Conclusion
WHS management emerged during the Industrial Revolution (Chapters 2 and 3) but has evolved from its domain within labour rights, to be positioned as a business risk requiring a systems-based approach to manage it (Chapter 7). Management of occupational health and incidents was conceptualised using the Swiss Cheese Model of incident causation. This theory proposes that when active failures (human error) combine with latent conditions (safety defence layer weaknesses that may lay dormant in organisations until an active failure occurs setting off a chain of events) it culminates in an incident (Chapter 5). Large-scale, critical incidents, have a substantial impact on people and businesses; it is these low probability–high risk events that present a substantial compliance, operational and reputational risk to organisations (Chapter 7).
While latent conditions can be addressed through safety management systems, the only way to really achieve effective safety management is via a strong organisational safety culture (Chapter 6). Safety culture motivates the ‘Do’ and ‘Act’ in the Plan-Do-Check-Act (PDCA) continuous improvement cycle (Chapter 10). From Reason’s perspective, it is the learning culture component of a safety culture that is most important. Learning from an incident, or most ideally from a near miss, should identify what to improve but only the culture can foster the authentic safety improvement required to reduce risk of an incident (Chapter 6). In examining safety management implementation, all staff have a role to play (Chapters 8–10), but leader commitment to safety is critical to resourcing safety management and setting the tone of an organisation’s safety culture (Chapter 7). When safety is not a moral imperative, business risk can be used to advocate for safety management, however, history cautions us that labour supply and demand will always play a role in the overall prioritisation of safety management as a business imperative (Chapters 2 and 3).
Fundamentally, as research on high reliability organisations informs us, when organisations take a moral stance and intrinsically value the health and safety of their workers, they stay preoccupied with safety because they have a strong safety culture that makes safety everyone’s business (Chapter 6). This is reflected in the transition from Safety I to Safety II, from AS/NZS 4801:2001 to ISO45001:2018, which now puts people at the centre of safety management. Keeping people at the centre of WHS should motivate all we. There should be no death statistics in WHS, we must remember deaths and injuries are the devastating consequences of poor business practices on people.
“Industrial Revolution, in modern history, the process of change from an agrarian and handicraft economy to one dominated by industry and machine manufacturing. These technological changes introduced novel wasy of working and living and fundamentally transformed society. The process began in Britain in the 18th century and from there speak to other parts of the world…the United States and western Europe, began undergoing the ‘second’ industrial revoltuions by the late 19th century” (Encyclopaedia Britannica, 2023, para. 1).
Labour "means any valuable service rendered by a human agent in the production of wealth, other than accumulating and providing capital or assuming the risks that are a normal part of business undertakings" (Encyclopedia Britannica, 2022, para. 1).
Business risk may be defined as "the exposure a company or organization has to factors that could lower its profits or lead it to fail” (Kenton, 2022, para. 1).
"A group or set of related or associated things perceived or thought of as a unity or complex whole" (Oxford Dictionary, 2023, para. 1).
Occupational health had its modest beginnings in first aid and disease controls for high risk heavy industry workplaces, such as mines, but gained greater recognition in the 1970s when the World Health Organization acknowledged its contribution to the identification of workplace-derived factors causing occupational illness and suggested its remit should be broadened to encompass public health. So, today, many occupational health specialists have more of a public health, and less of an immediate workplace, focus (Schilling, 1989).
In the WHS context, “An incident is an unplanned event or chain of events that results in losses such as fatalities or injuries, damage to assets, equipment, the environment, business performance or company reputation” (Wolters Kluwer, n.d., para. 1).
"James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures...According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with Swiss cheese. These weaknesses are inconstant – i.e., the holes open and close at random. When by chance all holes are aligned, the hazard reaches the patient and causes harm" (Perneger, 2005, p. 71).
"Human beings contribute to the breakdown of such [complex technological] systems in two ways. Most obviously, it is by errors and violations committed at the 'shape end' of the system...Such unsafe acts are likely to have a direct impact on the safety of the system and, because of the immediacy of their adverse effects, these acts are termed active failures" (Reason, 1997, p. 10).
