Webinar: The Story of the Lopsided Critical Risk Bowtie

Presented by Mark McLaren (Art of Work)

What’s covered?

What’s covered?

An enormous amount of time and energy is rightfully invested in understanding what causes and subsequently prevents a life-changing injury or a fatality from happening in the workplace.

This genuine pursuit can inadvertently contribute to some unintended outcomes. The bid to stop the unwanted event can lull an organisation into a false sense of confidence. It is easy to become imbued with misplaced confidence that the designed and assessed preventive Critical Controls will reduce the likelihood of something going wrong to almost zero.

This overconfidence effect is a well-established bias. It occurs when a person’s subjective confidence in their judgements is greater than the objective accuracy of their judgements. This overconfidence bias can lead to a misjudgement of the likelihood or probability of something happening. In this case, the belief becomes one of, “now everything has been thought of and put in place it cannot happen.” The initial reaction to such a bold statement is that we don’t believe this to be true; we know it can still happen, albeit it is extremely unlikely to happen.

Well here is a simple test. Q1. How many mitigating controls sit on the right-hand side of your organisation’s Bowties, and Q2. If the loss of control event occurred would those controls prevent a serious injury or fatality?

So maybe a way of righting the lopsided Bowtie is not to jettison the controls on the left but to ask a different type of question. If the loss of control event happens and the damaging energy is released, such as mechanical, electrical, or gravitational, how will the damaging energy be contained, distanced or deflected so it does not cause a serious injury or fatality? In this webinar, the question of how to design better mitigating Critical Controls is explored further.

Key links + references

• Critical Controls – Safety Differently (recent webinar with Art of Work)
• Jamboard PDF from the webinar
• Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems – Sidney Dekker
• Workplace Fatalities: Failure to Predict – Todd Conklin
• The Field Guide to Human Error Investigations – Sidney Dekker
• A capacity index to replace flawed incident-based metrics for worker safety – Sidney Dekker
• Reference to Michael Behm works
• ICAO Manual on Human Performance (HP) for Regulators – International Civil Aviation Organisation

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