1. Safety culture

Key message: safety culture is a climate in which people are comfortable being (and expressing) themselves

Organizations are under pressure to continually improve performance

Products have increasing economic, societal, and political impact

This combination can lead to stress and burnout

Organizations need to:

• Encourage behaviour that is good for all stakeholders including their workforce
• Foster shared beliefs, perceptions, and values to support this

In a safety culture, people:

• Are comfortable being (and expressing) themselves
• Feel trusted and valued
• Are prepared to point out risks even if this might reflect badly on them

Safety culture can be promoted by management commitment to realistic practices, continual learning, care and concern for the workforce

Complex systems:

• Always have multiple flaws and latent issues
• Continual changes means flaws continually change
• Most flaws are small, because of system resilience or human intervention
• Significant issues happen due to unpredictable combinations of flaws not due to a single root cause
• Dealing with issues requires knowledge, skills, and good working conditions:
  • Working conditions are critical when things get stressful
  • Culture like not blaming people, failure is an improvement opportunity
• People need confidence to share opinions and experiment

Behaviour patterns:

• Don’t just talk about why safety is important, do something about it
• Exhibit vulnerability: say when you have doubts and ask for help
• Foster feedback and act on it
• Be kind and compassionate: build human relationships
• Be realistic about failure: acknowledge that it will happen, and that people are not to blame, but the system

Inherently hazardous nature of complex systems:

Complex systems are intrinsically hazardous systems Complex systems are heavily and successfully defended against failure Catastrophe requires multiple failures, single point failures are not enough Complex systems contain changing mixtures of failures latent within them Complex systems run in degraded mode Catastrophe is always just around the corner Post-accident attribution accident to a root cause is fundamentally wrong Hindsight biases post-accident assessments of human performance Human operators have dual roles: as producers and as defenders against failure

All practitioner actions are gambles Actions at the sharp end resolve all ambiguity Human practitioners are the adaptable element of complex systems Human expertise in complex systems is constantly changing Change introduces new forms of failure Views of cause limit the effectiveness of defenses against future events Safety is a characteristic of systems and not of their components People continually create safety Failure‐free operations require experience with failure

Go back to Principles, models, and concepts to finish this section or to the main chapter ITIL 4 Managing Professional Certification Course: High Velocity IT (HVIT).