Safety and Performance Total Respect Management (TR3M): A Novel Approach to Achieve Safety and Performance Proactively in Any Organisation 163485845X, 9781634858458

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BUSINESS ISSUES, COMPETITION AND ENTREPRENEURSHIP

SAFETY AND PERFORMANCE TOTAL RESPECT MANAGEMENT (TR3M) A NOVEL APPROACH TO ACHIEVE SAFETY AND PERFORMANCE PROACTIVELY IN ANY ORGANISATION

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BUSINESS ISSUES, COMPETITION AND ENTREPRENEURSHIP

SAFETY AND PERFORMANCE TOTAL RESPECT MANAGEMENT (TR3M) A NOVEL APPROACH TO ACHIEVE SAFETY AND PERFORMANCE PROACTIVELY IN ANY ORGANISATION

PETER BLOKLAND AND

GENSERIK RENIERS

New York

Copyright © 2017 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected]. NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN: 978-1-53610-866-8 (eBook)

Published by Nova Science Publishers, Inc. † New York

The reader may notice that the following quote by H.W. Heinrich, the father of industrial safety, is surprisingly still current and applicable today. “There is a vast and practically virgin field of usefulness in applied safety psychology, and it is one that should receive more immediate and widespread consideration. By no means, however, would it be wise to act on false assumption that safety engineering has outlived its usefulness and that psychology is all that remains. As a matter of fact, a great deal of psychology is an inherent part of properly conducted safety engineering and is applied daily under the guise of better understood terms.” “Industrial accident prevention – a scientific approach” – Conclusion By H. W. Heinrich, 1931

CONTENTS Preface

ix

Chapter 1

Setting the Scene

1

Chapter 2

Total Respect Management, an Integrated and Systemic Approach to Achieve Excellence

9

Chapter 3

Total Respect Management–The Philosophy

33

Chapter 4

A Measuring System for (Un)Safety

53

Chapter 5

Total Respect Management – The Methodology – Leadership

67

Chapter 6

Total Respect Management – The Methodology – Management

99

Chapter 7

Total Respect Management – The Methodology – Excellence

135

Chapter 8

Change Management and Organisational Alignment

157

Chapter 9

Dialogue Skills and Working Methods for Total Respect Management

171

Total Respect Management in Practice – The ‘Framework’ and the ‘Cube’

221

General Conclusion

269

Chapter 10 Chapter 11 References

271

Author Contact Information

275

Index

277

PREFACE Writing a book is not just using words and making sentences, combining these sentences into sections and chapters, and finally finishing them into a book. It is much more. It is a constant endeavour, starting with the creation of a vision and wild ideas on a subject that matters to the authors and maybe to society. The vision and the related ideas need to be translated into images, necessitating a fitting description. It is the same as the work of a painter or a sculptor, trying to convey a message to an audience considered important enough to make that effort. And indeed, writing is an effort which requires a dedicated focus and tenacity in finding the right words, constructing meaningful sentences and putting them in the right order to picture one’s message and translate the ideas into concrete, acceptable and easy to understand concepts. Such an effort can only be sustained with the help and support of friends and family. It also requires the belief in its importance and the hope that someone will listen to its message. We sincerely hope this effort will not be expended in vain and that you can enjoy the fruits of this work. Thank you for joining us in this relentless endeavour to make a better world for all of us. We wish the readers true excellence in their private and public/work life. Peter Blokland and Genserik Reniers

Chapter 1

SETTING THE SCENE 1.1. SAFETY AND PERFORMANCE, TWO SIDES OF THE SAME COIN Safety and performance (with performance in the sense of productivity and innovativeness) are ever more important values in our modern society. Hence, organisations increasingly aim to accommodate for these values. As a result, continuous improvement of products and services has become a common practice in managing modern organisations. When such improved success has been reached, it ultimately leads towards a better life for more people. It has indeed always been the purpose of mankind to progress and it still is a focus of many people in society today. Progress often comes with a cost and it is best served when it can be propagated in a sustainable way. Therefore, progress should join and align the benefits of a long-term perspective of sustainability with the short-term needs for profit and success. This is what Corporate Social Responsibility (CSR) aims for. In a way, CSR is the art of combining performance and safety to reach sustainable progress. However, when you look around you, there is a lot to be noticed that is good and bad and which is intrinsically linked. You will see happiness and sorrow, success and failure, opportunities and threats, strengths and weaknesses, etc. It seems as if one aspect cannot exist without the other (linked) aspect. This is because both of these aspects are two sides of the same coin. In the same way valleys cannot exist without mountains and life itself goes together with death, the same duality exists when considering safety and performance.

Figure 1.1. Safety and performance: two sides of the same coin.

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By having goals and trying to achieve something you hold both the elements of gain and loss. You will have to deal with both aspects of this reality in your endeavours (good and bad, gain and loss). Separating those two sides of the same coin is impossible: if one side exists, the other will inevitably also exist. Performance represents the positive side of the coin, thus the objectives involved. Performance is the domain where we aim for maximising the positive consequences and increasing their likelihood of occurring in the pursuit and the presence of objectives. Safety is the opposite side of the coin, facing the negative effects on those objectives, aiming to minimise these negative consequences and to reduce their likelihood of occurrence, related to the presence or to the pursuit of the same objectives.

1.2. SAFETY-I AND SAFETY-II Performance can also be regarded as the state or the situation of an organisation in which as many things as possible go right. Hollnagel (2014) talks about Safety-I and Safety-II. Safety-I indicates all approaches to ensure that as few things as possible go wrong, whereas Safety-II encompasses all approaches to guarantee that as many things as possible go right. Since Safety-I is concerned with things that go wrong or that can go wrong, it is about the ways in which adverse events and adverse outcomes may happen, and about the possible causes and mechanisms that produce the undesired manifestations. Conversely, Safety-II deals with things that go right or that can go right, hence, it is about continuously trying to anticipate developments and events, and making the right decisions leading to excellence and success in the long term. This distinction between Safety-I (safety) and Safety-II (performance) is important, as it leads to some essential mind-set differences of leadership and management. For instance, in Safety-I thinking, humans are predominantly seen as a liability or a hazard, whereas in Safety-II thinking, humans are seen as a resource necessary for system flexibility and resilience. Also, on the one hand, in the Safety-I line of thought accidents are caused by failures and malfunctions. The purpose of an investigation in such a case is to pinpoint and determine the causes and the contributory factors. The explanation of accidents in Safety-II language, on the other hand, is that things basically happen in the same way, regardless of the outcome. Thus, the purpose of an incident investigation would be to understand how things generally go right as a basis for explaining how things occasionally go wrong. This book is about how to achieve organisational excellence, and as one of the side products, safety excellence. Hence, in brief, in this work a practical method is expounded on how to focus on Safety-II, thereby also achieving Safety-I.

1.3. GROWTH, PROGRESS AND SUSTAINABILITY One of the common characteristics of mankind is the continuing search for expansion and growth. Today we have more possibilities, more knowledge, more technology, more products and more services available than ever before. Growth and progress in science and technology are such that almost no problem is too big to be solved by humankind. Medical progress lets

Setting the Scene

3

us live longer and gets a grip on life-threatening diseases, more people in the world become wealthier, the whole world becomes more and more connected as more places can be reached easily and soon mankind will even be able to travel to Mars and be able to further explore the universe. The possibilities of the human race seem to be unlimited. However, economic setbacks and their consequences, climate change and its effects, migration and its complications, and wars and its worries are all negative symptoms of the same common cause: the search for growth. If you only focus on these negative effects, you could conclude: ‘the world is not enough,’ in the way people always want more, regardless of the consequences, just like in the James Bond movie with that same title. One could conclude the way the world population currently behaves is not sustainable. However, there is also the other side of the coin, the positive effects, providing the ability to oppose all the negative aspects of growth we are experiencing now. These features will allow growth in a sustainable way. But because you cannot have one without the other, one thing should be clear: something has to be done about these negative effects. An increase in performance needs to be balanced by an increase in safety if sustainability is a concern.

1.4. OPPORTUNITIES AND THREATS Fortunately, a lot of good things are already happening today: sustainable energy solutions have been discovered and are currently being developed, new economies create more prosperity for those who participate in it, and diplomats work hard to avoid and contain conflicts instead of having situations escalate into violent action. Furthermore, greenhouse gasses and their emissions are better understood and controlled as science and technology evolve. Additionally, increasingly more people, managers and business owners are aware of the fact that an extra effort and a change in thinking is needed, as it is not enough what is done today and they see that our society needs to perform better in using its crucial resources. This is even more the case if we want to grow and keep our current level of prosperity and reach a sustainable level of success for all. Population growth and the aspirations of mankind, together with stocks of vital assets, such as fossil fuels, precious metals, minerals and other primary waning resources, are trends that do not match with objectives of wealth, well-being and prosperity for all and they strongly show the urgent need for doing more with less, in order to perform better and to allow for a sustainable growth. Unfortunately, the current situation drives people and organisations more often towards short-term visions and it incites competition and struggle rather than inviting cooperation and success. Frequently, short-sightedness leads to a corporate world pursuing the pillage of scarce resources for the sake of profit, instead of to investing in future and sustainable solutions that lead towards a more sustainable and broader prosperity. Looking at short-term (financial) results and a focus on shareholder value and revenue as a proof of growth, is often punishing for investments. It is in contrast with focusing on aiming at sustainable results and stakeholder value, leading towards a more equitable growth in society. This more holistic approach not only requires attention to profit, but also asks for more consideration regarding people and the planet we are living on. Furthermore, this integrated line of thinking has to include innovation and often necessitates the discovery and development of new technologies in order to be able to do more with less. Although this

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approach is beneficial from a long-term perspective, it also involves massive financing in advance, turning money away from shareholders in the short run, but resulting in more money and benefits for all stakeholders, shareholders included, in the long run. One could say that, in general, looking for a better financial performance from a shortterm and shareholder perspective, is rarely served with large investments. Certainly in the corporate world, this quest for better performance is often understood as the need for cutting costs in order to beat the competition. From this shareholder perspective, it is rarely understood as the need for investing large amounts of money to build excellent and sustainable organisations, since performance in organisations is consistently measured in terms of (maximum) financial value for shareholders, which is not necessarily the same as the overall (optimum) performance of organisations as a part of society, with benefits for all stakeholders. Pure financial return on investment and its associated performance indicators are what generally still counts in business and what counts for managers on the board. Often these indicators improve when expenses are diminished and when ‘costs’ are cut. In essence this will be correct when the cost is purely the result of a waste and when the return on investment also serves society. In that case, money saved on expenses does not imply cutting into – and transpire into –parts of vital functions and structures of the organisation; ‘vital’ in the sense of being needed to support or to bring about the required performance, crucial to achieve desired results or benefits for society. In such instance, using a stakeholder’s perspective, reducing waste will actually increase performance and help increase the benefits for society. However, in reality this is rarely the case and often cost cutting also signifies cutting the means, supporting value creation, leading towards a loss in overall performance for the organisation as well as for society in the long run. It is certainly one of the causes of the downward spiral the Western world is regularly struggling with.

1.5. SHAREHOLDERS AND STAKEHOLDERS In order to create value in a sustainable way, performance in organisations should be much more than just the financial revenue or the level of service offered. The responsibility of organisations goes well beyond a just return for its shareholders. It is impossible to separate organisations from the context they operate in, the context being society and its stakeholders. Today, in the connected world we live in, this context has to be understood largely and even to the extent that everybody can be considered as being a stakeholder. Stakeholders matter more and more; the web of interdependence we live in makes it so. One never knows who will influence the performance of one’s organisation and no one ever knows in advance how an organisation will exert influence on the larger context of society. Nowadays, there are plenty of examples of society paying the price for the lack of insight or the short-term visions of decades ago, because short-term strategies have rarely led to sustainable solutions. Increasingly, managers and leaders have become aware of the importance of stakeholders and the need to see the larger picture. Those that have become aware of this understand how to proceed and why it is necessary to look at performance in different and new ways. Corporate social responsibility is also important for these organisations, not because it is good for marketing or their business reputation, but because they understand the fact that

Setting the Scene

5

performance is about the net result for society as a whole, including for their own organisation. Performance is also about raising the standards of living in a sustainable way.

1.6. IMPORTANT CHALLENGES By overcropping and depleting natural resources, the human species boomed in the twentieth century and over exploitation is still the most common standard today. In spite of today’s insights and efforts in improving sustainability, companies still drill for oil or force nature to hand over its resources, built up over eons. Notwithstanding the fact that organisations and countries in some parts of the world endeavour to change and regulate this, forests are still being chopped down and oceans are still being overfished in order to get the relatively short-term profits. These are only two examples of many more misuses of natural resources. This is not a sustainable situation and it only happens when people do not take the big picture into account. But what is this big picture? The most important facet of the big picture is that the world experiences a population explosion. To put the actual rate of growth into perspective, consider the following brainteaser about a pond filled with lilies. “A man has a pond and he plants lilies in it. These lilies grow and double each day. After 100 days the pond is full of lilies. The question is then: How many per cent is the pond filled with lilies after the 98th day?”

The Answer Is 25 Per Cent! To put this riddle into a perspective of population growth today: when Peter Blokland‘s eldest grandson Liam was born in 2012, there were more than 7 billion people on this planet. When Liam’s mother was born in 1982, there were less than 5 billion people on Earth. In 1957 when Peter was born, there were less than 3 billion people alive and when Peter’s father was born in 1929, less than 2 billion people walked on the planet Earth. Liam’s greatgrandfather and many of his contemporaries with him, still walked on Earth when Liam was born. So where are we at? The 98th day, halfway, or, have we already past day one hundred? Back to focusing on the main issue: more and more oil fields, gas fields and mining activities will have to be closed as natural resources become depleted and it is becoming increasingly more expensive to get some kind of return from them. Over the span of one lifetime mankind has, with regard to fossil fuels, exhausted a huge part of its treasures in the world. And also the world has changed drastically in the span of a lifetime. In fact, fast change has been the only constant in the past century and this continues today at an ever increasing pace. Pessimistically, this big picture does not promise much good. However, the progress of science and technology shows that humankind can handle challenges well and it has always been possible to find solutions for the problems encountered (as has been showed by addressing the ozone hole and the adoption of the Montreal Protocol that bans the production of CFCs, halons, and other ozone-depleting chemicals). More and more awareness on our

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current situation grows and answers to pressing problems are and will be discovered. Some people think humankind has to reverse time and discontinue the progress in lifestyle and standards of living. Their solution is based on a ‘do less with less’ principle, but this is not an option. There will be more people and they will all rightfully strive for a better life, which will require more, not less. This is why the world needs to take performance and safety seriously as it will have to do more with less. Change has also been very prominent in science and technology, wherein vast progress has been made, with a huge impact on society. For example, transportation has changed drastically in the past era, medical wonders have become common practice, and computers and the internet have connected the world and have produced previously unthought-of opportunities. Yet, there is always the opposite side of the coin. Therefore, often as a result of this progress, precious goods and resources were needed to make these changes possible and have become more and more scarce as a consequence. Climate change is tangible and migration all over the world has become a reality, putting a heavy burden on social systems in many parts of the world. Furthermore, the use of nuclear energy, which served the Western world well in its development in the past decades, is compromised by events such as Chernobyl and Fukushima. In the Netherlands gas fields need to decrease production or even close down as they empty and cause a lot of concern due to the risk of earthquakes and substantial damage to real-estate. All over the world, oil rigs need to be dismantled as oil fields dry up and oil companies need to drill for oil in very remote locations and harsh environments, such as very deep sea and at nearly inaccessible places in the polar region. They also turned to fracking in order to force oil and gas from the rocks in the earth, with uncertain effects on the environment in those regions. These ongoing, likely unsustainable solutions often happen at the risk of huge environmental and health costs, as, amongst others, has been shown by the accident of Deep Water Horizon in 2010 and the Southern California Gas Company leak at its Aliso Canyon natural gas storage facility, detected 23 October 2015, impacting on the balance of greenhouse gasses in the atmosphere. Preying on natural resources still continues, as performance is mainly measured in financial terms, while the cost for society, as a whole, is not included in the end result.

