Biomedical Engineering Reference
In-Depth Information
such a way that we get a deeper understanding. This understanding
can lead to new insights in how to organize that situation in such a way
that nobody is tempted anymore to behave in that way. The theory
states that as soon as an interpretation makes sense for us, it also creates
sense in how to deal with these kinds of situations. Sensemaking is
creating a new perspective together that gives new meaning to the same
facts.
Only by really understanding the behavior that led to an incident can we
use it for improving safety.
It can be said that this sounds good as long as there is an unforeseen
mistake. But what happens if the incident was the result of consciously
trespassing safety rules? Even then, management can try to understand
why an employee trespassed that rule. There can be many reasons for this
behavior, and it is very helpful to find out what really happened in the
mind of that person. Everybody wants to leave work in the same shape in
which he or she arrived; nobody deliberately wants to get hurt. So there is
always a pattern, however awkward it might be. Understanding these
patterns is much more effective than giving fines or penalties.
This example shows that the way in which we ascribe words to cer-
tain situations or happenings has a huge impact on how safety behav-
ior can develop. Communication plays a central role in sensemaking
and management plays a crucial role in this.
Case 1
In this case, it is crucial how the management of the commissioner and
the contractor reacts to the people who created the incident. Do they
see it as a shortcoming of themselves or as a shortcoming of the opera-
tor and the mechanics? Do they address issues of conduct with an
employee of another company, knowing that this is more difficult than
addressing the same issue with one
s own colleagues? Do they present
the results of the incident analysis as an explanation of what went
wrong or as an opportunity to learn for the future?
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9.6 MANAGING RULES AND REGULATIONS WITHIN AN
ORGANIZATION
Level 2 safety management is based on creating rules and regulations
to control behavior. This way of managing behavior has proven to be
