Biomedical Engineering Reference
In-Depth Information
operator, and then the second operator had to check whether the
cooler was blocked. The mechanics didn
t want to waste any more
time; the clock was running, and another job was waiting.
'
9.5 MANAGING AN ENHANCING SAFETY ATMOSPHERE
As safety is not intrinsically rewarding, it needs to be managed on a
permanent basis. Because it is much easier to notice aspects that are
not going well, there always is a slight feeling of discomfort around
this topic. It is seen as a role of management to compensate this atmo-
sphere. The way management deals with near hits and incidents
strongly influences the perception of the employees.
Weick, Sutcliffe, and Obstfeld (2005) introduced the concept of sense-
making as a way of turning circumstances into a situation that is com-
prehended explicitly in words and that serves as a springboard into
action (Taylor & Van Every, 2000). The main idea is to focus on the
impact of how we deal with circumstances and what kinds of words we
use while dealing with it. The best way to explain this is by giving two
options on how to approach a safety incident caused by an operator.
In the first approach, we focus on the operator and ask him why he
acted the way he did. Apart from the fact that we never get a real
answer on a
why
question (see Tip for transfer in the introduction of
Part 3), by doing so the discussion can easily be interpreted as blaming
a decision that caused the incident. It is only a small step from blaming
the decision making to blaming the one who made the decision, the
operator. Once the sense of blame is in the room, there is no fun any-
more in researching what went wrong and how this can be prevented
next time. If the operator later shares his perception with his own
team, the willingness to report future incidents will decrease.
The alternative is to analyze that same incident by focusing on the
task and the context in such a way that what happened starts to make
sense in a broader perspective. As soon as we can analyze the incident
without analyzing the actor, but focusing instead on the act, it creates
an opportunity to personally identify with what happened. We might
even understand the incident in such a way that we realize that we could
well have acted the same way in such a situation. At that moment,
learning starts because we fully experience the act in that specific
situation, which gives us the opportunity to reframe what happened in