CONCLUSION Although the prospect of the future might look gloomy to some and while future possibilities still seem uncertain, we want to bring a positive message. Because this book is written for all those who think positively and believe it is possible to do more with less, with the confidence and strong conviction that doing better and doing more with less, is certainly possible and will provide for sustainable profit and progress, also when taking into account corporate social responsibilities. Every problem or challenge holds an opportunity. New energy technology will provide for surprising (and unthought-of) possibilities, healthcare will provide for longer and healthier lives, and the world will become more and more connected. The ideas and examples provided in this manuscript are definitely meant for those who believe that standards of living can still be raised, even drastically for those in urgent need of it, and that society as a whole will be capable of delivering the efforts and results needed to grow towards a better and more sustainable world. As the writers of this book, it is our vision

Setting the Scene

7

that creating and spreading more value more evenly over the entire world and in a sustainable way, is necessary and possible today. It is our mission to further develop and spread our ideas and it is our ambition to contribute substantially in making this happen, working at spreading a more sustainable way of thinking and its associated mental models. Performance management science linked to a holistic framework such as Total Respect Management, introduced in the next chapter, and the process of determining adequate indicators acting hand in hand, will help organisations develop and employ an approach of continuous improvement and will eventually lead to organisational excellence.

Chapter 2

TOTAL RESPECT MANAGEMENT, AN INTEGRATED AND SYSTEMIC APPROACH TO ACHIEVE EXCELLENCE 2.1. RESPECT Why is this book on performance and safety management science about ‘respect’ management and what does the word ‘respect’ mean in this context? This might be an obvious question to ask when you are not familiar with this management concept, because the word ‘respect’ has many different connotations. Some associations provide good feelings, but others possibly trigger more unfriendly considerations and emotions, as respect does not have the same meaning to everyone. For instance, it is possible that respect is regarded as something belonging to past ages, where the concept of respect is strictly linked with obligations and privileges going together with hierarchy and social status or positions in organisations or society. Or, respect could be understood as a kind of awe or devotion for a specific person for its virtues or achievements. Respect could also be interpreted as keeping a distance to someone or something and avoiding to bother someone or something. However, none of these meanings are what we want to imply by using the word ‘respect.’ Respect in the way we intend to use the word in this book, is an expression originally derived from the Latin word respectus. In its turn respectus comes from the verb respicere, which means ‘to look again,’ ‘to look back at,’ ‘to regard’ or ‘to consider someone or something.’ In other words, the original meaning of the word ‘respect’ holds the connotation of giving someone or something your dedicated attention in order to have a better view on the matter or give it some thought, particularly to come to a better understanding. When used in the context of Total Respect Management this is exactly how the word ‘respect’ needs to be understood. It is a concept indicating a very specific attitude, which is a dedicated and appropriate focus on a certain subject, person, object or situation, in order to come to a deeper understanding of an issue and its context, and to be capable of making the right decisions. It is a basic attitude to be developed and ingrained in an organisational culture. It is a means of leverage which leads to a better understanding of individual and organisational issues, subsequently allowing for appropriate decision-making and action in the pursuit of individual and organisational objectives.

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Consider this for a moment. When do you feel truly respected? Is this not when you receive appropriate and dedicated attention from other people? Is this not when another person really wants to understand what you do or say? Is this not when individuals or institutions understand exactly what is important to you and act accordingly? The basic attitude which leads to this understanding and this way of acting, is what we want to indicate with the word ‘respect.’ In essence, Total Respect Management is about respecting People, Profit and Planet. It is about understanding how the three P’s of Corporate Social Responsibility (CSR) can be respected, to get sustainable results and an optimal performance. An example: Respect and Conflict in our society (a short story by Peter Blokland) Respect in the sense of giving a dedicated and appropriate attention to someone or something in order to better understand what is happening, also plays a crucial role in society as a whole. This was something I discovered during an exercise I facilitated during a course in systems thinking and system dynamics. The purpose of the exercise was making participants to understand and discover the dynamics of actual problems in society, such as conflicts and extremism. As a result of the dialogue and discussions in this exercise, a systemic map was constructed, using the parameters which surfaced during the discussion of the chosen subject. The participants wanted to understand the dynamics of the numerous conflicts going on in the world today. Discussing and telling stories regarding the issue of conflict and extremism revealed the important factors involved, as perceived by the participants in the dialogue. Consequently, the relationships between these factors were discussed and determined in the way systems thinking considers dynamics. Which factor influences which and how? Are the relationships equal (i.e., do they change in the same way, marked with an S or a plus sign) or are they opposite (i.e., do they change in opposite ways, marked with an O or a minus sign)? As a result of the dialogue, following elements surfaced as being of importance in conflicts in the world today and the following variables were selected to construct a systemic map on the theme CONFLICT: Conflict, Extremism, Economical Power, Prosperity, Dominance, Openness and Respect Although this is just a limited and very general perspective on the elements (variables) playing a role in conflicts, it gives an indication of what the participants perceived as being important in society regarding conflicts. Obviously, many elements were left aside in the map which can also be important. However, the group considered the mentioned variables as the most important factors concerning conflicts and extremism. The resulting map of this exercise is shown in Figure 2.1. When a set of variables forms a closed chain of effects and influence, we call this a loop. It is how reinforcing or balancing dynamics can be discovered in systems. The dynamics involving respect and conflict become evident when noticing the loops in the diagram.

Total Respect Management, an Integrated and Systemic Approach …

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Figure 2.1. Systemic map related to Respect and Conflict.

A very basic loop is the one between RESPECT and CONFLICT itself (R1). Both influence each other in opposite ways. The more respect (certainly in the way TR³M defines it), the less conflicts will arise. On the other hand, showing disrespect or less respect means conflicts will arise more probably. Also when there is a conflict, the more disrespect will emerge. In itself this is a reinforcing loop, triggering or sustaining conflicts. But reinforcing loops can turn both ways. So, on the other hand, when more respect is shown, the same reinforcing loop can also lead to the diminishing and ending of conflicts as shown by Muhammad Anwar El Sadat and Menachem Begin, ending the Egyptian – Israeli conflict in 1979. Another reinforcing loop adds to this via the variables OPENNESS and CONFLICT (R2). Conflict increases when there is less openness (secrecy) and when conflict increases, more concealment is a result. It is also by opening up to each other, people allow respect to

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develop, as shown by a third direct reinforcing loop between the variables RESPECT and OPENNESS (R3). The more people are open to each other, the easier it is to respect one another and vice versa. Likewise, the more respect people feel, the easier they will open up. Again, reinforcing loops can turn both ways. Less respect can lead towards less openness, which in its turn reduces respect and understanding for each other, possibly leading to conflicts. A positive example of this loop is Mikhail Gorbachev and his Glasnost (more openness) leading towards the end of the Cold War. Today, unfortunately, we see other, less promising examples of the opposite for example between the USA, Europe, Russia or Turkey, where positive evolutions of openness and more economical prosperity have come to a stop due to upshots of a lack of respect and unresolved conflicts, making the advent of war more likely. In the diagram above, it is clear that RESPECT and OPENNESS are the variables which provide leverage and who are able to determine in which way the dynamics in the system will progress, as they are the direct result of choices one can make. However, there are also other variables which can provide for balancing effects or disturb the positive dynamics, and which can lead towards negative dynamics of the same system. A balancing loop can possibly appear (B1) when OPENNESS leads towards better communication, cooperation, motivation, etc., increasing the ECONOMIC POWER of the society concerned. This, in turn, could lead to DOMINANCE. DOMINANCE in its turn often leads to a lack of RESPECT, leading to CONFLICT and less OPENNESS. This will eventually reduce the ECONOMIC POWER as a balancing effect. Perceived DOMINANCE as a result of ECONOMIC POWER or other factors can also have another secondary effect, triggering an opposing EXTREMISM, leading towards a negative and reinforcing effect on RESPECT (R4) and a second balancing loop (B2) when ECONOMIC POWER is involved. These loops can also trigger a reinforcing loop when a lack of OPENNESS is directly aimed at DOMINANCE or when DOMINANCE is an aim in itself (R5). A way to counter these pitfalls of ECONOMIC POWER and DOMINANCE is to develop the mental model that uses ECONOMIC POWER to bring PROSPERITY for all. It takes away the fuel to EXTREMISM and allows for more RESPECT, creating the outer reinforcing loop R6. However, when PROSPERITY for all is not the real aim of one’s efforts, one ends up with the reinforcing loop R7, leading to more EXTREMISM and CONFLICT; a situation which seems to be present at regular intervals in the world for the past decades and centuries. The purpose of Total Respect Management is to trigger and enforce R6 and create PROSPERITY for all the stakeholders; in a team, an organisation and society as a whole.

2.2. A SYSTEMIC APPROACH Respecting People, Profit and Planet is what Total Respect Management (TR³M) is all about. It is an inclusive management philosophy, methodology and a framework with a focus on the whole. This focus first and foremost leads towards an organisational attitude, allowing businesses to align strategic objectives, strategy and culture. It is a general method to progress towards an optimum performance (or Safety-II), doing more with less. Its philosophy is based

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on the fact that performance and safety are two sides of the same coin and that it is necessary to address both sides in a balanced way. It is also an integrated methodology and framework to line up performance and performance management with the safety of core objectives of an organisation. In essence, TR³M consists of a balanced and integrated combination of leadership (respecting people), management (respecting profit) and excellence (respecting the planet) in order to get the desired performance and sustainable results. An example: When looking at the systemic map in Figure 2.1, let us reflect on the reinforcing loops R5 and R7 and how they result from acting on symptoms and also how R6 could offer a more fundamental solution to conflicts, in society as well as in organisations. R5 = Respect – Conflict – Openness – Dominance – Respect R6 = Respect – Openness – Economic power – Prosperity – Extremism – Respect R7 = Respect – Conflict – Openness – Dominance – Extremism – Respect A perceived lack of respect, when reacted upon with emotion, can lead more towards a conflict, and a perceived conflict in its turn can reduce the willingness to be open towards one another. Less openness in its turn incites trying to be more dominant, which in turn can be perceived as having less respect. (R5) Perceptions and emotional reactions can quickly create a reinforcing loop, and a dynamic that increases the level of conflict. Every loop R5, R6 or R7 can be triggered at any element of the loop when people immediately react to negative perceptions and when balancing thoughts do not enter the loop. In a way the same happens with R7, where one of the reactions to dominance can be destined to counter the dominant factor, creating the possibility of extremism to counter the mainstream of the dominant party. The dynamic of the reinforcing loop R7 then generates an increase in extremism and conflict. The dynamics, described by R5 and R7, can be seen as a part of the explanation of the world-wide rise of extremism and its associated terrorism witnessed in the past and also at the beginning of the 21st century. The (perceived) dominance of a nation or culture and a (perceived) lack of respect to other nations or cultures, have started these loops many times in history. Today, it has also resulted in a conflict which still expands today. Seemingly a situation with no way out, but aggravated by reacting to the symptoms of conflict (extremism and terrorism) returning this lack of respect by conflict, passing by and not considering the more fundamental issues regarding dominance and respect. However, a solution lies hidden in the same loops, but more specifically in reinforcing loop 6. When economic power is used to share and bring prosperity, and when this is done while showing respect (dedicated and appropriate attention), the reinforcing loops can turn the other way and create an upward spiral of prosperity having a diminishing effect on extremism. Respect will reduce the level of conflict and open the path to more openness, starting the reinforcing loop to take momentum when this openness leads towards more economical power and prosperity, reducing extremism and leaving more room for mutual respect, closing and reinforcing the loop.

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Total Respect Management is a ‘systemic’ approach in achieving performance and safety. The indication ‘systemic’ points to a holistic approach, extended throughout the whole of an organisation or enterprise, including its environment in the largest sense of the word. A systemic methodology always takes the involved system as a whole into account and how this system fits into a larger entity. It also considers how a system is comprised of its subsystems and how these subsystems interact to produce the outcomes of the whole. As a result, systems thinking looks at the dynamics in the system and aims to address issues at a fundamental level. Therefore, it avoids reacting to symptoms of events happening. Because when issues are addressed by dealing with the symptoms only, these issues do not get solved and continue to produce the effects that need to be countered. It is not enough, and often wrong, to directly react to unwanted events. Reacting to events and their associated visible symptoms without knowledge and understanding of the underlying structures and systems, rarely provides the good (long-term and lasting) solution to a problem. When it is unclear how these events come about, reacting reflexively can even aggravate situations and problems, as the fundamental dynamics, triggering the unwanted results, remain intact. When vital resources are spent to counter problems in a reactive manner, a lot of means will be lost without reaching a lasting effect or sustainable results. When this happens, the same symptoms will reoccur soon and the resources and capabilities, necessary to deal with these issues, will diminish. When these archetypes of fixes that fail and of shifting the burden occur, it eventually becomes impossible to effectively address the origin causing a lack of performance, which will lead towards further decline. Unfortunately, promptly reacting to symptoms is something which occurs a lot and in many organisations today. Most of the time this prevents organisations and society from doing more with less, as the real problems remain unsolved and money is spent without a proper return on investment. TR³M is designed to avoid this waste of effort and resources. When events happen, it seeks to discover and understand the underlying systems, structures and the associated mental models that are at the core of the system and its dynamics. Even more, its intention is to build this systemic understanding into the systems and culture of an organisation from the start. This makes it possible to develop the necessary insight to comprehend how the whole system produces its results, wanted and/or unwanted, in order to manage and boost performance, and to improve safety by reducing unwanted results. Once the whole system can be mapped and understood, it is possible to find the mental models and ideas that lie at the heart of success, but also at the heart of failure. Addressing these mental models solves problems at the core and allows for success and growth in a sustainable way. As soon as the unsupportive mental models are identified and changed into mental models supporting success, the system itself and its structure will change, leading to different and better results, reached in a more sustainable way. As Dekker (2015) indicates, in the early 20th century, the human factor used to be seen as the cause of safety trouble. For instance, individual differences between people were to be exploited to fit the human to the system, and the line of thought was that safety problems needed to be addressed by controlling the human. In the late 20th century, the human was considered the recipient of safety trouble. Hence, safety interventions then targeted the system, with a better design, a better technology and a better organisation. At present, early 21st century, humans, and their accompanying mental models, are seen as the protagonists of making the right decisions and letting things run well in an organisation. Humans are

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therefore the clue to achieve excellence, or Safety-II to speak in Hollnagel’s language, and thus also (indirectly) to have no safety trouble. In the following chapters we will provide the ideas that are fundamental to this novel management method and how respect, leadership, management and excellence fit together in creating a better and holistic understanding of performance in organisations.

