Safety I & Safety II

Safety I & Safety II (Also known as Safety 1 and 2)

For anyone familiar with the concepts of Resilience Engineering, you may have heard of the work of Erik Hollnagel, who states that “resilience engineering maintains that ‘things go wrong’ and ‘things go right’ for the same basic reasons.” It’s through this reflection that he made the distinction between “Safety I” and “Safety II”. Safety I can be considered an approach where we try to ensure that “as few things as possible go wrong”, whilst the Safety II perspective focuses on ensuring “as many things as possible go well”.  Things do not go right because people behave as they are supposed to, but because people can and do adjust what they do to match the present conditions.

As John Allspaw and Sidney Dekker both state of “Murphy’s Law” – it’s not true. Murphy’s Law (What can go wrong will go wrong) is wrong – in fact, “what could go wrong almost never does, but we don’t pay much attention to that.” We pay more attention when things go wrong, and try to prevent that happening again. This is a valid approach, and typical of the vast majority of safety practice, but tends to result in the creation of policies, guidelines, processes, and protocols to avoid error. Indeed, it’s easy to over-rotate on Safety I approaches, which can be triggered by a single, rare, unlikely event and result in cumbersome procedures to avoid that event happening in the future, no matter how highly unlikely it is to happen again. This can have a chilling, calcifying effect on organisations.

There’s a great and very comprehensive paper here at Skybrary that describes Safety I and II from an aviation perspective. 

Just as “You don’t learn the secrets of a great marriage by only studying divorce.“, we don’t learn a great deal about success by only studying failures. Safety II focusses on that big green area in the diagram above, not just the tiny red slice of failure where Safety I focusses.

It’s fairly clear to see from this that Safety II takes a more proactive, continuous, human-focussed, and systems-thinking approach to improvement. Neither approach (I or II) is sufficient alone, but together, the two approaches can enable lower risk together with higher performance and resilience. There are various ways to do this in practice, but some key takeaways are:

• Concentrate on frequent events. Safety I focusses on rare events, but slightly improving something that happens very often will have a much bigger impact.
• Take a systemic view of failure and success. Not every failure can, or should, be avoided. The cost of preventing a rare and low-impact failure can be high.
• Focus on people. People are the part of a system that make it resilient and adaptable. Safety I views people as flawed, risky – a liability. Safety II sees people as necessary for learning, adaptation, agility and resilience.

And because of that focus on people, both Safety I and Safety II fundamentally require a foundation of psychological safety. We require psychological safety in order to speak up with ideas for improvement, highlight concerns, and take a wide view of failure – often outside our immediate zone of influence or authority.

This newsletter is sponsored by Conflux.

Conflux is the leading business consultancy worldwide helping organisations to navigate fast flow in software. We help organisations to adopt and sustain proven, modern practices for delivering software rapidly and safely.

Many organisations today are stuck using ways of working from a bygone age. In this article, Sophie Weston, Principal at Conflux, takes a look at why knowledge work needs a new approach in which psychological safety is a key ingredient.

Psychological Safety In the Workplace:

I’m a massive fan of Charity Majors. Charity always seems to be able to write what I think I want to say, but with more clarity, detail, and precision than I ever could. This piece by Charity on feedback is no different. The main takeway from this (and there are many) is to consider the ratio of positive and encouraging feedback vs critical, constructive feedback. I’ve always been very conscious that people on my teams should hear, frequently and specifically, about what they’re doing well and how much I appreciate their efforts, and this article goes into actionable depth about why that’s so important and how to do it.  

In a similar vein, here’s a great piece from Ed Batista about how difficult and painful delivering bad news can be, and presents a brief framework that addresses how to make it less painless, and instead make it constructive. Ed also positions the final steps in a similar way to David Marquet’s Intent Based Leadership, by instead of asking “What should we do?” or stating “Here’s what I’m going to do.”, saying “I intend to…”, which shows that you’ve thought about solutions, but you’re also open to suggestions.

