AEE 2022 Conference

Applying Systems Thinking for Risk Management & Harm Mitigation: Understanding Safety I and Safety II

Workshop Description

Effective risk management requires understanding what went wrong when an incident occurs (Safety I) and what is going right that prevented incidents (Safety II). Modern Safety Science utilizes both approaches to optimize safety of any program. This workshop will focus on Rasmussen’s System Thinking approach to risk management by applying incident data analysis techniques to determine the Contributing Factors and Mitigating Factors in a complex system. Participants will gain practical experience in applying a Systems Thinking through small group analysis of an incident case study, how to build AcciMaps, and discuss how to apply these techniques within their own organization.

We’ll use the Risk Assessment & Safety Management (RASM) framework as an entry point to analyze contributing factors in an incident and develop the response plans for mitigation strategies to reduce risk. From there we will explore the Systems Thinking approach of Jens Rasmussen for the range of contributing factors that can occur both inside and outside of an organization. We’ll use case studies to examine these concepts in detail, both a well-known sample accident, and participants will be able to analyze their own accidents.

Participants will learn how to use a causal taxonomy for relating contributing factors and build an AcciMap, a graphical representation of the interactions between contributing factors. The next stage of the workshop will be exploring the basic concepts represented in Safety II – that is how positive operations and practices prevent accidents from occurring. Rather than only looking at “what we do after the bad thing happens and how we keep it from happening again”, participants will also learn to focus on “what’s working now.” In this section participants will assess positive safety/mitigation factors that prevented an accident from occurring and build a PreventiMap, a graphical representation of the interactions between risk prevention factors. Finally, we’ll wrap up by exploring the impact all of these factors have particularly identifying those areas where organizations have significant levels of control to create change (in scope), and those areas where organizations do not have much control (out of scope). This will help programs focus on the best in scope risk management strategies. 

Goals

• Participants will learn how a comprehensive incident data reporting system combined with causal factor analysis will identify risk trends and mitigation strategies.
• Participants will develop an understanding of the Systems Theory model of risk management and how to utilize Safety 1 approaches post-incident and Safety 2 approaches pre-incident.
• Participants will learn to use the Systems Thinking Model to determine which factors that are ‘in scope’ allowing actionable steps to be implemented or ‘out of scope’ limiting organizational response.
•  Participants will walk away with concrete tools to carry out their own incident analysis and implement a data-driven approach to managing safety.