2.3. LEVELS OF AWARENESS OF COMPLEX ADAPTIVE SOCIO-TECHNICAL (ORGANISATIONAL) SYSTEMS Figure 2.2 illustrates how it is possible to look at reality when adopting a systemic perspective, and also which approaches should be used at these different levels of awareness (of the system) in order to change and improve the events it generates.

Figure 2.2. A systemic viewpoint on reality (Schaveling et al, 2006).

2.3.1. Events The most obvious to notice and easiest to be aware of are the events, the visible and observable facts that are happening around us. Events happen because a system exists and allows these events to come about. Sometimes events are concealed and can only be discovered after a while, but more often events are easy to notice. An example of an event is the driving of a car on the road. This is something visible to anyone who is on or near the road. An example of an unwanted event related to driving a car on the road, is an accident occurring.

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2.3.2. Trends and Patterns When events happen more than once and the interval of occurrence is short enough, one can discover patterns and trends over a period of time. When these trends are noticeable and patterns can be recognised, it also becomes possible to anticipate and take measures to prevent these events from happening or when prevention is not possible, to limit the adverse effects of those events. Discovering trends and patterns already requires more effort to become aware of, certainly when the frequency is low or when the effects are difficult to perceive. This is the level of awareness where usually most efforts are spent in relation to safety (Safety-I). It is why safety is often involved in gathering data and keeping statistics of events. It is also one of the reasons why current safety related models, such as the bowtie model, talk about barriers in order to prevent events from happening or, should these events occur, to limit their negative consequences. When analysing car accidents, one can discover that alcohol is a common cause to certain types of accidents, or that the same types of injuries occur. To anticipate these accidents and injuries, laws, regulations, practices, organisational measures and technical solutions can be developed. It is why drinking and driving is regulated or prohibited and why in most countries cars have ABS and wearing seatbelts is required by law. In this way, these measures anticipate the possible consequences of accidents.

2.3.3. Systems However, accidents are the result of the dynamics of a system – the car and its driver on the road – that affect a larger system – the road and all other vehicles, subjects and objects in its vicinity. Although parts of that system are very visible, it is much more difficult to become aware of the whole system. The complexity of the system then determines the effort needed to become fully aware of the system causing the events to happen. When safety is taken seriously, accidents will be investigated, as the complexity of an accident is such that all elements of the system, their relationships and the dynamics involved, can only truly be established after the event took place.

2.3.4. Structures When the awareness regarding the system and its subsystems is high enough, the structure of that system can be defined. The structure is the way how all subsystems fit together and influence each other in order to produce events. It is easier to determine the structure of mechanical systems than it is for complex adaptive socio-technical systems. In mechanical systems the awareness is such that accident investigations can accurately determine cause and effect relationships. For example, when an unwanted event occurs due to a mechanical failure, the dynamics of that failure and its consequences can be retraced and understood; when at the beginning of the jet age, aircraft crashed due to high cycle metal fatigue, the root cause for the unwanted event of an aircraft crash was quickly understood and dealt with.

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In socio-technical systems it is the human factor complicating things. For instance, over time it became clear that drinking alcohol or taking drugs while driving cars, generated unwanted events. The structure of a drunk driver in a car, who is driving on the road, generates a system’s dynamic that is likely to create a disaster, the same way high cycle vibrations and metal fatigue caused the early jet aircraft to crash. At the structural level, it is necessary to redesign the structures of the systems involved. Redesigning cars, road crossings or laws are some examples of redesigning structures which will alter the whole system of road transportation.

2.3.5. Mental Models - Cultures Although it seems that knowing the structure of a system gives the insight and awareness to prevent unwanted events from happening, it is insufficient to really proactively achieve safety and performance in a durable way. The factors that are really at the heart of systems producing events, are what can be called the ‘mental models’ which generate these systems. Only insight in and knowledge of the mental models present in a system provide the basis for understanding how fundamental changes can be made in order to proactively obtain more performance and increased safety in a sustainable way (Senge 1990). Mental models, how people perceive and regard issues, are at the core of the structure designs which determine the systems that generate safe performance or cause accidents to happen. An example of this is how parents educate their children when they are young. They try to instil mental models, such as ‘always look left and right and take care before you cross a street.’ It is a mental model which will generate a safe crossing of the streets when parents are successful in convincing their children to heed their words. ‘Drinking and driving do not go together’ is another proactive mental model that generates safety in a durable way. Today this is a mental model shaping young drivers, who have been brought up with this idea. This is in stark contrast to the mental models of older drivers who still drink and drive and think it is no problem for them to do so. As a final example, aviation could not be safe enough without a whole industry that is ingrained with mental models regarding the safety of aviation from the designer and the producer of aircraft components, to the crew and the handling personnel that operate these machines in a very unforgiving environment, always balancing and managing the good and the bad things that can happen when you fly. Once full awareness has been reached it is easy to understand that at every level of awareness (mental models, structures, systems, trends and events) an action has to be undertaken in order to achieve an optimum result. Although this full understanding requires effort and time, sometimes people will have to react immediately to unwanted events. Occasionally this is really necessary. As an example, when a fire occurs it is best to extinguish the fire as soon as possible, before it causes too much damage. However, when fires happen more than once, over time, trends and patterns can be discerned. Understanding these visible trends can help anticipate and can aid decision-making to take precautionary measures in order to be ready to react and prevent damage. But even more important is to ask why these fires occur. What is the system that causes the fires to emerge? And furthermore, how does the structure of that system facilitate the fires to develop? Finally, one has to ask the question what mental models give rise to the dynamics and structure of the system that causes fires to happen. It is only at these less visible levels of awareness and understanding where

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the real causes of fires happening can be found and effective changes can be implemented. The regeneration of mental models, the redesign of structures and the reframing of systems are the necessary changes to improve organisations so they are able to anticipate and react to unwanted events. When fully aligned, these efforts lead towards desired and sustainable results. (Bryan et al, 2006). This is exactly what TR³M helps achieve.

2.3.6. Safety Nudges A possible way to take the existing mental models into account while developing safety measures, is to conceptualize and employ safety nudges. Safety nudges result from the application of insights gained in the field of behavioural economics, and more specifically in the design of contextual effects to 'nudge' safer behaviours. Changing the behaviour of people, e.g., employees of organisations, towards safer behaviours, has been a subject of much interest to researchers and practitioners (e.g., safety managers). The main thinking in this area has been much influenced (although sometimes in an implicit way) by behavioural assumptions of rational behaviour. It is largely assumed that the behaviour of individuals is triggered by two ‘rationality’ assumptions: (i) people know what is best for them, and (ii) they act on that knowledge. In this regard, 'classical' economists have often emphasised that incentives and education are very effective in changing behaviour. However, studies in cognitive psychology provide wide evidence that the rationality of individual decision makers (e.g., companies’ employees) is bounded, that they are affected by contextual effects, and the effectiveness of incentives and education do not always lead to better decisions. Thus, the rational 'homo economicus'-approach has been too dominant in changing people’s behaviours, through the design of the organisational environment, regulation, rules, guidelines and enforcement, education and training. However, in many organisational contexts, bounded rationality is clearly evident. Therefore, there is room to incorporate more insights from the emerging field of behavioural economics in the design of interventions and measures to change people’s behaviours. Behavioural economics can be described as a science seeking to understand behaviour that deviates from the predictions of rational choice models by incorporating insights from behavioural sciences into economics, giving more weight to what are sometimes called ‘irrational’ motives and behaviours (Avineri and Goodwin, 2010). Research in behavioural sciences, especially cognitive psychology, indicates that individuals' choices in a wide range of contexts deviate from the predictions of rational behaviour. Some of these deviations are systematic, consistent, robust and largely predictable (Tversky and Kahneman, 1974; Kahneman and Tversky, 1979, 1984). One of the terms most associated with behavioural economics, and its application to influence behaviour, is the concept of Nudge, coined by Thaler and Sunstein (2008): “A nudge, as we will use the term, is any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid.”

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Another definition is given by Hausman and Welch (2010, p. 126): “Nudges are ways of influencing choice without limiting the choice set or making alternatives appreciably costlier in terms of time, trouble, social sanctions, and so forth. They are called for because of flaws in individual decision-making, and they work by making use of those flaws.”

Thaler and Sunstein (2008) and Thaler et al. (2010) advocate the use of ‘choice architecture’ to influence behavioural change; they illustrate how ‘nudges,’ small features designed in the environment of choice making, could help individuals overcome cognitive biases, and to highlight the better choices for them (by helping make better decisions in an ‘automatic’ way) and increase the effect of behavioural change – without restricting their freedom of choice, and without making important changes to the physical environment, the set of choices, or the economic attributes of the choices. Choice architecture may be perceived by policy makers as less controversial and cheaper than larger scale interventions, which might have contributed to its recent popularity (Avineri and Goodwin, 2010).

2.4. AN INTEGRATED APPROACH The statement ‘Total Respect Management is an integrated approach,’ postulates that TR³M helps managers and executives look at complex adaptive socio-technical systems as a whole and to be able to see whether the individual components fit, support and fulfil the main objective of the organisation. ‘Integrated’ also indicates that this vision culminates in the connected application of many different functions and diverse disciplinary fields in order to reach a collective and optimum performance at a minimum cost. It is how the corporate objectives are pursued cooperatively and how they can be achieved in a sustainable manner, resulting in long-term benefits for the organisation and its stakeholders. A ‘systemic’ approach points out that it is based on a holistic view on reality, and an integrated approach reminds you of the fact that from this systemic view, an organisation is able to fit in all the elements needed to pursue and achieve its objectives. An integrated method also ensures all these elements are mutually connected and balanced, and function in concert. Those elements can be seen as everything needed to endeavour such as individuals, teams, equipment, training, financing, hardware, software, processes, procedures, tasks, habits and so on, both in the internal and external context of the organisation.

2.5. THE CYNEFIN FRAMEWORK A way to see how the main elements of TR³M (Leadership, Management and Excellence) work together in the search for sustainable results, is by means of the Cynefin framework (Kurtz, Snowden, 2003). This framework encompasses both the tangible and intangible aspects of place or habitat, in a way that it describes the place of one’s multiple belongings, including things such as the local climate, the language, the religion, the stories, the history

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and so on. In fact, it is more a notion which indicates one’s reality and how this reality is embedded in history and how it is perceived. This framework is a sense-making model and decision-making framework and it can be used to describe many aspects of the reality of organisations. Most models are categorisation models, where the framework precedes the data and where the model is used to categorise data by dropping data in a corresponding part of the model to exploit the data. However, in the case of a ‘sense-making’ model, the model is used to make sense of the data and act accordingly. So, the Cynefin framework is destined to help understand reality and how to deal with it. Consequently, it delivers a clear view on an organisation’s context in its largest sense. It includes both the internal as well as the external environment and provides insights in how to think, act and decide as a result. The framework divides reality into five specific domains, each domain related to the degree of complexity of the reality one finds him or herself in and the perception one has of that reality.

2.5.1. The Quality of Perception Before explaining the framework any further, it is important to define the concept of ‘quality of perception.’ The way people experience reality is always through their individual perception of reality and each individual will always have a different perception of the same reality. This is due to the fact that every person has different sensorial capacities, different beliefs and convictions, or a different focus, just to name a few of the many factors that influence perception and which are the reasons why perceptions of reality vary.

Figure 2.3. High deviation of perception from reality.

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Sometimes these beliefs and convictions, sensorial capacities and focus lead towards a very sharp and correct image of a certain element of reality. In such an instance everything is clear and understood and it is possible to say that the quality of the perception regarding this issue is high. Consequently, the deviation of the perception of reality from reality itself is low and the specific context and situation is fully comprehended, allowing for sound and instant decisions. At other times focus, sensorial capacities, beliefs and convictions are such that the image of reality is blurred or maybe sharp but incorrect. In that case the quality of perception is low. Then, the deviation of the perception of reality from reality itself is high and the situation is not understood at all, or worse, the understanding is incorrect. In this case, decision-taking becomes either difficult and hesitant or incorrect (Figure 2.3). It is obvious that making sense of things is important in order to increase the quality of one’s perception and when the quality of perception is high, one is more inclined to take accurate decisions.

Figure 2.4. Low deviation of perception from reality.

Total Respect Management is an integrated way to increase the quality of perception in organisations. TR³M helps in making sense of reality (context, situations, issues, matters…) and therefore leads towards taking the right decisions throughout the whole organisation. Figure 2.5 displays the Cynefin framework with its five domains. The domains to the right are the ordered domains and the domains to the left are the unordered domains. The domain of disorder in the middle is to describe the situation where you do not know in which of the other four domains you actually are (Snowden, 2010). Each domain has its specific characteristics and requires a different approach and different thinking patterns in order to increase the quality of perception and making sense of things. In that sense it is also a framework that operates by increasing degrees of awareness, where the different thinking patterns help, to move from high uncertainty and complexity towards a higher quality of perception, less uncertainty and less ill-understood complexity. The Cynefin framework’s

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value resides in the fact it prescribes a set of behaviours and practices, which are appropriate for a given domain. For example, it provides insight on how to think and act in order to move from ‘chaos,’ where the quality of perception is very low and uncertainty is very high, towards the full understanding of reality and certainty in the ‘simple domain,’ where matters are fully under control. In this way, the model shows how to develop new practices into best practices.

Figure 2.5. Cynefin framework (reformulated, based on Kurtz & Snowden, 2003).