I often highlight ceremonies and rituals as important practices to build psychological safety in teams, and here’s a good article in HBR about the power of a ritual implemented at Weber Shandwick called “Time To Connect”, which sounds like a very good practice. I’m not convinced that all rituals need be unrelated to the company’s stated mission as stated in the article though. Some rituals such as daily standups are very tied to delivering the mission, but are still powerful ways to help deliver value whilst helping people build strong connections. However, the point stands that rituals that are not connected to the mission may be even more powerful, possibly for that very reason.

This is a fantastic article from Dr Eric Lang about countering internal organisation threats, from a human factors and sociel science perspective. Lang’s “6th Commandment” highlights the importance of psychological safety – and even goes so far as to suggest that organisations still adopt a Safety I approach to insider threats, instead of Safety II.

Here’s a wonderful piece from Ann Kowal Smith of Reflection Point, and there are two points I’d like to draw out here: one is what Ann alludes to, but have called the psychological safety “backpack” – the baggage we bring with us from previous experiences that can make us feel unsafe even when there is no actual threat. And another is the often asymmetrical nature of psychological safety, which speaks essentially to intersectionality and how privilege can influence psychological safety to a degree.

Here’s a great podcast from the BBC where Laura Simpson discusses how meetings have changed for the better through the pandemic – “out have gone the suits, glass tables and rigid hierarchy; in have come moments of vulnerability, the hand raise function, and unannounced visits from children.” Personally, I think this has also helped foster psychological safety, or at least raised the profile of psychological safety as a phenomenon. Thanks to my mum for sending this to me 😀

Things to do and try:

Simply enough this week, remember what is in your control, and outside your control. This is a wonderful diagram from Alana Carvalho – The Codependent Perfectionist on Instagram.

This week’s poem:

Warning, by Jenny Joseph

When I am an old woman I shall wear purple
With a red hat which doesn’t go, and doesn’t suit me.
And I shall spend my pension on brandy and summer gloves
And satin sandals, and say we’ve no money for butter.
I shall sit down on the pavement when I’m tired
And gobble up samples in shops and press alarm bells
And run my stick along the public railings
And make up for the sobriety of my youth.
I shall go out in my slippers in the rain
And pick flowers in other people’s gardens
And learn to spit.

You can wear terrible shirts and grow more fat
And eat three pounds of sausages at a go
Or only bread and pickle for a week
And hoard pens and pencils and beermats and things in boxes.

But now we must have clothes that keep us dry
And pay our rent and not swear in the street
And set a good example for the children.
We must have friends to dinner and read the papers.

But maybe I ought to practise a little now?
So people who know me are not too shocked and surprised
When suddenly I am old, and start to wear purple.


Thanks to Sophie Weston for the suggestion, and a hat tip to my mum again, because this is one of her favourite poems 🙂 

Mission statement

The mission of this newsletter is to make the world of work a better, safer, more inclusive and equitable place. We work towards this by sharing, as widely as possible, new research and opinion, case studies, news, practices and methods related to psychological safety. 

This includes topics such as inclusion, human factors, facilitation, safety critical environments, systems thinking, leadership and management, diversity and equity, mental health, organisational dynamics, culture, ethics, and more. 

A core goal is to amplify the voices of minoritised groups and those who are less represented in this field. This includes (but is not limited to) voices of people of colour, neurodiverse people, LGBTQ+ people, women in leadership and tech, and more.

Another goal is to share insights and best practices across different domains: for example, so that those of us in tech may learn from healthcare, and those of us in education can learn from aviation.

I believe knowledge is worthless unless it’s accessible. A key principle of this newsletter is to only share content that everyone can access. This excludes content behind paywalls, research papers that are not open-access, and proprietary tools that don’t open source their algorithms (preventing us from observing how systems make decisions about us). There may be some exceptions to this principle in practice, for example, where authors are able to share original texts of papers.

Whilst this statement will evolve this over time, the core principles of equity, amplification, and progressive & humanistic leadership shouldn’t change.