No theory forbids me to say "Ah!" or "Ugh!", but it forbids me the bogus theorization of my "Ah!" and "Ugh!" - the value judgments. - Theodor Julius Geiger (1960)

New models for new times

Le Coze, J.C. (2013), New models for new times. An anti-dualist move, in: Safety Science, 59, 200-218


In this paper, Jean-Christophe Le Coze discusses the recurrence of accidents and disasters in different high-risk industries over the past decade, creating a sense of déjà vu. He presents a table of disasters that occurred in the 1970s-1980s and a similar one in the 2000s-2010s. Both tables seek to highlight the intense national and international scrutiny and interest these disasters have generated. Different dimensions that help to explain the variations between sectors. The pattern of recurring accidents could be interpreted as a failure to keep up with technological advancements or a result of the complexity of high-risk systems. Various research traditions in safety have flourished over the past 40 years, producing different perspectives based on experiences in various industries and disciplinary backgrounds. Three popular models in safety are discussed, selected using qualitative criteria, namely: their specific innovation, empirical and conceptual basis, generic ambition, normative aspect, simplicity and clarity of basic principles, ability to translate principles through graphical representations, popularity and ability to appeal, and strength and influence of an associated network of active promoters. The three models discussed are Reason’s models, Rasmussen’s models, and Karl Weick’s insights. Other models from other research traditions are relevant and sometimes even superior, but have not been as successful in comparison to the three models discussed.

James Reason is a psychologist who has worked on various topics related to safety, including cockpit ergonomics, transportation systems, everyday life errors, safety and error management, and cultural and organizational issues. Reason's main contribution, discussed in this paper, is his model of safety, which distinguishes between active and latent failures. The model consists of basic elements, including decision-makers, line management, preconditions, productive activities, and defences, which represent a series of planes that contribute to creating a trajectory of opportunity. The model's strengths include its ability to provoke discussions, provide a systemic approach, and focus on organizational factors rather than individuals.

Jens Rasmussen is an engineer who turned to the study of human-machine interfaces and safety in the context of the development of nuclear energy. Rasmussen investigated various areas, including human-machine interface design, cognitive models, human error definition and human reliability, accident investigation, and socio-technical modeling. He explored these topics successively between 1969 and 2000 and he proposed two central graphical representations that still characterize some of the current challenges in developing relevant empirical and theoretical safety research. The first model is the model of migration, which moves from a study of micro behavior of the individual to macro behavior of socio-technical systems. The second model is the socio-technical system view, which complements the migration model from an analytical point of view. These models indicate the importance of taking an interdisciplinary and functional approach to thinking about industrial safety problems and replace the notion of error and failure with the notion of variability and adaptation. These models also suggest an intuitive and appealing analogy between cognition and organization. These models are not without weaknesses though, and they imply a hierarchical vision of the socio-technical system, with authorities at the top, who seem to be in a position of top-down control over companies, which seems doubtful these days.

Karl Weick is a social-psychologist who introduced innovative views on organisations. His approach to organizing has constructivist elements with keywords such as enactment, sensemaking and equivocality. One of his significant areas of investigation has related to the HRO project, which he has been closely involved with. Weick's model of collective mindfulness is associated with a graphical representation and includes five basic cognitive processes generating the mindfulness needed to operate safely: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and underspecification of structures (later redefined as 'deference to expertise'). The model emphasizes both individuals and their interactions, creating or constructing their environment together. Instead of focusing on isolated actors, collective mindfulness advocates an overall analysis that places less emphasis on individuals likely to make errors in favor of an understanding of the constant flow of reciprocal actions between individuals. The model brings a normative theoretical framework to the descriptive nature of the studies of the HRO project, combines the outcomes of two approaches in the field of safety, considers interactions between individuals as key to understanding safety, and focuses on the positive contributions of individuals interacting with one another.

Resilience Engineering is both a collective and an individual initiative. It was introduced in a book published after a symposium held in Sweden in 2004, with contributions from many safety experts. Resilience Engineering became part of the safety sciences field due to its collective dimension. Erik Hollnagel, a researcher from the cognitive engineering community, has made the most extensive contribution to this research program. He promoted an approach to the reliability of cognition in the 80s and 90s, emphasising the study of normal operation instead of errors, which led to the development of the COCOM model which served as a basis for analysing human reliability. The philosophy underpinning this model provides a better understanding of the developments in Resilience Engineering. Resilience Engineering has been criticised for introducing a new vocabulary to the field of safety, and for its definition of resilience, which some authors believe is not of interest in safety.
No model can be considered superior to another since new research can lead to the improvement or weakening of a model's analytical power. While old models may lose their popularity, they can remain influential in guiding ideas for current research. Le Coze provides a synthesis of the attributes of the models discussed. Each model has its own specific innovation and ambition, normative aspect, simplicity and clarity of conceptual bases, and popularity and ability to appeal to academic and practical circles. The models are useful in communicating about safety, and the Swiss Cheese Model has become the central model of the field, widely accepted by both academics and practitioners.