2.5.2. Simple Domain The lowest degree of complexity and uncertainty is found in the ‘simple’ or ‘obvious’ domain. It is where we are fully aware of what is happening and in which context we are operating. This domain is characterised by the fact that cause-and-effect relationships are obvious and easy to discern. It is the domain where reality is understood correctly and where the quality of perception is highest and taking decisions is easy. The way of approaching the situation is ‘SENSE’ i.e., observe the circumstances, then ‘CATEGORISE’ i.e., classify and order the elements in the situation, which is clear and easy to do as knowledge and awareness of the situation are fully developed, and finally ‘RESPOND.’ Responding is actually what follows after taking a decision. In the simple domain it is enough to see what is happening and what the current situation holds to be able to decide on the course of actions to be taken. Therefore, this is the domain where the best practices reside, often translated in welldefined production or operational processes, procedures and tasks.

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2.5.3. Complicated Domain The second domain is called ‘complicated.’ Here, relationships between cause and effect are not so clear, they are no longer obvious, but with some effort, they can still be determined and studied before they produce outcomes. The first two domains are also referred to as the ordered domains as a certain order can be established and made visible. Therefore, the way of thinking has to be different in order to make sense of the situation. The right order is ‘SENSE,’ i.e., look at what is happening, then ‘ANALYSE’ i.e., investigate the different possibilities and combinations of the complicated cause and effect relationships present, and only when matters have been analysed, ‘RESPOND.’ This is the domain of the good practices, where awareness and insight are sufficient to see the benefits and drawbacks of different options. In this domain resides the challenge to find out what the best option is. This is correspondingly the domain of expert opinions and scenario thinking. Analysis of the possible relationships will provide the basis for good decision making and continued organisational learning.

2.5.4. Complex Domain In the third domain, the cause and effect relationships cannot be established beforehand. They can only be recognised in hindsight, when events have already happened and consequences are clear. This domain is called the ‘complex’ domain. By its nature this domain is where uncertainty is prominently present and the quality of perception is lower. This, again, requires a different way of thinking in order to make sense of situations and take adequate decisions. The first thing to do in the complex domain is to ‘PROBE,’ which is an exploratory action designed to investigate and obtain information on a remote or unknown area of interest. The next step is ‘SENSE.’ It means having a dedicated focus on the information that results from the probing action. The information obtained then leads towards ‘RESPOND’ and decides on taking further steps in the process. The complex domain is a great opportunity for organisational learning and to increase the quality of perception. In safety matters this domain is where accident investigations reside. In organisations, this is the domain of research and development where emerging products and practices can be developed.

2.5.5. Domain of Chaos Finally, there is the domain of ‘chaos.’ In this domain it is impossible to establish any cause-effect relations, even after events took place. It is a domain where the quality of perception is very low and uncertainty is very high. It is the moment when people do not know what is happening or cannot make sense of what they observe. Chaos first requires one to ‘ACT.’ An action will give meaning to the context and can be used as a starting point to increase awareness and the quality of perception. The next step then is to ‘SENSE’ and see what happens. This is the first step in a learning process, as the first results of the previous action will give the feedback needed on how to ‘RESPOND’ regarding the situation at hand.

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When this learning process evolves, one creates a form of order in the chaos which allows moving forward into the complex domain. Chaos also has its upside, because this is the domain where new practices arise, where innovation is rooted and where leaders can inspire other people with their vision.

2.5.6. Domain of Disorder Being in the domain of disorder is the situation where it is unclear for a person in which of the four domains he or she actually resides. It is in fact the situation one finds oneself in most of the time and this can become problematic. Because being in disorder means one will revert to one’s default and preferred method for decision making to interpret a situation and take action. For persons who have operated a long time in a routine and bureaucratic environment, problems will mainly be seen as a failure of processes. When you are an expert, problems seem to result from a failure of time and resources to do sufficient analysis. The reaction of natural complexity workers, such as politicians and battlefield commanders, will be to get lots of different people, with different backgrounds together, hoping they will come up with a solution to the problem. It also indicates that people thriving on chaos will try to leverage crisis so they can take command and tell everybody what to do. So, what one gets in a normal decision environment is that people are in the disordered space, assessing issues to their preference for action. It means one’s perception of reality itself is always a mix of the different domains of the Cynefin framework, with issues reflecting varying degrees of complexity and uncertainty. This mix is unique for every person and only depends on one’s quality of perception on the different aspects of one’s ‘habitat,’ and the moment one lives in. The closer perception approaches reality itself and the better the understanding of reality, the more one moves towards the simple domain. On the other hand, the more understanding is lacking and perception is deviating from reality, the more one digresses towards chaos. The borders between the domains are therefore flexible and depend on how one learns and sees reality. Each individual is dealing with different domains and the corresponding boundaries will shift when understanding grows. This is the same for organisations.

2.6. THE CYNEFIN FRAMEWORK AND RISK MANAGEMENT ‘Risk’ means different things to different people at different times. However, as already mentioned, one element characterising risk is the notion of uncertainty. Unexpected things happen and cause unexpected events. The level of uncertainty can however be very different from event to event. Roughly, three types of uncertainties can be distinguished: uncertainties where a lot of historical data is available (type I), uncertainties where little or extremely little historical data is available (type II), and uncertainties where no historical data is available (type III).

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Whereas type I negative risks usually lead to LIHP events, or Low Impact High Probability events, such as most work-related accidents such as falling, little fires, slipping, etc., type II negative risks can result in catastrophes with major consequences and often with multiple fatalities, so-called HILP events or High Impact Low Probability events. Type II accidents do occur on a (semi-)regular basis in a worldwide perspective; large fires, large releases, explosions, toxic clouds, etc., belong to this class of accidents. Type III negative risks may transpire into ‘true disasters’ in terms of the loss of lives and/or in terms of economic devastation. These accidents often become part of the collective memory of humankind. Examples include disasters such as Seveso (Italy, 1976), Bhopal (India, 1985), Chernobyl (USSR, 1986), Piper Alpha (North Sea, 1988), 9/11 terrorist attacks (USA, 2001), and more recently Deepwater Horizon (Gulf of Mexico, 2010) and Fukushima (Japan, 2011). Remark that once type III risks have turned from the theoretical phase into reality, they become type II. To prevent type I risks turning into accidents, risk management techniques and practices are widely available. Statistical and mathematical models based on past accidents can be used to predict possible future type I accidents, indicating the prevention measures that need to be taken to prevent such accidents. Type II uncertainties and related risks and accidents are much more difficult to predict. They are extremely difficult to forecast via commonly used mathematical models since the frequency, with which these events happen, is very low within one organisation and the available information is therefore not enough to be investigated via e.g., regular statistics. The errors of probability estimates are very large and one should thus be extremely careful while using such probabilities. Hence, managing such risks is based on the scarce data that is available within the organisation, and, more generally, on a global scale, and on extrapolations, assumptions and expert opinions. Such risks are also investigated via available risk management techniques and practices, but these techniques should be used with much more caution, since the uncertainties are much higher for these types of risks than for type I risks. A lot of risks (and latent causes) which never turn into large-scale accidents due to adequate risk management and very few risks which turn into accidents with huge consequences exist. The third type of uncertainties is extremely high, and the related accidents are simply impossible to predict. No information about them is available and they only occur extremely rarely. They cannot be predicted by past events in any way; they can only be predicted or conceived by imagination. Such accidents can also be called ‘black swan accidents’ (Taleb, 2007). Such events can truly only be described as ‘the unthinkable’ (which does not mean that they cannot be thought of, but merely that people are not always capable of realising (or mentally ready to realise) that such event really may take place). Any company can choose its own way to develop an information-variability matrix. For example, a concrete risk type matrix for an organisation may look like the figure below (Figure 2.6). The company can then further elaborate and define the qualitative parameters of the matrix from Figure 2.6 (‘very low,’ ‘low,’ ‘very limited,’ ‘limited,’ ‘adequate,’ etc.) and use the matrix to distinguish between different areas A, B, C, D. At first sight, these areas can subsequently be used to relate them to the Cynefin framework: see Figure 2.7a.

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Figure 2.7a is a possible representation on how types of risk can be linked to the domains of the Cynefin framework. However, this figure would not be able to capture all the different possible combinations of information, and the processing capacity available compared to the complexity and variability of situations one can find oneself in regarding one’s quality of perception. In the figure below it seems more suitable to start from a centre of complete ignorance, where even the simplest things can be perceived as being chaos, where very little information and processing capacity is needed to shift through the domains to reach simplicity. The figure below also indicates that even highly variable and complex matters can become simple when sufficient information and processing capability is available. Variability is not the only parameter to influence one’s quality of perception, also the level of complexity of the issues at hand largely determines the amount of information and processing capacity needed to leave the domains of chaos, complexity or complicatedness to reach simplicity. It also shows that the effort needed to make matters more understandable increases with increasing complexity and variability. It is obvious that, assessing the type of risks under consideration by means of determining the domain of Figure 2.6 in which the risk can be categorised, it is also possible to link the risk immediately to the Cynefin framework. As such, it is possible to verify what management strategy is needed to deal with which risk. By employing Figure 2.7b, it is thus possible for organisations and their leadership and management, to work out approaches to handle variability and information availability about risk scenarios.

Figure 2.6. Illustrative example of a matrix for determining the operational risk type and the area.

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Figure 2.7a.

Figure 2.7b. Relation between the type of risk and the Cynefin framework.

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Ideally, organisations strive to have risks in the complicated domain (C). The reason is that a sufficient amount of information about risks is available (thus about opportunities and threats, as well as uncertainties) to be able to optimise decision-making, leading to maximising the positive side of risks and minimising the negative side of risks. In domains A and B, the most profit can be made, but also the most damage can be suffered. High positive uncertainties (and thus high potential profits) go hand in hand with high negative uncertainties (and thus high potential losses). In domain D, there is a lot of competition, uncertainties are low, leading to low possible profits and going together with low possible losses. The idea/purpose is thus to turn risks, when identified, into the complicated domain, to handle them. Figure 2.7b shows that this can be achieved by reducing the variability and complexity, while also increasing the information availability and processing capacity, as explained in the following example.

2.6.1. An Example: Sound Recordings of a Concert Recording the sound of a concert, whether it is a rock band or a symphonic orchestra, recorded live or in a studio, is a complex system with a lot of interdependent cause-andeffect relationships. For the layman, unaware and ignorant of sound recording and its book of knowledge, this system is pure chaos; the variability present in the system, the uncertainty regarding the purpose and the layman’s limited knowledge of this system, put him in the zone of type A risks. Musicians, instruments, microphones, cables and mixing panels represent too much information to be handled by this untrained brain. The controls on the mixing panel, the position of microphones, the score for the musicians, and so on, they have no real meaning for this person. In case this person would be responsible for making a recording, the result would certainly be a disaster. However, the likelihood of such a person making a sound recording is very low, as the actual perception of reality lacks the needed quality in order to make sense of all the equipment. In this state, it is impossible to make a valid decision on the aspects of the sound recording. What is needed here first is to build a vision on what is going on and what is possible, and also what should be achieved by the recording. What is the purpose and what is the ambition of this recording? Is it just a demo or is it a recording to gain a large audience? What should the end result sound like? When a person is interested in sound recordings and is inspired by their purpose, he or she is motivated to take action regarding this specific expertise; he or she can act. Gathering information on the sound and registration equipment, and getting to know the music, the characteristics of the instruments and the musicians, will feed the apprentice with information to get a comprehensive picture of what sound recordings are like. For instance, the interested person discovers and learns the different possibilities of the controls on the mixing panel, learns why and how to change the position of the microphones or to ask the musicians to play different parts of the music to see how the instruments interact with the recording equipment. The apprentice can act, observe what is happening and learn what more needs to be done to actually make a good sound recording of the music played. Gradually, the quality of his perception will rise and the uncertainty regarding the outcome of the sound recording starts to change. When the purpose of the sound recording and the ambition are clear, the complexity and variability diminish, as certain possibilities are now

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excluded and the learning process can further develop into the next stage. Sound recording is no longer chaos; it has become an objective and a complex reality which needs to be mastered. The risk to get a disastrous sound recording still exists, but still unlikely to occur, as the apprentice still lacks the knowledge to do so. However, information and processing capacity are sufficient to proceed to the next (complex) domain. Hence, it becomes important to probe and analyse what happens before taking (final) decisions on the recording. In order to learn more, the sound recording’s apprentice starts probing the elements that make out the system of sound recording. He learns what the different controls do on the mixing panel, he learns what the characteristics of the different instruments are or what equipment is needed to capture the right sound and combine these elements into specific sound, analysing the result of what has been put together over and over again. It is hard work, but the quality of perception still increases and the uncertainty of the outcome of the sound recordings diminishes. Soon the apprentice becomes a professional. Although the likelihood of a disastrous outcome further diminishes, the likelihood of actually making a sound recording increases. Sound recording is no longer a complex system; it has become complicated. In essence, the complexity and the variability of the system have not changed, but the information and processing capacity have increased. Accordingly, the risk has changed too. Even for experts, sound recording is a complicated matter, because sound recordings vary and many options are possible to make a good sound recording. There are a lot of variables that can influence the recording of sound. What is the type of music played? Which recording equipment can be used? Which effects can be used? Who are the musicians playing and where are they playing? Sometimes a concert is in a hall, another time it is outdoors or maybe the recording is made in a studio. Also the musicians differ from day to day and each kind of music brings its specific problems and requirements. Different options have to be tested to get a good recording. Still, the learning continues and the quality of perception increases further. The certainty to make a good recording increases as well. At a certain moment the professional becomes an expert. Experts on the matter know what to do when they have to do a specific sound recording. They sense the conditions, the environment, the musicians, the music and the equipment available for this specific sound recording. The variability further diminishes and when the information and processing capacity have further increased, they know everything that matters for that specific sound recording, because they know the musicians, the music, the equipment, the studio and so on. Then they can categorise and respond and can immediately decide what to do to make an impeccable sound recording. It is just a matter of the quality of their perception to be certain it will be perfect, because for the expert the sound recording has become simple and the risk of getting a bad sound recording has become very low.

2.7. CYNEFIN AND TR³M Total Respect Management is a systemic method and approach, covering all aspects of organisations. By its use, it continuously enhances one’s perception. When correctly implemented, it takes individual and organisational perception from the domain of chaos,

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where the quality of perception is low, towards the simple domain, where everything is clear and understood. Each step of the way it enables practitioners to make informed decisions and progress towards a high quality of perception and expert results. In doing this, TR³M fits remarkably well with the Cynefin framework, as it covers all domains in a connected way. It is important to notice that innovation occurs best in the domain of chaos, where rules are absent and everything is possible, but uncertain. However, to develop innovative ideas into success, it is necessary to decrease uncertainty and go through the different domains of the Cynefin framework to reach a full understanding and a control in the simple domain. Furthermore, it is also important to mind the fact that complexity and variability are increasingly higher in society today, and that operating in the complicated domain is what most organisations will experience at best, and where only a limited number of aspects of the organisation will persistently be in the simple domain. How TR³M fits with the Cynefin framework to increase the quality of perception is described in the following sections and is further explained in the next chapters.

