This time around I’d like to discuss two recent books by one of my professional heroes, Sidney Dekker. Space is way too limited so I will be only able to scratch the surface and hopefully make you curious enough to explore these books for yourself the first of which lets you see accidents or incidents from a totally different angle than we safety professionals usually take.
(originally published as a Dutch review in NVVK Info December 2015, see original here)
Second Victim
In some ways “Second Victim” (2013) is a continuation and elaboration on Dekker’s seminal book “Just Culture”, but largely seen from the point of view of a second victim. This is a practitioner who is involved in an incident that kills or injures someone else and for which they feel personally responsible. Typically, a lot of attention related to incidents goes to the ‘first’ victims (those who were harmed) and finding out what caused the accident. While second victims are in fact victims themselves, and go through trauma and guilt, in many cases the second victims are neglected or others (like investigators, regulators, managers, prosecutors and the media - often also colleagues) treat them as part of the problem or even vilify them.
The first three chapters deal with victimhood, emotional and cognitive psychological reactions, trauma and guilt. One typical thing with second victims is that they may feel guilty even if others think that they are not - because of a great sense of responsibility or professional pride. Guilt and shame are not typical subjects in a safety book - here you will find them.
Support
External influences are an important factor in these cases. Society often demands an explanation or even some kind of retribution or at least an apology. Even stronger: sometimes even the second victim himself thinks he deserves to be punished! The centre of the book deals with these subjects in chapters about Investigation (how to approach these cases in a proper way that acknowledges all perspectives - importantly not settling for an easy explanation but to look for ‘second stories’), Justice (the downsides of retributive justice and criminalization of error and the benefits of restorative justice) and Forgiveness (which should not be degraded to a formal act of ‘cheap grace’).
Social support (preferably by colleagues who can relate to the situation the second victim was in) is probably the most important element in determining if a second victim is to drop out (there are tragic examples of second victims ending their lives), to recover or actually to grow through the experience and even going to thrive. Dekker spends an entire chapter to discussing support (organisations are strongly advised to invest in this) and this leads then into the final chapter about ‘Resilience’, discussing how things can actually improve from a tragic event (even for the second victim) and one important lesson is that if an organisation learns to embrace its second victims and helps them to become resilient, that this also helps the organisation becoming more resilient.
Passionate and personal
The book contains many examples (some of them extremely tragic), many of them taken from the medical world or aviation, but of course there are many situations imaginable where alike problems may arise (police, train drivers or care providers to name just some) so the material is relevant in many other sectors.
It’s a slim volume of exactly 100 pages whose greatest drawback (for me) is the great number of academic styled references that are found throughout the text that diminish accessibility somewhat. On the other hand, however, we have Sidney’s passionate and very personal style of writing that clearly makes up for most of this.
For me this was an important experience to make the mental switch and see things from another perspective. I imagine that this different view will be valuable to many others.
Field Guide
Understanding why people make the decisions they make, seeing things from their perspective ‘inside the tunnel’ and helping to find ways to improve things are also central subjects of the other book I’d like to discuss. Last year the third edition of “The Field Guide to Understanding ‘Human Error’” was published. This version is rewritten and restructured from previous versions. I haven’t read the earlier versions (shame on me for sure!) so I can’t tell how different this one is, but I expect that while many of the main themes are in common, the new version adds plenty of new stuff to justify your attention.
Do mind the quotation marks in ‘Human Error’ - these are essential because we are to take this hindsight verdict or explanation with a pinch of salt. Or actually, we should abandon it as much as possible at all. It’s a judgement, not a fact. The Field Guide propagates a ‘New View’ on ‘human error’ as opposed to the ‘Old View’ that is characterized by a.o. seeing human error as the cause of trouble and people as a problem to control.
Symptom
Of course it’s Sidney’s intention to move beyond ‘human error’. As he explains early on in the book, a focus on ‘human error’ makes you do all the wrong things. In the New View human errors are seen as a symptom of trouble deeper inside the system and therefore we have to look beyond the people who make mistakes.
The Field Guide aims to help us understand how we see ‘human error’ and how we should see it urging that we must contain our intuitive retrospective, judgemental and counterfactual reactions. After that the book proceeds to guide us through a way of doing a good (or at least better) ‘human error’ investigation (an eye-opener for me was here the discussion of organizing by ‘time’, and I recommend reading sides 82 to 86 which perfectly reflect on an investigation) and a chapter is spent on explaining the patterns of breakdown, discussing factors like cognitive fixation, plan continuation and technology.
The weakest part of the book (IMHO) is the first half of the chapter on accident models. Dekker doesn’t like the dominos too much and barrier models only barely fare better - both of which I think do have their value for certain purposes and there is also a totally misplaced and misguided digression about the triangle. Just skip those two pages (124/125) and you haven’t really missed a lot. Much better are the parts on systems theory and drift into failure. The final sub-chapter links towards resilience and Safety I and II.
Safety Department
There is a chapter titled “Creating an effective Safety Department” which doesn’t entirely fill the expectations that the title may rise (that is, in case you expect a cookbook-like recipe for your safety department), but there are good discussions of staff and line responsibilities and about taming the safety bureaucracy. Actually the stress is more on effectiveness than on safety department. After this Dekker proceeds discussing building a safety culture. One item that stands out here is the caution to resist behavioural safety interventions. This conflicts severely with some common practices across industries. A lot of space is also devoted in dealing (most critically) with ‘zero’.
The final chapter is titled “Abandoning the fallacy of the quick fix” and this title contains a wise lesson: working on safety and human factors seriously is hard work and requires you to get out of a comfortable position with hindsight knowledge, little uncertainty and restraints in time or resource, and put yourself in the position of those on the sharp end. Only then one can discover the things that may go wrong again and truly improve the system. There is a fantastic guide to further literature on the last pages.
Both books discussed here come highly recommended and frankly, any safety professional’s bookshelf must contain at least one version of The Field Guide. Good thing I got that covered now!
Second Victim: Error, Guilt, Trauma and Resilience
ISBN 978-1-465-8341-2 / www.crcpress.com
The Field Guide to Understanding ‘Human Error’ (3rd edition)
ISBN 978-1-4724-3905-5 / www.ashgate.com
Visit also Sidney’s website (www.sidneydekker.com) where you can find many articles and more interesting material.
