Erik Hollnagel
Abstract: Safety is usually seen as a problem when it is absent rather than when it is present, where accidents, incidents, and the like represent a lack of safety rather than the presence of safety. To explain this lack of safety, one or more causes must be found. In the management of industrial safety, the human factor has traditionally been seen as a weak element; human error is often offered as the first, and sometimes the only cause of lack of safety and human factors have since the early days offered three principal solutions, namely training, design, and automation. Of these, training has considerable face value as an effective means to improve human performance. The drawback of safety training, however, is that it focuses on a single system component, the human, instead of on the system as a whole. Safety training further takes for granted that humans are a liability and focuses on overcoming the weakness of this specific component through simplistic models of what determines human performance. But humans may also be seen as an asset which changes the focus to strengthening how a complex socio‐technical system functions. A socio‐technical system comprises multiple functions that must be finely tuned in order to ensure expected and acceptable performance. Since systems cannot be made safer without developing effective ways of managing the conditions in which people work, system tuning offers an alternative solution to an old problem.
Keywords: system perspective; functional analysis; human factors; Safety‐II
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