2.7.1. Leadership and Respecting People Chaos is the moment when the quality of perception is very low, where everything is unclear and uncertainty is high. Anything and everything is possible, it is the ideal ground for innovation and new ideas. When everything is new, when chaos is prevalent and comprehension of issues and situations is missing, leadership is the most prominent process to be used. Leadership can and needs to provide directions and ideas to create a dedicated focus and move in a certain direction. It starts with having or developing a broad vision on the situation which in turn leads towards the discovery and development of a focussed mission, expressed in a clear ambition. By developing these mental models, structures and systems can emerge which will provide elements with which followers can align their bearings. This is how leaders deal with chaos and move on towards a more certain future. Because a clear ambition, grounded in an all-encompassing vision and linked with an explicit mission, can be translated into specific objectives and a strategy to pursue this ambition. It is where action starts, and people get the drive to move and improve as the quality of perception increases. When people in organisations can be part of this leadership process and can develop their own clear vision, mission and ambition aligned with the organisational objectives, it will be well received and recognised as a form of respect. It will give them a sense of commitment and importance, which will give them a boost and drive their performance. Therefore, well developed strategic objectives provide direction and lead away from chaos into the domain of complexity by respecting people.

2.7.2. Management and Respecting Profit Once leadership has determined the ambition and strategic objectives, the management process becomes the most important aspect in leading organisations. At this stage, the purpose, why action has to be taken, is clear. Yet, it is still unclear what needs to be done to achieve success. The complexity is such that cause-effect relations are still obscured as knowledge and understanding are still insufficient. However, in the complex domain, when

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objectives and the context are cleared out, one can probe reality to identify risks, analyse a risk, evaluate a risk and consequently deal with the uncertainty affecting the objectives by a proper risk treatment. For Total Respect Management, management is about reducing the uncertainty regarding objectives in order to make sure objectives will be reached in the best possible way, maximising the profit or desired effect while minimising the cost and losses. Therefore, all management should be considered as being risk management. The (risk) management process will further enhance the quality of perception, linking the risk and the objectives, and allows determining in what way objectives will be pursued. When this process is well understood, one can take more (positive sides of) risks, while reducing the (negative sides of) risks to a strict minimum. In other words, the management process allows increasing the quality of perception as it creates insight in benefits and losses and how to maximise the first and reduce the latter. Such an approach results in higher value creation, because obtaining more benefits and incurring less losses both respect profit.

2.7.3. Excellence and Respecting the Planet When management has determined the course of action regarding their objectives in line with the vision and mission of the organisation, one knows what to do and one moves from the complex into the complicated domain. Here, cause-and-effect relationships can be determined as action is taking place. Learning and increasing the quality of perception is not about what to do, but about how to do it. Therefore, further analysis is needed in order to understand how exactly existing structures and systems produce the outcomes and how results are recorded. How does the organisation fit into the larger perspective of the planet? How can positive effects be enhanced, as well as how is it possible to reduce unwanted results and waste? Here, system dynamics and the learning organisation are concerned with the process of continuous improvement. This is the process needed to pursue excellence and transform good practices into best practices. Systems thinking and the understanding of larger complex systems are required to improve and embark into the right direction, taking into account the larger reality and the long-term effects of actions taken on all stakeholders. In the learning organisation, the quality of perception further increases and allows Total Respect Management to lead organisations into the simple domain and towards a sustainable and optimal value creation, respecting the planet by eliminating the negative effects of one’s endeavour on nature and society. Hence, TR³M is a holistic and integrated approach for organisations with a long-term perspective, aiming at CSR and sustainable value creation for all stakeholders. TR³M acts by perpetually covering all areas of the Cynefin framework, and therefore totally respects the specific requirements of learning organisations. Another insight the Cynefin framework offers is the kind of leadership behaviour which is needed in the different domains of the framework in order to get the best possible results in learning and getting a higher quality of perception. (See also Chapters 5, 6 and 7 – TR³M the Methodology). In chaos charismatic, very clear, strict and directive leadership is needed, as in chaos one requires clear concepts and directions in order to create structure and meaning. As soon as this is achieved, one will have to deal with complexity which requires a different attitude. Here leadership is a more supportive kind of leadership (paternal/matriarchal). Here, there is

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room for error and the leadership style is focused on coaching and on the development of individuals. Making mistakes and genuine learning allows one to develop and move from the complex towards the complicated domain. Here, one requires less attention in the form of coaching, but gradually, as one’s self-leadership and expertise develops, there is a need for some support and for the possibility to participate in autonomous decision-making. So, in the complicated domain, participative leadership is the most appropriate way to govern organisations. Finally, in the simple domain, experts know what needs to be done and there is no more room for error. Here, only command and control are required. Simple concepts do not allow a big margin for interpretation, nor do they provide the freedom the other domains possess. Each time the best practice has to be executed to the same standards and specifications.

CONCLUSION In this chapter, different domains of reality have been provided and discussed using the so-called Cynefin framework. To achieve organisational excellence, it is necessary to use an integrated and systemic approach. Hence, to have a good perception of reality, or better yet, of the possible realities depending on different perspectives, the circumstances, management and leadership-skills need to be interrelated. To this end, the Cynefin framework is related to the different types of risk using (i) the variability and (ii) the availability and the processing capability of information as categorization parameters. Using this one-on-one relationship, it is possible to operationalize risk management in the context of excellence. By increasing the quality of perception of the reality(ies), the adequate leadership and the management steps (e.g., the elaboration of adequate safety nudges and self-leadership) can be conceptualized and worked out further by any organisation to achieve excellence.

Chapter 3

TOTAL RESPECT MANAGEMENT – THE PHILOSOPHY 3.1. A MATTER OF CHEESE AND HOLES The original idea of Total Respect Management is based on the way the Belgian Air Force applies the Swiss cheese accident causation model (Reason, 1990, 1997) for its aircraft accident prevention and investigation efforts. Besides leading to the explanation why accidents happened, it also provides important feedback and recommendations for performance improvement and for enhanced operational safety. The Swiss cheese accident causation model, in a different way from the Cynefin framework, also allows the development of a systemic view on reality. The use of this model will help one find out how (apparently) unrelated causes (can/could) lead towards unwanted events and accidents. This systemic view consequently helps make informed decisions on how to prevent bad things from happening. The model uses the metaphor of the Swiss cheese and describes reality as such. When picturing a Swiss cheese, people imagine a cheese with holes in it. In this metaphor the cheese itself can be understood as everything that goes well. It relates to the objectives that have been achieved and which are safeguarded (hence, the cheese stands for Safety-II). On the other hand, the holes in the cheese are the different reasons which contribute to things going wrong (thus, the holes in the cheese represent Safety-I). These are the objectives which have not been achieved and which could not be safeguarded. This model soon became a reference in accident investigation and prevention and inspired others to further develop it for the use in more specific ways. To understand how to view this model, also according to Total Respect Management, it is important to remember that the reality is dynamic and that conditions change from one moment to another. It means that this Swiss cheese is also dynamic and you have to picture a Swiss cheese of which the holes constantly change positions and dimensions. In his book ‘Managing the risks of organisational accidents’ (Reason, 1997), James Reason states: “Although the model shows the defensive layers and their associated ‘holes’ as being fixed and static, in reality they are in constant flux. The Swiss cheese metaphor is best presented by a moving picture, with each defensive layer coming in and out of the frame according to local conditions. […] Similarly, the holes within each layer could be seen as shifting around, coming and going, shrinking and expanding in response to operator actions and local demands.”

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It indicates that, at a certain time, something is going well, but at the next moment the same thing can go wrong. The theory of the Swiss cheese model says that whenever these little and big holes in the cheese align themselves to make one big hole in the cheese from end to end, an important accident occurs. Therefore, accident investigation is an attempt to get a complete picture of the cheese at the moment before and after an accident took place. Because it is important to discover the holes involved in the accident and come to understanding how these holes aligned themselves to produce the unwanted event and its unwanted consequences. This knowledge can then be used to improve and prevent the same events from happening or to limit the consequences in case such an event would occur.

Figure 3.1. Traditional Swiss cheese model (Reason, 1990).

3.1.1. Latent Conditions – Objectives Not Safeguarded/Protected There are – and always will be – holes in the cheese, although these holes can be perceived very differently from time to time and from one person to another. Nobody and nothing is perfect all the time, but most of the holes are small and insignificant enough not to be a bother and not to get people’s real attention. On other occasions, holes are visible and noticed, but nobody takes the effort to do something about them, as they seem not important enough to cause serious trouble. Sometimes, holes are noticed but everybody tries to work around them, because either the will or the possibilities are lacking to get rid of them. And finally there are the holes nobody perceives and which will only be discovered when they cause sufficient damage to be noticed. These are situations and practices what Reason calls the ‘latent conditions,’ being the preconditions that provide the basic circumstances needed to generate a noticeable accident. In his model he specifies these latent conditions as being organisational factors, unsafe supervision and preconditions to unsafe acts. Although these

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categories are certainly valid, the model fails to reach its full potential when one’s intention is to strictly adhere to these classifications.

3.1.2. An Example: 4M The aforementioned categories can be seen as different ways to slice the cheese in order to find the holes. However, the accident investigators in the Belgian Air Force use this cheese model differently by slicing the cheese in their own way, befitting the manner aircraft accidents are investigated. The Belgian Aviation Safety Directorate and its Aircraft Accident Investigation Service use a 4M approach (Man, Machine, Medium and Management) in combination with the Swiss cheese philosophy, which provides a flexible way of looking at the various aspects of an aircraft incident or accident. ‘Man’ is the human factor involved in the accident, while ‘Machine’ represents the technical factors contributing to the unwanted event. ‘Medium’ is everything which can be understood as environment, physical as well as psychological. The slice ‘Management’ is in a way comparable with Reason’s organisational factors, including leadership and management decisions. Depending on the circumstances, these four parts of the cheese can be sliced into tinier pieces according to what is discovered during the course of the investigation. Each slice can again be divided in the four M’s, until sufficient detail and understanding of the accident dynamics have been reached. This method allows for the cheese to be sliced into ever tinier pieces to discover and connect the holes that were present years before the unfortunate outcome until the actual time the events took place. It gives a systemic view on the objectives that failed or that had not been safeguarded, how they were connected and how they influenced each other. Also, at the same time during such an investigation, failed objectives become clear. These objectives did not necessarily play a role in the investigated events or accident, but they can also be incorporated in the performance improvement process afterwards. This is why accident prevention is always a result of performance improvement. The way TR³M approaches the Swiss cheese metaphor is by stating that each of these latent conditions can be seen as accidents on their own. These ‘accidents,’ or failed/failing objectives, result from specific systems, created by mental models existing in, or surrounding, the organisation. It is just the level of importance and number of objectives involved that differentiate the ‘accidents’ from these apparently ‘less important’ holes. In general, it is only when these holes are seen as real accidents they are considered worth investigating. However, each of the holes is meaningful and needs one’s respect. Hence the name ‘Total Respect Management.’ The objectives, and the level at which they are negatively impacted by the occurring event(s) or condition(s), and the consequences which result from the failure of these objectives, are essential. An aircraft crash or a similar important accident, in the processing industry for instance, has an impact on many important objectives. These objectives range from very specific and individual goals towards very general and societal aspirations. They also cover different dimensions, for instance individual objectives regarding life and health, or financial objectives of the organisation regarding profit and continuity of operations or objectives regarding our environment on a societal level, and so on. The more objectives impacted by the accident and the more valuable they are, the more they will be perceived as

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an accident. One only has to think of the countless individual, organisational and societal objectives which were impacted by the Fukushima disaster. It is the range, the number and the importance of those goals that caught everybody’s attention and which will remain in mankind’s memory. Nevertheless, this accident only happened because of some latent conditions that existed in the nuclear plant and in the organisation which was operating that power plant; the protective measures, equipment and procedures in place did not achieve the objectives they were intended or designed for. Existing holes in the system nobody was aware of, or no one bothered to take action against, until it was too late. For TR³M every latent condition is a failure and as such an ‘accident’ on its own, characterised by the objectives that are not achieved or were not sufficiently protected/safeguarded. Objectives are linked to each other and when one objective fails, many others can fail too as a domino effect, causing the very small holes in the cheese to grow. It is this interconnectedness of various objectives that makes it very difficult to predict the outcome of an accident (sometimes referred to as the ‘butterfly effect’ in chaos theory), because the level of failure of one objective can influence the achievement (or not) of other objectives, causing a chain of parallel events, leading to a noticeable and undesired outcome. The complexity of society and organisations today is such that they operate ever more in the complex domain of the Cynefin framework, as conditions change at an ever increasing pace. This constant change makes it much more difficult to operate in the complicated and simple domains of good and best practices. It explains why more and more risk management is needed to stay on the safe side and keep the holes in the cheese to a minimum. When holes in the cheese, e.g., unachieved or lost objectives, are considered accidents, a loss of cheese, as a consequence, is also a loss of potential profit or value for the individual, the organisation, society or other stakeholders. This is the case when the cheese itself (and not the holes in it) is also seen as the objectives being achieved and being safe, creating value and profit for the organisation and its stakeholders. However, the cheese and the holes belong together (just like Safety-II and Safety-I belong together), you cannot have one without the other. Cheese is the performance of the system and the existence of holes in the cheese is the unsafety, or lack of safety, in that system. In other words, a lack of safety is also a lack in performance, which in turn leads towards a lack of profit, or is at least the achievement of suboptimal results.

3.1.3. Active Failures – Objectives Not Safeguarded/Protected The model developed by Reason makes a distinction between latent conditions and active failures and when considering human error, both are needed for accidents to occur. For TR³M however, there is no difference between latent conditions and active failures. Both are the result of unachieved or lost objectives. It is just the level of importance, the moment and the characteristics of these failed objectives which differentiate the various categories with which the cheese can be sliced. For TR³M any method to slice the cheese and find the holes is good, because the quality of perception in the case of an accident is low. This can be regarded as being in the chaos or the complex domain of the Cynefin framework. When one would know the cause-effect relationships beforehand, one would probably take action to prevent the accident from happening. As a consequence, it is reasonable to assume a good approach to deal with this

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situation is to do something and when a direction is found, to probe, sense and respond, as described by the Cynefin framework. The basic philosophy governing TR³M is to look over and over again to find the holes before they cause real trouble. Once discovered it is the purpose to deal with the fundamental systems that generate the holes and to modify them and develop systems which create cheese instead of holes. In other words: find the objectives that support performance and make sure they are protected and achieved, but also find the unachieved and lost objectives, together with the conflicting objectives and solve the issues involved.

