8:30 AM Registration Main Conference Room
8:30 – 9:15 AM Welcome Presentation – Creating Value Introductions, Wednesday Breakout Sign Up Sheets, Why we are Here, Present State of Safety, Current Breakdowns in Learning, Opportunities for this Workshop, Why Industry needs Safety-II.
Presenters: Tom McDaniel and Entire Design Team
9:15 – 10:00 AM Introduction to Safety-II
A general introduction to what Safety-II and what it isn’t.
Presenter: Dr. Erik Hollnagel
10:00 – 10:30 Break
10:30 – 11:30 AM Theme I: The Implications of Safety-II for reporting and analyzing significant events

The focus of Safety-I is on adverse outcomes, primarily accidents and incidents. These are diligently analyzed in order to determine their causes so that these can be eliminated as far as possible (cf., Theme III). The focus of Safety-II is on the successful accomplishment of a task or an activity, on how things go well. Since these events are useful, they should be supported and augmented rather than eliminated.

Presenters: Ron Gantt, Tom McDaniel, and Design Team Support
11:30 – 12:15 PM Case study: Human Performance Contributions to Safety in Commercial Aviation.
Presenter: Jon Holbrook
12:15 – 1:15 PM Lunch Hyatt Lobby
1:15 – 2:00 PM Theme II: The implications of Safety-II for performance measurements.

KPIs Performance measurements serve several purposes. One is to know how well an organization (a department, a group, etc.) does as part of assessing the status and progress made (cf., Theme V). The other is to be able to compare performance to a norm or reference or to rank organizations relative to each other. Performance measurements in Safety-I have mainly been in terms of unwanted outcomes (accidents, incidents, working days lost, etc.). Since the essence of Safety-II is that as much as possible goes well, we need meaningful performance measurements that can further that purpose.

Presenters: David Provan, Tom McDaniel, and Design Team Support
2:00 – 2:30 PM Case study: Accommodating Different Identities – A Pathway to Resilience.
Presenters: Jim Marinus, Lisa Lande & Kevin Jones
2:30 – 3:00 PM Break
3:00 – 3:15 PM Safety-II in Practice, A view from the Front Line
Presenter: Jeff Lyth
3:15 – 4:00 PM "Translating Qualitatively Identified Drivers of Safety II from an ICU to Other Microsystems in a Children’s Hospital"
Presenter: Thomas Bartman, M.D., Ph.D.
4:00 – 4:30 Open (structured) discussion
Moderator: Chris Nemeth
Q&A based on questions collected during the day
7:00 – 9:00 PM Evening Session - Healthcare Issues
Presenter: Dr. Terry Fairbanks
Tuesday, February 26
8:30 – 9:00 AM Open Discussion on Current Attendee Issues
Presenters: Jeff Lyth, Beth Lay – Design Group Support
9:00 – 9:20 AM Safety-II in Practice – The view from Healthcare
Presenter: Dr. Terry Fairbanks
9:20 – 10:00 AM Theme III: The implications of Safety-II for learning (organizational and individual)

The focus of learning in Safety-I has been on accidents and other things that went wrong in order to eliminate their causes and thereby prevent them from occurring again. Learning is therefore based on random cases where the organization did not function, as it should. Safety-II proposes that learning should be proactive and continuous and serve to ensure that work goes well, hence to increase safety, productivity, and quality at the same time. Learning must therefore include the significant events that make work go well (cf., Theme I).

Presenters: Dr. Terry Fairbanks, Ron Gantt. Design Group Support
10 – 10:30 AM Break
10:30 – 11:00 AM Case Study: Information Visualization as a Driver of Safety-II.
Presenters: Sudeep Hedge, Aaron Z. Hettinger & Ann M. Bisantz
11:00 – 12:00 Theme IV: The implications of Safety-II for standards, guidelines, and procedures.

Standards, guidelines, and procedures (SG&P) are needed by people who are responsible for the work of others at a distance (such as managers, regulators and authorities). SG&P should enable people at the sharp end to do their work as well as make them aware of possible risks and hazards. In Safety-II, SG&P are not just a feeble guarantee against “unsafe practices” but provides a constructive way to ensure that work goes well. This has important consequences for how SG&P should be developed and implemented (cf., Theme V).

Presenters: Beth Lay, David Provan, Jeff Lyth
12:00 – 1 PM Lunch
1:00 – 2:45 PM Theme V: The implications of Safety-II for managing and developing an organization (S-II as a management principle)

Managing and developing an organization can be likened to steering a vessel. In order to succeed it is necessary to know the current position (cf., Theme II), the target or goal, and how to change the organization so that it develops in the right direction and with the right “speed”. While there are many theories and models that help us “understand” how organizations fail, there are few that can be used constructively to bring about genuine performance improvements. Safety-II provides a comprehensive basis for management of organizational safety and beyond.

Presenters: Erik Hollnagel, David Provan
2:45 – 3:00 PM Case study: Is the SMS an Adequate Framework to Support Safety-II?
Presenter: Daniel Slattery
3:00 – 3:20 PM Break
3:20 – 4:00 PM Open (structured) discussion

Moderator: Peter Hancock
Q&A based on questions collected during the day
Conclusions and the way forward
Design Team: Tom, Ron, Erik, David, Beth, Jeff, Terry
7:00 – 9:00 PM Evening Session - TBD
Wednesday, February 27
8:30 – 2:00 Sacrifice Decision Workshop

We often work in the space of degraded conditions (anomalies are omnipresent) but we need to notice when to back off or slow down, as conditions are increasingly degraded. In this workshop, we will explore generalized principles and patterns of resilience and trade-offs using the Oroville Dam Spillway event case study and a NASA Space Station event roll-play simulation. Learn practices to improve response to the unexpected including noticing weak signals and making decisions under uncertainty. Apply Safety II and Resilience Engineering to your safety organization to increase their contribution to managing significant emergent risk.

Tom Seager, Sustainable Engineering and Resilient Infrastructure, Arizona State University
Daniel Eisenberg, Research Assistant Professor, Naval Post-Graduate School
E. Asher Balkin, Ohio State University
Beth Lay, Director Safety and Human Performance, Lewis Tree Service
David D. Woods, Ohio State University
David Provan, Griffith University
Mike Rayo, Ohio State University
Chris Hansen, Manager, Extravehicular Activity Office, NASA, JSC
Steve Gawenis, Space Station Mission Planning and Operations Manager, NASA, JSC
Chris Nemeth, Principle Scientist, Applied Research Associates
2:30 - 4:00 Creating Adaptive capacity – panel discussion / workshop

Safety II and Resilience Engineering claim adaptive capacity is necessary for successful work but neglect to explain what adaptive capacity is and how to get more of it. In this workshop, we will discuss varieties of adaptive capacity and strategies for increasing adaptive capacity. Workshop participants will be asked to share their practices for increasing adaptive capacity.

Facilitator: David Provan
Mike Rayo, Ron Gantt, Beth Lay
In collaboration with Tarcisio Abreu Saurin