The emergence of terms like complexity, emergence, non-linear causality, networks, uncertainty, unpredictability, and constructivism in the field of safety, challenge the established pillars of conventional and modern societies, which rely on objectivity, reductionism, determinism, and linear causality. Many authors have critiqued the nature/culture and subject/object dualisms that underpin these pillars. Morin introduced complexity as a way of grounding human and social nature in physics and biology without reducing it to either of these dimensions. He also reintroduced the category of events in a world dominated by the search for laws in a supposedly mechanistic and deterministic universe. Latour has been a central contributor to the constructivist discourse of the socio-technical systems field, promoting the position that one must not study empirically and understand separately technology, science, nature, and culture. He has been working explicitly towards a non-modern philosophical program that criticizes the two dualisms.
Le Coze argues that there is room for alternative safety models based on complementary insights from several areas of study to cope with complexity. He does not promote new models with the idea that they replace old ones. Instead, he proposes a pluralistic epistemology, where diversity has its virtue. The alternative models aim to capture insights that were either not available, were overlooked or were deliberately left out at the time of production of the earlier models. The notions of model, metaphor, and theory, are relevant to safety models. The hierarchy of increasing relevance between metaphor, model, and theory reflects a classical view of science dominated by a simplified idea of the scientific method which led to the success of physics.

Systemic and Dynamic Sensitising Model of Safety

So, in the field of safety management, there is a need for alternative approaches to the current methods used. Some widely recognized models have been criticized for their lack of precision when it comes to understanding organizations and socio-technical systems. While these models provide valuable insights into cognitive processes, they fall short in analyzing the intricate dynamics of organizations and socio-technical systems. Since the 1980s, the field has evolved, and various models, including the popular concept of collective mindfulness, have emerged. Even this model has its weaknesses, since it fails to adequately differentiate between different categories of actors within and outside companies, such as engineers, managers, operators, and regulators. Furthermore, it lacks a technical dimension and does not account for different levels of interaction and the linkages between micro, meso, and macro perspectives. To address these shortcomings, Le Coze proposes a new design rationale for assessing safety. By drawing from research traditions in managerial, social, and political sciences, such as safety management systems, safety culture, high-reliability organizations, and accident investigations, he identifies common threads and distinctions between descriptive and normative positions. He also considers the inclusion of macro dimensions alongside micro and meso ones. By doing so, develops a model that incorporates managerial, sociological, and political insights. This alternative model begins by incorporating the principles of safety management systems, which have been implemented in various industries for over twenty years. This step aligns the model with real-world practices and introduces the normative aspect of control. The next step involves integrating sociological and political approaches that emphasize the importance of understanding the micro, meso, and macro levels of analysis and their connections to technology, cognition, culture, and power dynamics.

By combining these normative and descriptive threads, Le Coze arrives at a sensitizing model. This model can be summarized in six key sentences:

  1. Leaders' strategic adaptations to the organization's environment (economic, political, social, and technological) lead to...
  2. Technological and organizational changes at different levels, which can have positive or negative effects on...
  3. The design and implementation of safety barriers by operational personnel (teams and departments). This process is monitored and controlled by...
  4. The ability to process signals, including concerns raised by "whistleblowers," regarding safety problems or the negative impacts of changes to safety barriers. This relies on...
  5. A safety department that challenges the organization regarding changes to safety barriers and the processing of signals. The department is supported by...
  6. Safety reviews, conducted internally or externally, that serve as a form of organizational redundancy for the safety department. These reviews focus on the same issues.

The model serves as a tool to sensitize situations, identifying areas of investigation concerning ongoing transformations, their impact on safety, and the system's ability to control these impacts. By merging a managerial model with a sociological and political one, this new model retains the essence of Rasmussen's migration metaphor while offering analytical insights. It examines the interplay between technological design, tasks, organizational structure and function, as well as cognitive, cultural, and power-related factors at multiple layers of analysis.

Socio-Natural-Technical System

Le Coze discusses the need for a refined analytical model for safety assessment, taking into account the dynamic and systemic aspects of safety. He emphasizes that the natural, technological, and social dimensions need to be considered simultaneously when assessing safety. Furthermore, scientists (whether 'hard' or 'soft') should be seen as active players of the system, not external. To move beyond the current understanding of safety and accidents, a research strategy built on multi- and inter-disciplinary cooperation is necessary. This interdisciplinary approach can help understand global behavioral patterns, organizational structures, the impact of change, and the quality of decision-making processes.

Full paper here.