Figure 3.2. Swiss cheese model (reformulated, based on Reason, 1990).

3.1.4. An Example: Latent Condition or Active Failure? What was the active failure in the Fukushima disaster? Was it the earthquake? Was it the tsunami? Was it the failure to design the defences? Was it the management decision to restrict the specifications to which the nuclear reactor had to be designed? Was it the mindset of politicians when they allowed the nuclear reactor to be built to those specifications and location? The natural phenomena are just preconditions, but the decisions regarding the nuclear power plant can be categorised as both organisational factors and active failures when viewed against the requirement of safely providing nuclear power to the society in an environment known for its earthquakes and tsunamis which are known hazards as a result of the location where the nuclear power plant was built. Certainly, conflicting objectives influenced the answers to the above questions. Management also had to think about profit and politicians also had to take care of the energy needs of society. Both are, in the short term, conflicting objectives to the requirements of building safe nuclear power stations in hazardous regions. But what would have been the decisions of the company and the government if they would have known the earthquake and the tsunami would have taken place in a relatively short time frame? What if their quality of perception would have been higher?

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3.2. SAFETY, PERFORMANCE AND SUSTAINABILITY 3.2.1. Conflicting Objectives? When dealing with objectives, whether individual, organisational or societal, there will always be conflicts. Conflicting objectives are often the source or onset of failed or lost objectives. Objectives often characterise conflicting or contradicting aspirations and their associated diverging mental models. The most common are the conflicts resulting from the time perspective one holds. Short-term perspectives often, if not always, clash with long-term, habitually more sustainable, perspectives. It is often, if not always, a matter of ‘pay me now or pay me later,’ with paying me later always being by far the more expensive option when taking all stakeholders into account, or as the saying goes: ‘Penny wise and pound foolish.’ The same is true for the conflicting perspectives of shareholder value and stakeholder value. When shareholder value prevails, sooner or later this will ricochet as a cost to all stakeholders, and eventually also to the shareholders, as has been proven by large catastrophes such as the Deep Water Horizon or the Fukushima disasters, but also by less iconic accidents, such as the ones of Texas City, Exxon Valdez, P&O Zeebrugge and many others, where short-term shareholder perspectives clashed with the long-term societal aspirations. Although these differing perspectives seem to be in contradiction, this does not necessarily mean that they are. Paying more attention to stakeholder value also makes shareholders benefit in the longer run. As stated in the introduction and the sections above, safety and performance belong together. It is the same as making cheese and simultaneously avoiding the appearance of holes in the cheese. In essence, this is the basic idea and philosophy of Total Respect Management: making and maintaining the best possible cheese without holes; a cheese without holes indicates more value when the size of the cheese is the same. Furthermore, keeping holes from appearing in the cheese requires a dedicated and positive attention to as much factors as possible influencing the cheese and its making. It requires respect for all the stakeholders (‘people’), respecting the finances (‘profit’) and also respecting the sustainability, by dealing with environmental issues (‘planet’). It means that a lot of these aspects, with sometimes seemingly conflicting objectives, need to be managed. When the focus is on ‘people’ and ‘planet,’ this could hinder ‘profit’ and when too much emphasis is put on ‘profit,’ this might result in a lack of respect for ‘people’ and ‘planet.’ However, these three aspects can and should work together: respecting people, while taking sustainability into account, will result in a sustainable profit when the right balance is kept.

3.2.2. Corporate Social Responsibility When people, profit and planet are important to an organisation, the strategic objectives will be determined accordingly. It is a mind-set and a mental model, which will generate a system that will develop the structure and the strategy to pursue the corporate goals and create value in a safe way.

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By its concept of linked processes regarding leadership, management and excellence, TR³M increases the quality of perception in a structured way. Its purpose is also to align individual, organisational and societal objectives. As a result, it reduces the uncertainty regarding the creation of value, which is the cheese in Reason’s metaphor. Only when people, profit and planet are truly equally important to an organisation, an awareness of the possible conflicts that come together with the short-term and long-term conflicting goals can be developed. Only when this awareness has really been established, does it become possible to address these issues and does it create more value in a sustainable way instead. More value results from increased performance and the ability to avoid losses at all levels of an organisation. It is why ‘performance management science’ belongs together with ‘safety management science.’ Performance can only grow in a sustainable way when safety grows accordingly. Therefore, it is necessary to develop an oversight of what is actually happening. Small (or very small) companies are able to keep that kind of oversight informally, but once organisations grow, this oversight diminishes. This is why it is important to develop a system which can keep track of the actual performance and level of safety, using performance and safety indicators that actually describe what has been done, what is going on and what is going to happen. But the system also requires to provide understanding of what went wrong and of which objectives have failed. The question is: how can this be accomplished? How can organisations increase their quality of perception regarding the total value that has been generated and the (un-)safety that has been achieved?

3.2.3. Heinrich and Reason Revisited Performance and safety have always been issues in organisations, certainly in an industrial context. Hence, the cost of accidents and the danger they present to organisations, have already been recognised a long time ago. A pioneer in this field was Herbert W. Heinrich, well known for his theories regarding human error and safety, expressed in concepts such as the domino theory or his accident pyramid (sometimes also called Heinrich’s safety triangle). For many years these theories have dominated the realm of accident investigation and prevention. To a certain extent and in one form or another, Heinrich’s theories are still valid and used today. In fact, you could consider Reason’s Swiss cheese model as an extension or a more comprehensive development of the domino theory, indicating accidents happen due to a multitude of, most of the time human, factors influencing each other. The holes in the slices of cheese in Reason’s model are nothing more than the dominoes in Heinrich’s model. The strength of both models lies in their metaphors; they provide ways to understand the complex reality of accidents and loss. On the other hand, the weakness of both models lies in the fact that they focus on human behaviour and error and as a consequence, errors are categorised and given specific significance. Although it helps to have a limited number of categories and a specific significance, it sometimes leads people to dismiss the basic knowledge both models provide. Besides human error, other factors which are not represented in these models also play a role in organisational safety and performance. This makes these models incomplete from the start when only these specific categories are considered, certainly when maintaining a very strict interpretation on their significance. However, dismissing these models should not lead to

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dismissing the general meaning of their metaphors. When practitioners interpret these models strictly, they will soon find out that the models do not describe every accident and that maybe other categories should have been considered as well. Likewise, sometimes it also leads practitioners in the wrong direction. For instance, in the way they have to solve the problem of fallen dominoes and holes in the cheese, by limiting themselves by trying to take the dominoes away or by attempting to put barriers in front of the holes or behind them. Although these measures are valid from a short-term perspective, these are not the fundamental solutions to the problems posed by the metaphors. However, when a practitioner first considers the metaphor and finds or develops his own categories, depending on the situation at hand, both models provide the same insight. In the same way that Reason considered his slices of cheese and holes needed to connect, Heinrich considered that his dominoes (categories) needed to tumble and hit one another to have an accident. For Heinrich’s model it is important to keep the dominoes standing up and for Reason’s Swiss cheese model it is important to block the holes or make them disappear. When abstraction is made from the categories of both models and when fallen dominoes or holes in the cheese are being considered as failed objectives, both models keep their relevance and usefulness, whatever the industry or the circumstances were when the accidents took place. The models can be used universally. In other words, both want the objectives related to the dominoes or the holes in the cheese to be achieved. The holes need to be(come) cheese and the dominoes need to keep standing up. Another aspect which is still valid, is the fact that it requires more than just one objective to fail before a substantial accident occurs because important matters will always be a construction of many less important or less obvious objectives, which need to fail first, often happening considerably spaced in time.

3.2.4. The Concept of Unsafety Since performance and safety belong together, it is very difficult to indicate and prove the effect of safety. What part of the cheese is actually due to the efforts regarding safety and which part is solely a result of intrinsic performance? It is hard to tell and it is why safety always has a hard time to prove itself to managers and business owners. In fact, the only thing regarding safety which can be demonstrated is the actual lack of safety. An exact identification of safety is not possible; only unsafety can be determined exactly: only when an accident occurs, the proof of a lack of safety is delivered. Hence, the credo “If you think safety is expensive, just try an accident,” coined by Trevor Kletz. Unsafety is a much easier concept to verify. And this is what safety statistics generally indicate, but all too often in a very incomplete way. It is not the level of safety which is reported, but the level of unsafety regarding very specific objectives instead. Unsafety has to be seen as being the presence of the small and large ‘accidents’ that will be reported and put into statistical evidence. In fact, the real level of unsafety of an organisation is the whole of small and bigger objectives that have failed, not just those indicated by the (un)safety statistics used in general (such as LTIR, etc.).

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However, even on a personal level, it is very difficult to make a list of all the objectives a person pursues or considers important. Objectives are never isolated and they form a very complex web of interdependent, connected, specific or less specific goals, unconscious desires or other wants and needs. Furthermore, these objectives (also on a personal level) work in concert or conflict with each other. So it is very difficult to know if these objectives have all been reached and whether or not they are safe. For organisations this difficulty is even more obvious as the objectives of all stakeholders should be taken into account and without proper consultation and communication, stakeholder objectives often remain obscured and unaccounted for. A moment of unsafety, however, can and should be noticed. When objectives are negatively affected and fail, when they are disturbed or have not been achieved, consequences will sooner or later become noticeable and will indicate this lack of safety and performance. But the gravity of the symptoms and consequences of affected objectives depends on the importance of the objective that has been touched and, regrettably, most of the time these losses and warning signals, although noticed, are not significant enough to be investigated or not even to get reported. Nevertheless, it is just at this basic level of insignificant failures where the real level of safety can be determined, because little insignificant losses have the potential to add up and cluster, becoming bigger and becoming more significant losses. Small holes in the cheese come together to form larger holes, until they are large enough to cause real trouble, thus when reporting or an investigation is needed. In the meantime, a lot of time, energy and money are lost as a consequence of these negatively affected goals (Cf. Accident Causation Model, Meyer and Reniers, 2013). TR³M aims to respect (look again at) all stakeholders’ objectives. Although it is seemingly impossible to do so, the more these small and trivial failures can be noticed and reported, the more it will provide an insight in the actual level of safety of an organisation and its objectives. It is a matter of how precise an organisation can detect unachieved and failed objectives of all the stakeholders that will provide a clear view on the level of safety of that organisation. This is what Heinrich already noticed when he formulated his law on the safety triangle or also called the accident pyramid, as he noticed a relationship between the number of insignificant failures, significant and important accidents, and human catastrophes.

3.2.5. Definitions Providing a Foundation for Safety Science (by Peter Blokland*) In order to understand safety/unsafety it is helpful to use a coherent set of definitions. From a Total Respect Management perspective, the following set of definitions, aligned with ISO 31000, should be used: Occurrence = Something happening or not happening Circumstances = Influencing factors (dictionary.com) – (using the word factors in its broadest sense) Event = occurrence or change of a particular set of circumstances (ISO 31000) Incident = an event having a negative effect on objectives Happening = an event having a positive effect on objectives Accident/Mishap = an event having an unintentional negative effect on objectives

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Attack/Onslaught/Assault = an event having an intentional negative effect on objectives Design = a construct having an intentional positive effect on objectives Uncertainty = the state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood (ISO 31000) Risk = Effect of uncertainty on objectives (ISO 31000) Risk source = element which alone or in combination has the intrinsic potential to give rise to risk (ISO 31000) Consequence = outcome of an event affecting objectives (ISO 31000) Likelihood = chance of something happening (ISO 31000) Regarding safety as a device or situation Safe(ty) (broad perspective) = the condition/set of circumstances where the likelihood of negative effects on objectives is Low Safe(ty) (narrow perspective) = the condition/set of circumstances where the likelihood of unintentional negative effects on objectives is Low Secure(ty) = the condition/set of circumstances where the likelihood of intentional negative effects on objectives is Low Unsafe = the condition/set of circumstances where the likelihood of negative effects on objectives is High Unsecure = the condition/set of circumstances where the likelihood of intentional negative effects on objectives is High Regarding safety as a result Performance = the result of conditions/sets of circumstances Excellence = the result of conditions/sets of circumstances where the likelihood of positive effects on objectives is High Failure = the result of conditions/sets of circumstances where the likelihood of negative effects on objectives is High Safety = the result of conditions/set of circumstances where the likelihood of negative effects on objectives is Low Safety (narrow perspective) = the result of conditions/set of circumstances where the likelihood of unintentional negative effects on objectives is Low Security = the result of conditions/set of circumstances where the likelihood of intentional negative effects on objectives is Low Unsafety = the result of conditions/set of circumstances where the likelihood of negative effects on objectives is High Success = the resulting state where excellence is High and failure is Low Some additional notes expressed in the ISO 31000 standard:  An event can be one or more occurrences, and can have several causes  An event can consist of something not happening  An effect is a deviation from the expected — positive and/or negative  Objectives can have different aspects (such as financial, health and safety, and environmental goals) and can apply at different levels (such as strategic, organisation-wide, project, product and process).

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Risk is often characterized by reference to potential events and consequences, or a combination of these.  Risk is often expressed in terms of a combination of the consequences of an event (including changes in circumstances) and the associated likelihood of occurrence. * With a special note of gratitude to Laobing Zhang for his valued contribution in developing a coherent set of definitions. 

3.2.6. Heinrich’s Pyramid and Consequences of Human Error Heinrich’s pyramid resulted from studying human error in a socio-technical context. One could say he focused on the specific individual objectives regarding the performance of men in an industrial environment. Specifically, he built his law on the personal/individual objectives of health and the prevention of injury. His law describes the ratio of injuries (accidents) compared to the number of potential accidents or ‘near misses.’ In his book ‘Industrial accident prevention’ (Heinrich, 1931), he puts forward the following statement: “[…] for each accident producing a personal injury of any kind (regardless of severity) there are at least ten other accidents; furthermore, because of the relative infrequency of serious injuries, it requires 330 accidents to produce only one major injury and 29 minor injuries.” It is what has become to be known as Heinrich’s safety triangle or ‘accident’ pyramid.

Figure 3.3. Heinrich’s accident pyramid (Heinrich, 1931).

