From: Alan Hall <oldeddoc**At_Symbol_Here**GMAIL.COM>
Subject: Re: [DCHAS-L] [New post] Why do things go right?
Date: Fri, 28 Sep 2018 10:38:28 -0500
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Message-ID: CALDugaZM2B8qXqTaMAgGnniLYN+koc4V72EG2K3DjOiKeig_mg**At_Symbol_Here**
In-Reply-To <764C67BA-F429-4163-9B98-6A688E5E11DB**At_Symbol_Here**>

Ralph et al,

A very interesting article.. THANX! Yhprum's Law (Murphy spelled backwards): "Sometimes things go right."

But why do they go right? Luck vs. smart? Do we know? How can we find out?

Consider the following pseudo-parable:

There's a fellow who drives from his home to a certain destination every day, always in the very early morning or late evening hours when traffic is light. Because like many he is a creature of habit, he always makes a wrong turn into a one-way street going the wrong direction. After a few blocks without having an accident, he realizes the mistake, turns and goes around the block, drives the correct direction down the one-way street and arrives safely at his destination. He does this 1,000 consecutive times in a row, and never has had an accident. Then some random factor such as his alarm clock did not go off and he overslept, so he left at a different hour when traffic was heavy, did his habitual thing, and was killed in a head-on collision on the one-way street. Surviving for a short time, he in bewilderment told the responding paramedics: "But I've done it a thousand times before and nothing bad ever happened!"

It may be better to be lucky if you can't be smart, but it's much better to be smart and not have to depend on luck which can be fickle at best.

Seems like those of us here on this Listserve hear a lot of stories rather like this pseudo-parable.

Just try and convince certain types of line managers that safety measures are a potential revenue center rather than a cost certer (what you don't spend on process down-time, lost work days, increased workers' compensation insurance costs, lawsuites, hiring and training replacements, etc.-- not considering the human factors of pain and suffering which cannot really be priced -- just drops to the bottom line -- a hard sell if there ever was one). Maybe others have had some luck with this. In general, I haven't, but ithat doesn't mean we should quit trying.

Alan H. Hall, M.D.
Medical Toxicologist

On Fri, Sep 28, 2018 at 9:00 AM Ralph Stuart <000005bc294e9212-dmarc-request**At_Symbol_Here**> wrote:
There is a very interesting discussion of safety management practices at

The introductory paragraphs are an indication of the larger argument of the post.

- Ralph


In his 2014 Safety I and Safety II: The past and future of safety management, Erik Hollnagel makes the argument that we should not (just) try to stop things from going wrong. Instead, we need to understand why most things go right, and then ensure that as much as possible indeed goes right. It seems so obvious. Yet it is light years away from how most organizations =E2=80=98do' safety today, with their focus on low numbers of lagging indicators, incidents and injuries.

That said, many organizations have now begun to recognize the severe organizational deficiencies, cultural problems and ethical headaches that lag indicators create for them.

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