"Fallibility is an inescapable part of the human condition, it is now recognized that people working in complex systems make errors or violate procedures for reasons that generally go beyond the scope of individual psychology. These reasons are latent conditions....poor design, gaps in supervision, undetected manufacturing defects or maintenance failures, unworkable procedures, clumsy automation, shortfalls in training, less than adequate tools and equipment - may be present for many years before they combine with local circumstances and active failures to penetrate the system's many layers of defences" (Reason, 1997, p. 10).
A critical incident is “a sudden, unexpected and overwhelming event, that is out of the range of expected experiences” (UNHCR, 2019, para. 1).
“Compliance risk primarily arises in industries and sectors that are highly regulated” (Kenton, 2022, para. 9).
Operational risk “arises from within the corporation, especially when the day-to-day operations of a company fail to perform” (Kenton, 2022, para. 10).
Reputational Risk “Any time a company’s reputation is ruined, either by an event that was the result of a previous business risk or by a different occurrence, it runs the risk of losing customers and its brand loyalty suffering” (Kenton, 2022, para. 11).
A safety management system is “ a systematic approach to managing safety. It is designed to continuously improve safety performance through the identification of hazards, the collection and analysis of safety data and safety information, and the continuous assessment of safety risks” (Civil Aviation Authority of New Zealand, 2023, p. 12).
“A culture that supports an organization’s OH&S management system is largely determined by top management and is the product of individual and group values, attitudes, managerial practices, perceptions, competencies and patters of activities that determine commitment to, and the style and proficiency of, its OH&S management system” (Standards Australia and Standards New Zealand, 2018), p. 27).
“The Plan-do-check-act cycle is a four-step model for carrying out change. Just as a circle has no end, the PDCA cycle should be repeated again and again for continuous improvement” (ASQ, 2023, para. 1) where the different steps are: “Plan: Recognize an opportunity and plan a change, Do: Test the change. Carry out a small-scale study; Check: Review the test, analyze the results, and identify what you’ve learned; Act: Take action based on what you learned in the study step” (ASQ, 2023, para. 3).
James Reason conceptualises a safety culture as comprising “four critical subcomponents of a safety culture: a reporting culture, a just culture, a flexible culture and a learning culture” (Reason, 1997, p. 196). By focusing on the development of these individual subcomponents, he believes that a safety culture will emerge as “ways of doing, thinking and managing that have enhanced safety health as their natural byproduct” (Reason, 1997, p. 192).
Near misses are "unplanned incidents that occurred at the workplace that, although not resulting in any injury or disease, had the potential to do so” (Archer et al., 2015, p. 86). When contextualised in the Swiss Cheese Model of incident causation, they can be understood as "an event that could have potentially resulted in…losses, but the chain of events stopped in time to prevent this” (Wolters Kluwer, n.d., para. 1).
Moral judgement is the “evaluation of actions with respect to moral norms and values established in society” (Thoma et. al. 1991 cited in Li et al., 2017, p. 122).
High reliability organisations are distinguished from other organisations as they have a: “…preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience and deference to expertise” (Weick & Sutcliffe, 2001, p. 30).
Safety management is increasingly being classified into two eras (or paradigms); Safety I and Safety II.
Safety I, the dominant safety management paradigm from the 1960s into the 2000s, can be explained as a safety management approach that " presumes that things go wrong because of identifiable failures or malfunctions of specific components: technology, procedures, the human workers and the organisations in which they are embedded. Humans—acting alone or collectively—are therefore viewed predominantly as a liability or hazard, principally because they are the most variable of these components" (Hollnegal et al., 2015, p. 3). The Swiss Cheese Model of incident causation is an artifact of Safety I conceptualisations of safety management.
Safety II has emerged across the 2000s with Hollgegal advocating for a shift "from ensuring that ‘as few things as possible go wrong’ to ensuring that ‘as many things as possible go right’" (Hollnegal et al., 2015, p. 3). Their 2015 white paper "From Safety-I to Safety-II" essential coined the two terms and explained Safety II as assuming "that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and hence is the reason why things go right. Humans are consequently seen as a resource necessary for system flexibility and resilience" (Hollnegal et al., 2015, p. 3).
In summary, Hollnegal et. al. consider Safety I’s focus to be on people as a source of error (active failures), whereas Safety II sees people as a “resource necessary for system flexibility and resilience” (Hollnegal et al., 2015, p. 4).