This pyramid from Figure 3.3 can be interpreted in different ways, but Heinrich was very clear to what it explained and what not: “In determining the ratio of 329 no-injury accidents to one major injury, only actual visible evidences of man failure that resulted in narrow escape from injury – such as dropping or fumbling of tools or other objects, falls of persons, and unsafe practices – were included, and practically all accidents caused by machines were excluded, even though the latter would have raised the no-injury frequency materially.” (Heinrich, 1931)

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Nowadays the validity of Heinrich’s pyramid is being questioned, and indeed, only human error (visible evidences of human failure) resulting in injury or death was considered. When people consider the exact numbers used in his pyramid and use these numbers for other types of failures (other objectives), it is easy to contradict this law and dismiss it as it is conceivable other laws and ratios govern these different objectives. However, with the following saying in mind: ‘The pitcher goes so often to the well that it is broken at last,’ it is easy to recognise the wisdom that is expressed in Heinrich’s law. When a pitcher is not perfect and shows some flaws in the form of little cracks, it only takes a number of times for the pitcher to go to the water for the little cracks to become bigger and join other cracks, until a crack is big enough for the pitcher to break. In fact, the same applies for the Swiss cheese, where little holes in the cheese merge making bigger holes, until a hole is big enough to go through the whole cheese and then an accident or a disaster occurs. The more and the bigger the cracks, the sooner the pitcher will break. Safety statistics that are kept are mostly about health and safety issues, often expressed in the form of injury records (Total Recordable Injury Rate (TRIR) or Lost Time Injury Rates (LTIR) for example). Zero accident statistics and policies to chase these records create false beliefs that the organisation is safe when no injuries are recorded, whether due to all kinds of practices to trick reality or due to the actual caution of people who mind their own well-being. It is another reason why the usefulness of Heinrich’s law can easily be contradicted as well, as a specific focus on one’s own well-being will not necessarily lead towards a better performance in general, nor will it be valid for technical issues and other organisational shortcomings, as interactions and the cause-effect relationship is never clear beforehand. In the case of Heinrich’s study, the relationship of human error and physical harm is much easier to conceive and predict beforehand. Although the link between personal objectives regarding the prevention of injuries and organisational performance goals exists, it is often unclear to individuals how this link works and how it depends on the concerned sector or the industry’s hazards, opportunities, strengths and weaknesses. Therefore, to have a better understanding of the level of safety, it is important to understand which individual, organisational and societal objectives are involved and how they mutually relate and interdepend. Life is like building the longest line of domino blocks. It involves a lot of dominoes and you do not want them to tumble until it is time to break the record. Each domino is an objective, linked with other objectives. If one falls, a lot of other dominoes will tumble as well. Unless you are able to stop the chain reaction when an error occurs while building the cascade, your record attempt will fail and unless everything goes as planned, you will never be able to predict which domino will fall first. In other words, you can never be sure which failed objective will trigger the domino effect. Reason’s Swiss cheese model is focused, in the same way as Heinrich’s study, on human error, not only at the individual performance level, but also on its repercussions at the organisational level. This indicates that objectives are more than just individual ones. Besides objectives of individuals, organisational objectives can also be found at different levels in the hierarchy of organisations. One can also consider objectives which transcend organisations, as they are common to communities or society. When the ‘cracks in the pitcher,’ the ‘holes in the cheese’ or the ‘dominoes’ are only of concern to individual objectives, then the accident or the disaster will be an individual one. This is actually what Heinrich’s study was all about. Workers make mistakes and a statistical relationship between uneventful mistakes (near misses), light injuries, severe injuries and deaths can be established. It is a relationship in one

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dimension and a specific set of related objectives, being the correct execution of tasks, related to the likelihood of injury. He never made a link to organisational or societal objectives in his study. His study and the law derived from it were about a well-defined cause-effect relationship. Organisational objectives are built up by a large variety of different kinds of individual objectives, of which health is just one tiny, even though important, aspect. Likewise, societal objectives are a mix of many individual and organisational objectives. Therefore, it becomes impossible to draw the same statistical conclusions between observed accidents and the underlying errors and events that are at the root of these accidents. Organisations and certainly society are very complex systems where cause-effect relationships are most of the time beyond the comprehension of men. However, understanding these relationships and how they lead to consequences, is exactly what safety science should aim for. How do individual objectives impact organisations and how do individual and organisational objectives impact society or even the whole planet? On a deeper level, one could also ask the question: “Where do these objectives come from?” Safety is about understanding where the cracks in the pitcher come from and how the cracks come together to form bigger cracks until the pitcher breaks. In order to come to this understanding it is important to measure what is really happening. What is the performance of individuals, organisations and society as a whole and what is the level of (un)safety accompanying these performances? This is a matter that TR³M also takes a better look at and tries to gain insight in.

3.3. MEASURING (UN)SAFETY When it is in the philosophy of TR³M to give the appropriate attention to objectives up to the individual level as much as possible, it is also important to know what is happening to all of those objectives and how these objectives interact to form cracks in the pitcher or holes in the cheese. Therefore, TR³M is destined to build systems knowing how cracks can be avoided and in which way more cheese can be obtained.

3.3.1. Level of Impact When affected objectives are of an organisational dimension, accidents or disasters will impact organisations. Likewise, when societal objectives are involved, the same happens to society as a whole. Conversely, individual objectives will always be involved and impacted when organisational objectives are affected. In the same way, individual and organisational objectives will also suffer when societal catastrophes occur. As a result of its philosophy, Total Respect Management aims to cover not just the individual tasks and responsibilities, but the whole range, from individual to societal objectives, and not only the objectives related to injury, but to a wide range of dimensions, in order to develop a systemic and comprehensive view on individual, organisational and societal safety. It wants to respect all objectives and have them as safe as practicable, knowing it is an impossible task to achieve a safety of one hundred per cent. But the real aim is to keep on improving in this, whatever the level at the start.

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3.3.2. An Example: Volkswagen Group In 2015 organisational objectives of the Volkswagen Group to increase profit, while becoming the number one car manufacturer, were apparently conflicting with environmental and societal objectives of lower carbon dioxide (CO2) and nitrogen oxide (NOx) emissions. Not taking the objectives of society (always a very important stakeholder when sustainability is an issue) into account resulted in a financial and reputational loss for the VW Group and its managers and a loss on environmental objectives for society. On 18 September 2015, the United States Environmental Protection Agency (EPA) issued a notice of violation of the Clean Air Act to the German Volkswagen Group, after it was found that the car manufacturer had intentionally programmed turbocharged direct injection (TDI) diesel engines to fool official instances; special routines were meant to activate certain emission controls during laboratory emission testing and only during this testing. The programming caused the vehicles' NOx output to meet the US standards during regulatory testing, but in reality they emitted up to 40 times more NOx. Volkswagen put this programming in about eleven million cars worldwide and in 500,000 cars in the United States in the period of 2009 through 2015. (These findings stemmed from a study on emissions discrepancies between European and US models of vehicles commissioned in 2014 by the International Council on Clean Transportation (ICCT), summing up the data from three different sources on 15 vehicles. Among the research groups was a group of five scientists at West Virginia University, who detected additional emissions during live road tests on two out of three diesel cars. ICCT also purchased data from two other sources. They provided their findings to the California Air Resources Board (CARB) in May 2014). As a result of this disregard of societal objectives, Volkswagen became the target of regulatory investigations in multiple countries and Volkswagen's stock price fell by a third in the days immediately after the news. Volkswagen Group’s CEO was forced to resign. Furthermore, the head of brand development, the Audi research and development head, and also the Porsche research and development head were suspended. Volkswagen announced plans to spend (USD) $ 7.3 billion on rectifying the emissions issues and planned to refit the affected vehicles as part of a recall campaign.

3.3.3. Categories and Dimensions of Objectives In the example above, it is clear that individual (shareholders and top managers), organisational (board and management) and societal (environmental) objectives are linked in many ways. Egos wanting to become the number one and managers trying to find the shortest way to success, combined with the company’s goal concerning profit and a return on investment, impacted on societal objectives regarding the health of people and planet; it was obviously easier and faster to come up with cheating software than to develop sound and sustainable solutions to comply with the environmental regulations, putting individual and organisational objectives before societal requirements. This is an example of the ‘pay me now or pay me later’ principle at work in the industrial practice. Short-term thinking to avoid costs to boost profit (pay me now) has been followed by the fines and the necessary rectifying

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actions (pay me later), where the latter will largely outnumber the first. This interconnectedness of objectives is typical for the complexity of today’s society. So it has already happened before and it will happen again: individual goals conflict with the company’s objectives, which in turn conflict with the societal needs and requirements, resulting in a loss for the individual, the company and society. Financial crises, environmental disasters and individual harm are just some of the many possible negative outcomes in the long run. Understanding these different levels of objectives and how they interact is a difficult task. Therefore, it is important to be able to measure the (un)safety starting at the individual level. As indicated before, it is very difficult to measure safety, but it is much easier to measure unsafety. However, to understand what is really happening and to be able to anticipate or even to be proactive regarding safety and performance, it is very helpful to distinguish the different categories and dimensions of the objectives. There are many ways to determine these categories and dimensions and although Total Respect Management is interested in every category or dimension, this would not be very practical. Therefore, to measure unsafety in organisations, a standardised set of consistent, encompassing categories and dimensions should be selected in a way that they are valid for any organisation, whatever the size or sector it is operating in. We have already mentioned the individual, organisational and societal impact levels. But these could also be more fine-tuned with team, section and division dimensions for organisations, or community and planet dimensions for society. Although these impact levels provide a sense of gravity of loss and performance, it is equally important to be able to understand which kinds of objectives are impacted. To be able to compare organisations, it is necessary to determine appropriate sets of categories of objectives. Deciding on a minimum set of encompassing impact levels, dimensions and categories will make the development of a universal measuring system possible, able to measure (un)safety in organisations, which is, as much as it can possibly be, indifferent from the size, the sector or the industry. This is necessary if one aims to develop an understanding on a systemic level; it is only possible to compare and benchmark organisations in an unambiguous and impartial way when a common set of dimensions, categories and severity levels can be agreed upon. It is also necessary to build the sound statistical evidence to learn how objectives at different levels in the hierarchy of an organisation and different categories are linked to and influence each other.

3.3.4. The Numbers Tell the Tale When managing organisations, it is of the utmost importance to know what is happening. When the organisation is a very small SME, it remains possible for the manager or the owner to have and maintain a very good picture of his or her business. He or she does not need anything more than just one’s own perception, because the manager or the owner is aware of everything that happens in and around the organisation. However, when organisations develop, the need grows to maintain a certain level of the quality of perception regarding the organisations performance, as well as of its health and safety. Therefore, when the organisation grows beyond the control of one manager, the need for clear and correct performance and safety indicators intensifies.

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The larger the organisation, the more individual goals will be involved and the more important it becomes for society. Beyond a certain number of employees, it becomes impossible for the owners and managers of the entity to maintain a correct picture of the organisation’s performance and well-being. Due to more complex systems and the multitude of objectives, it is very difficult to avoid generalisations and distortions of particular results, leading towards a generalised, but often distorted, vision of the organisation’s reality. Without corrections, the distorted views will lead towards skewed decisions and suboptimal results. It is why larger organisations need exact numbers, in the form of performance indicators, risk indicators or success indicators to tell the tale. Exact numbers are hard to find on a moment’s notice. Most of the accurate indicators are lagging, often even far, behind. It makes these indicators unfit to be used as a basis for instant decision making. When organisations are very small, this is not a real problem. A look at the bank account and counting the orders and the anticipated expenses, already give a good idea of where the situation is headed. But as organisations grow, time lapses between the actual performance and the numbers become clear. Therefore, the need for leading indicators increases. Additional leading indicators illustrate future situations. The better they predict future situations, the more they can be used as a basis for decision making and to keep the organisation on track. However, reliable leading indicators depend on a lot of internal and external factors and are not easy to conceive. It becomes even more problematic when lagging indicators are unable to translate numbers into a correct view on the actual situation of the organisation and when these indicators are used to determine the general course of action. Sometimes it takes time to develop anticipated results while moving into the right direction. Insufficient reliable and leading indicators can easily lead to missing the promising signs of future success and to showing only the disastrous situation of past times. Likewise, a disastrous situation can remain hidden by the indicators and perceptions of a past success. When lagging indicators are taken too seriously it can lead to making the wrong decisions and doing exactly the opposite of what should be done. It is like instinctively reacting to events instead of reacting after careful consideration to the forces that generated the events.

3.4. UNCERTAINTY MANAGEMENT AND HIGH RELIABILITY ORGANISATIONS The best available ‘classic viewpoint’ of risk management is one of the (narrow) thinking of purely organisational risk management, and taking different domains within the company into account: integrating them to take decisions to maximise the positive side of risks and to minimise the negative side. The process for taking decisions in organisations, however, should be much more holistic than this. Risks are characterised by internal as well as external uncertainties. Hence, all these uncertainties and their possible outcome(s) should be anticipated, identified and mapped for every risk, and by different types of experts and stakeholders. If this can be achieved, the optimal decisions can be taken. The end goal is to use all the right people and means at the right time, to manage all existing risks in the best possible way, whether the risks are positive or negative, or whether they are known or not.

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After all, a part of risk management is improving our perception of reality and ‘thinking about the unthinkable.’ This boils down to the philosophy of ‘Total Respect Management.’ To manage uncertainties and risks efficiently a composite of three building blocks (knowledge and know-how, stakeholders and expertise, and mind-set) can thus be conceptualized. For each of these building blocks, needed by an organisation to efficiently perform ‘uncertainty management’ (or adequate Total Respect Management), some recommendations can be suggested. To deal with the knowledge and the need for know-how, cognition should be present in the organisation about past, present and (e.g., scenario-based) future data and information, and about risk taking, risk averting and risk neutral items. Furthermore, the organisation should collect information on laws and regulations, rules and guidelines, and best practices and ideas, and also on the procedural, technological and people domains. To address the stakeholders and expertise building block, the involvement should be considered ranging from different organisations, authorities and academia, to the other stakeholders (clients, personnel, pressure groups, media, surrounding communities, etc.), and to different types of disciplines (engineers, medical people, sociologists, risk experts, psychologists, etc.), and this involvement should be used where deemed interesting. The mind-set building block indicates that, besides existing principles, some additional principles should be followed for adequate uncertainty management: circular, non-linear, and long-term thinking, the law of iterated expectations, scenario building, the precautionary principle, and operational, tactical, and strategic thinking. All these requirements should be approached with an open mind, which is truly very important. Actually, organisations capable of gaining and sustaining high reliability levels are called ‘high reliability organisations’ or HROs. Despite the fact that HROs deal with hazardous activities within a high-risk environment, they succeed in achieving excellent health and safety figures. Hence, they identify and eliminate risks very efficiently and effectively. A typical characteristic of HROs is collective mindfulness. Hopkins (2005) also indicates that HROs organise themselves in such a way that they are better able to notice the unexpected in the making, and halt its development. Hence, collective mindfulness in HROs implies a certain approach of organising themselves. Five key principles are used by HROs to achieve such a mindful and reliable organisation (Weick and Sutcliffe, 2007). The first three principles mainly relate to anticipation, or the ability with which organisations can cope with unexpected events. Anticipation concerns disruptions, simplifications and execution, and requires the means of detecting small clues and indications, with the potential to result in large, disruptive events. Of course, such organisations should also be able to decrease, to diminish or to stop the consequences of (a chain of) unwanted events. Anticipation implies the ability to imagine new, uncontrollable situations which are based on little differences with well-known and controllable situations. HROs take these into account in principles 1, 2 and 3. Whereas the first three principles relate to pro-action, the fourth and fifth focus on reaction. It is evident that if unexpected events happen despite all the implemented precautions, the consequences of these events need to be mitigated. HROs take these into account in principles 4 and 5.

