Erik Hollnagel

Ph.D., Professor, Professor Emeritus

• One rule is negative reporting, which means that only deviations or things that go wrong should be reported. In consequence of that, the absence of a report is interpreted as meaning that everything is well. The rule clearly improves efficiency, but may have consequences for safety.
• Another rule can be called the prioritising dilemma or the visibility-effectiveness problem. Many organisations realise that it is important for managers at various levels to be visible in the organisation, which means that they should spend time to find out what is going on and become known among the people they manage. On the other hand, managers are often under considerable pressure to be effective, to perform their administrative duties promptly even when deadlines are short. They are therefore required by their bosses to be both efficient in accomplishing their administrative duties, and thorough in the sense that they are good managers – i.e., highly visible. Managers will in practice often focus on efficiency (accomplishing their administrative duties) and trade-off thoroughness, being less visible in the organisation. If nothing untoward happens, he or she will be praised for the efficiency, but if something goes wrong, they will be blamed for their lack of thoroughness.
• Report and be good. Yet another example is in the relation between an organisation and a subcontractor or a supplier. Here the safety ethos prioritises openness and reporting of even minor mishaps. Subcontractors and suppliers thus often feel under pressure to meet the organisation’s standards for openness and reporting. But at the same time they may have experienced, or believe they will experience, that they will be punished if they have too many things to report, while a competitor that reports less may be rewarded. In ETTO terms it is thorough to report everything and efficient to report enough to sound credible but not so much that one loses the contract.
• Reduce unnecessary costs. While this may sound plausible enough at first, the problem lies with the definition of ‘unnecessary.’ The rule is used to improve efficiency, at the cost of thoroughness.
• Double-bind describes a situation where a person receives different and contradictory messages. A common example is the difference between the explicit policy that ‘safety is the most important thing for us,’ and the implicit policy that production takes precedence when conflicts arise. The double-bind that results from this is used to improve efficiency, at the cost of thoroughness. Another example is the visibility-effectiveness problem described above.