Heinrich’s Local Rationality: Shouldn’t ‘New View’ Thinkers Ask Why Things Made Sense To Him? – Carsten Busch

Why don’t new view thinkers apply their trade, e.g., local rationality, when describing Heinrich?

Carsten Busch’s really interesting 2018 Masters thesis dives into this question and more.

Some extracts:

· Heinrich “is one of the most influential pioneers within safety. His concepts, originally from the late 1920s, influence safety practice and theory, even today”

· It’s said we often “take the term ‘new view’ just as a given, as if it were an objective indication. It is not, it is merely a practical shorthand … We should keep in mind that ‘new’ is not an absolute term, but a relative one”

· And interestingly, “Let us not forget, Heinrich was part of another ‘new view’ back in his days … [where] Petersen states … “Heinrich’s ideas were a departure from the safety thinking of the time”

· Tl;dr: prominent new view thinkers have characterised Heinrich’s work based on “normative and judgemental language [which] serves as a pedagogical device”, which in creating a new movement, has created a “new hero” to battle the “villain”

· Carsten describes how authors like Dekker, Hollnagel, Long, Conklin and more have framed Heinrich’s work – check out image 2 for a summary, but I’ve skipped most of this

· However, critiques were framed around things like the 88% of accidents being human in nature, linear causality and more; problematically, many new view authors “often stay on the surface and do not delve much into the relevant context”

· For example, critiques of the 88% ratio of accidents and human error is “about direct and proximate causes”

· “Marriott put things into perspective with his nuanced view that precisely hits the point, “At its core, the 88 per cent quote is no more useful than saying, ‘Most of our activities involve people”

· New view arguments have included cherry picking by ignoring context; and one could “argue that ‘new view’ authors use these extreme examples as a pedagogical device to make a point”

· And the new views “emphasises complexity”, implying that “telling one version of a story is not enough since one point of view is not able to capture the complexity and many facets of a case”

· However, some new view critiques seem to favour single narratives to debase Heinrich’s work and significance, e.g. around stable ratios across industries, which “Heinrich did not claim”

· Further, while “The ‘new view’ tells us to avoid judgement and normative language … the simple act of labelling things as ‘new’ and ‘old’ is a mild form of judgement”

· Use of ridicule was found, like “The ‘younger’ authors, Dekker and Conklin, and especially Long on the other hand are much harsher and range from ridicule like “goofy pyramid” (Conklin, 2017a) to various forms of dismissal, like “nonsense of Heinrich” (Long, 2017a), “that damn triangle” (Conklin, 2018) and many other derogatory terms”

· While the new views are “critical of blame … on occasion, blame creeps into the arguments of ‘new view’ authors while discussing

· And a key argument is that new views seem to often ignore local rationality: “Why did things make sense to people, then in that situation, given their knowledge and objectives?”

· “With a few exceptions, ‘new view’ authors do not ask for or try to explore Heinrich’s local rationality, but rather impose their perception. To paraphrase Dekker (2014a), authors often point out that Heinrich zigged when we know now that he should have zagged”

Carsten also challenges some misconceptions of Heinreich, including:

· “Heinrich suggests aiming at events rather than consequences, because the consequences of accidents may be rather random”

· He argued that “The severity of an injury is largely fortuitous…”, hence, “It was not the outcome, but the potential that is interesting from a safety management (and prevention) point of view”

· For Heinrich, “one should address all accidents, not merely those that had led to injuries” and hence, “the simple principle of addressing events instead of consequences is forgotten or ignored in many applications of the triangle”

· Further on the triangle, “as a metric is not Heinrich’s message, and turning it into a ‘number’s game’ as described by Dekker (2014a, p.176-177) has nothing to do with the principle, but rather with how safety is ‘managed’”

· “One should also note that the triangle was originally an argument against “suppressing such learning opportunities” (Dekker, 2014a, p.176) and rather an invitation to use these opportunities”

· While critiques of practitioners who “waste countless hours each week reporting on things that don’t matter, tabulating data of irrelevance and maintaining worship to Heinrich and Bird by statistics…” (Long, 2018c)”, Heinrich “Heinrich was a practical man who was no fan of unnecessary paper work and unpractical solutions”

· Heinrich also didn’t intend statistics “as a bureaucratic enterprise”, but as a means to provide “richer information to base their decisions on and direct their accident prevention work”