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3.4.1. HRO Principle 1: Targeted at Disturbances This principle asserts that HROs are very actively, and in a proactive manner, looking for failures, disturbances, deviations, inconsistencies, etc. because they realise that these phenomena can escalate into larger problems and system failures. They achieve this goal by urging all employees to report (without a blame culture) mistakes, errors, failures, nearmisses, etc. HROs are also very much aware that a long period of time without any incidents or accidents may lead to employee complacency, and may moreover lead to less risk awareness and less collective mindfulness, eventually leading to accidents. Hence, HROs rigorously make sure that such complacency is avoided at all times.

3.4.2. HRO Principle 2: Reluctant for Simplification When people – or organisations – receive information or data, there is a natural tendency to simplify its meaning or to reduce its size. Parts of the information which are considered as non-important or irrelevant, are omitted. Evidently, information that may be perceived as irrelevant might in fact be very relevant in order to avoid incidents or accidents. HROs will therefore question the knowledge they possess from different perspectives and at all times. This way, the organisations try to discover ‘blind spots’ or phenomena that are hard to perceive. To this end, extra personnel (as a type of human redundancy) is used to gather information.

3.4.3. HRO Principle 3: Sensitive towards Implementation HROs strive for continuous attention towards real-time information. All employees (from front-line workers to top management) should be very well-informed about all organisational processes, and not only about the process or the task they are responsible for. They should also be informed about the way that organisational processes may fail and how to control or repair such a failure. To this end, an organisational culture of trust between and among all employees is an absolute must. A working environment in which employees are afraid to provide certain information, e.g., to report incidents, will result in an organisation which is lacking in information, and in which working efficiently is impossible. An ‘engineering culture,’ in which quantitative data or information is much more appreciated than qualitative knowledge or information, should also be avoided. HROs do not differentiate between qualitative and quantitative information. HROs are also sensitive towards routines and routine-wise handling. Routines can be dangerous when leading to mindlessness and distraction. By installing a job rotation and/or task rotation in an intelligent way, HROs try to prevent such routine-wise handling. Furthermore, HROs view near-misses and incidents as opportunities to learn. The failures that go hand-in-hand with the near-misses always reveal potential (and otherwise hidden) hazards. Hence, such failures serve as an opportunity to avoid similar incidents in the future.

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3.4.4. HRO Principle 4: Devoted to Resiliency HROs define ‘resiliency’ as “the capacity of a system to retain its function and structure, regardless of internal and external changes.” The system’s flexibility makes it possible to keep on functioning, even when certain system parts do not function the way they should anymore. An approach to ensure this resilience is to let employees organise themselves into ad hoc networks when unexpected events happen. These networks can be regarded as temporary and informal networks capable of supplying the required expertise to solve the problems. When the problems have disappeared or are solved, the network ceases to exist.

3.4.5. HRO Principle 5: Respectful for Expertise Most organisations are characterised by a hierarchical structure with a hierarchical power structure, at least to some degree. This is also the case for HROs. However, in HROs the power structure is no longer valid in unexpected situations in which a certain expertise is required. The decision process and the power are transferred from those at the top of the hierarchy (in normal situations) towards those with the most expertise regarding certain topics (in exceptional situations).

CONCLUSION The philosophy of Total Respect Management is about having an eye for not only the cheese, but also for the holes in it. This seems easier and more straightforward than it really is. Excellence, and thus maximally avoiding losses in combination with maximally increasing gains, requires very sound definitions for safety, security, etc. being holistic enough and at the same time still understandable and down to earth so that they can be used in organisational practice. Using these well-defined definitions, an open mind, cooperation with the stakeholders, the expertise, and the knowledge and the know-how, are required to find all of the holes. Furthermore, it is also possible to employ the High Reliability Organisation principles in this regard, as they are very much in line with the TR³M philosophy.

Chapter 4

A MEASURING SYSTEM FOR (UN)SAFETY Measuring performance is already a well-developed field of management science, especially from a financial perspective. Certain systems based on business methodologies, like the balanced scorecard for example, help translate corporate objectives and related strategies into targets and goals which can be scored, providing a lot of data and information to build meaningful indicators and dashboards. The problem here is the effort needed to build a comprehensive list of aligned targets and indicators. Although common indicators can be determined, due to the uniqueness of every organisation, most of these targets are distinctive to the organisation, making it difficult to compare and benchmark performance between organisations, certainly when these organisations belong to different sectors. Total Respect Management proposes a bottom-up approach aligned with its philosophy and its definition of ‘unsafety’ as ‘objectives that have failed’ instead of working top-down and translating corporate objectives and strategy into indicators. TR³M determines a set of universal categories and dimensions of objectives which can be used for reporting and monitoring on a continuous and permanent basis, making it possible to discover those failing objectives, even when they have not been considered in a balanced scorecard-like system. The TR³M system pays attention to everything that is going wrong in the organisation and is also able to cover and deal with implicit objectives (objectives that are not consciously, explicitly considered or reflected upon), which are difficult to incorporate in traditional performance management systems. Obviously this system is not meant to replace existing performance management systems. One needs both systems to fully comprehend what is happening in the organisation. The measuring system that TR³M puts forward is aligned with its philosophy, which means that it aims to respect all the small holes in the cheese and gives them the attention they need. It is why it also incorporates implicit individual goals and the losses incurred by these individuals when their individual objectives fail. The challenge with this approach is to actually capture the failures of these individual goals (which are always failing before the organisational goals do), requiring the individuals to report about their failures and about those of their colleagues. This is only possible in a ‘no blame’-culture and when a focus on continuous improvement exists. As a consequence, such a culture is essential in Total Respect Management.

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Most of the time ordinary things just work out fine. Daily routines become habits and we do not consider the risks anymore. As an example we consider the drinking of coffee at work. In itself, drinking coffee is a very trivial thing, happening every day all over the world. However, it is a risky thing to do, because many implicit objectives can be linked with drinking coffee at work. One aspect can be the desired availability and quality of the coffee and its positive effect on the good mood of the people working in the organisation. When everything is fine, nobody will notice anything regarding this trivial and individual objective. However, what happens when this basic need is no longer satisfied? People start complaining, become bad tempered, irritated or worse. When the objective of a good coffee break fails, this can lead to many unwanted negative effects in the organisation. When this only happens occasionally and the spirits are high (very limited failed psychological objectives), it does not pose a real problem. But, if it happens frequently, when the organisational atmosphere is already tense and everybody is on edge (a lot of failed emotional objectives), this could lead to serious troubles within the organisation with the possibility of people deciding to go on strike, which could impact the whole organisation in a negative way. A different way how failed objectives regarding the drinking of coffee can impact individuals and the organisation becomes evident when coffee is spilled. One of the implicit objectives related to drinking coffee at work is to drink it warm or hot and to keep the coffee in the cup until it is consumed. Nevertheless, once in a while this objective fails and coffee is spilled. When this is the only objective which fails, little harm is done. But it is easy to imagine cases where hot coffee is spilled on clothes and body parts, causing unwanted stains or worse, severe burns. In other instances, when the coffee spills on vulnerable equipment or important documents, the damage can also be significant and costly for the organisation itself. As soon as other objectives are impacted due to the failed objective(s), the level of importance scales up rapidly.

4.1. LOSS CATEGORIES As indicated in the examples above, consequences of failed objectives can be very diverse. These consequences can be seen as objectives that fail as well, generating the loss. To see the safety of an organisation clearly, it is necessary to create structure in the different consequences. Some consequences require immediate action; others may be dismissed. Some consequences will only impact the individual and others can impact the whole organisation. In order to be proactively safe, it is important to recognise the objectives that need to be safeguarded or restored, before knock-on effects increase the holes in the cheese. To structure these trivial and often dismissed losses or failed implicit objectives, one can imagine different and distinctive categories for which clear indicators can be determined. Hence, the TR³M unsafety measuring system proposes the following limited list of distinctive, but still interdependent, loss categories which need a dedicated attention to become proactively safe for organisations and to help them perform well.

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4.1.1. Time Loss The loss of time is probably the most frequent loss in organisations. It is also a loss category often forgotten. It is why projects are late most of the time. However, not every loss of time is a waste of time. The effect of uncertainty can also have positive effects. So this category concerns the moments when a loss of time is also experienced as a waste of time. This loss of time can be less than an hour, less than a day or more. Time is money, so time lost also means money has been lost. Remark: This notion has to be balanced by the concept of gaining time. Gaining time can also mean gaining money. However, this will only be true when no negative effects of uncertainty have been introduced. Otherwise, time gained can become money lost. Many accidents result from taking shortcuts in order to gain time, eventually resulting in losses for all the other loss categories, as has been illustrated by the example of Deepwater horizon accident (2010).

4.1.2. Emotional/Psychological Loss When people become upset, are worried, angry or experience any other negative emotion, this incurs an emotional or psychological loss. This disturbance can be present for a short time or it can build up over a longer period of time. Negative emotions can prevent people from doing their job properly. In extreme cases this can even lead to suicide. A more common situation is people who are forced to stay at home due to a burn-out or a depression which also results in time and possible financial losses. Capturing emotional losses at an early stage can therefore be very important to gain insight and prevent this kind of loss, which often creates effects with a considerable impact on organisations.

4.1.3. Material Loss When property or equipment is damaged or lost, this can be identified as a material loss. Material loss often generates further effects of time loss and/or financial loss when equipment needs to be repaired or replaced. Material loss can also result in emotional loss when the object damaged or lost has a strong emotional value and when it is difficult to restore.

4.1.4. Financial Loss Any negative deviation from an expected financial outcome is a financial loss. These deviations can comprise unexpected expenses, an unexpected decreased income or any other loss directly expressed in financial terms. Like any cost has its financial repercussions, financial loss should not be a duplication of other losses, unless they are an additional followup effect of these other types of losses.

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Peter Blokland and Genserik Reniers An example of escalation effects and financial losses

A material loss requires a financial effort to restore the situation. A part of that financial effort is the equipment itself. This part of the financial loss does not need to be duplicated as a financial loss. But the indirect costs resulting from the material loss, such as a functionality loss (equipment unavailable to do the job), resulting in a negative deviation from the expected income, can clearly be considered as financial losses.

4.1.5. Physical Loss Any physical injury or physical pain is a physical loss. In the same way as the previous examples, this type of loss can easily lead towards knock-on effects, resulting in functionality, emotional and/or financial losses.

4.1.6. Reputational Loss Any negative impact on one’s reputation is a reputational loss. This can occur at the individual, team, organisational and even at the societal level. Reputational loss will, in one way or another, eventually result in financial loss.

4.1.7. Functionality Loss A functionality loss occurs when a person, a group of persons or some equipment is impacted in such a way that they are unable to execute and/or accomplish their normal and dedicated tasks. This functionality loss can be momentary, for a longer period of time or even permanent. This kind of loss will always affect other loss categories whether or not the situation has to be restored or when the situation of functionality loss persists.

4.1.8. Environmental Loss Environmental loss is any loss perceived in one’s physical environment as a result of a failed objective. As an example, spilled coffee can have an impact on the physical environment, causing stains or other unwanted effects on one’s environment. When the environment needs to be restored, it will also impact other loss categories, such as time loss, emotional loss, material loss, etc.

4.1.9. Considerations One could also imagine the category ‘technical loss.’ However, a technical loss is either a functionality loss (equipment does not achieve its intended objective), a material loss

A Measuring System for (Un)Safety

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(equipment is defective and needs repair or replacement) or a combination of both of these categories. Although the above categories of failed objectives or losses are distinguishable, they are also interrelated as shown by the many examples of interrelated effects. The effect of uncertainty on one objective (e.g., drinking coffee at work) can have an indirect effect on many other objectives, resulting in damage to the organisation. When there is no coffee and people are upset, the loss is emotional. In the case of spilled coffee, the loss can be material due to damaged equipment, physical when burns are incurred, reputational (e.g., when bad things keep on happening with the same person), financial (directly e.g., for the extra cost of the dry cleaner and indirectly as a result of having to restore functionalities), time (e.g., to clean up) or even environmental when visible stains degrade the outlook of the working environment. Objectives fail either unintentionally or by a deliberate action. When a loss is unintentional, one can consider this as a lack of safety and when a loss is the result of a deliberate action, it can be considered as a lack of security. The only distinction between safety and security is seen in the different approach and the expertise which are needed to understand and deal with the situation. In both cases different questions have to be asked and different actions have to be taken, but in essence, they both are the result of failed objectives.

4.2. SEVERITY LEVELS For each loss category, universal severity levels can and should be determined. The unit in which to express the loss incurred is dependent on the category. Two of the most appropriate parameters to describe a loss are time and money. Although one can say time is money, this is not entirely true. Of these two, time is the most precious good, as it can never be recovered. Lost time is lost forever. Although time and money can be transmuted into each other in certain ways, both parameters are different and have their specific significance. Therefore, they should both be recorded in order to construct meaningful data and dashboards derived from that data.

4.2.1. Time In case of time loss, very clear and common severity levels, indifferent from one organisation to another, can be determined. These levels can coincide with how we measure time in a standardised way: seconds, minutes, hours, days, weeks, months and years. Boundaries of severity levels can for example be expressed as follows: < 1 hour, < 1 day, < 1 week, < 1 month, < 1 year, more than 1 year and permanent (eternal). Maybe, in certain sectors such as the aerospace, healthcare or process industry, one can also imagine very precise boundaries, such as < 1s. It all depends on the objectives involved and precision available to measure the time related to the loss.

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Peter Blokland and Genserik Reniers

4.2.2. Money Financial parameters are more difficult to handle in developing a common basis for the benchmarking of organisations, irrespective of their size and the industry they are in. A small amount of money will be much more important to a small company in comparison with a multinational. It means benchmarking will be very difficult. However, pure financial parameters can also be translated into relative financial parameters, taking the size and the sectors of the organisation into account, providing figures which can be handled for the benchmarking and a common understanding. Monetary severity levels can, in analogy with time, be expressed in a more logarithmic scale. The following boundaries can then be used: < 10,