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.


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