SIDNEY
TODD DEKKER | CONKLIN
西德尼 托德·德克尔 |康克林

Do Safety Differently   以不同的方式执行安全

Contents  内容

Foreword  前言

Acknowledgments  确认

Preface  前言

Change How Your Organization Thinks About Being Safe
改变您的组织对安全的看法

They're not following the procedure!
他们没有遵循程序！

Not everything goes right
并非一切都一帆风顺

1. Zero events are the only safety outcome acceptable.
   零事件是唯一可接受的安全结果。
2. Every event has a root cause.
   每个事件都有一个根本原因。

We are our own worst problem
我们自己最糟糕的问题

Leadership will need extra care and feeding
领导层需要额外的照顾和喂养

Chapter 1  第一章

Do Safety Differently：以不同方式 $\times$$\times$xx\times 方得安全 From outcome to capacity
Do Safety Different：以不同方式 $\times$$\times$xx\times 方得安全 From outcome to capacity

＂The single，biggest challenge we had in our company was getting our folks to see and talk about safety in a different way． We completely underestimated how difficult it would be to introduce a new way to define safety．＂
“我们公司面临的最大挑战是让我们的员工以不同的方式看待和谈论安全。我们完全低估了引入一种定义安全的新方法的难度。

－An Executive of a Fortune Five Hundred Organization
- 财富 500 强组织的高管

实全有崩力便我情师利断行。

• Not having had any bad outcomes doesn’t mean that you’re safe. It just means that you haven’t had any bad outcomes
  没有任何糟糕的结果并不意味着你是安全的。这只是意味着你没有遇到任何糟糕的结果
• Indeed, the absence of negative outcomes doesn’t automatically imply the presence of positive capacities. It could be due to luck, or to smart counting (see next bullet)
  事实上，没有消极结果并不意味着存在积极的能力。这可能是由于运气，也可能是由于聪明的计数（见下一个项目符号）
• You can help your run of no bad outcomes by calling bad outcomes something else (by putting people on ‘suitable duties,’ for instance) or by allowing your people to underreport
  您可以通过将坏结果称为其他名称（例如，通过让人们承担“适当的职责”）或允许您的员工少报来帮助您实现无坏结果
• Most things go well, rather than badly. Much more goes well than goes wrong in your organization. So, if you’re focusing your safety efforts on those few things that go wrong, you’re only using a tiny portion of the data available about how your operations are doing.
  大多数事情都进展顺利，而不是糟糕。在您的组织中，顺利的事情比出错的事情要多得多。因此，如果您将安全工作集中在那几件出错的事情上，那么您只使用了有关运营情况的一小部分可用数据。

• If more injuries lead to fewer fatalities, does that mean that we should be injuring more people to avoid blowing things up and killing them instead?
  如果更多的伤害导致更少的死亡，这是否意味着我们应该伤害更多的人，以避免炸毁并杀死他们？
• Was Heinrich wrong?  海因里希错了吗？
• Is it unsafe to try to achieve zero harm?
  尝试实现零伤害不安全吗？
• Should we even be looking at safety as the absence of negative outcomes (like injuries)?
  我们是否应该将安全性视为没有负面结果（如受伤）？
• And if we do that, then what kinds of safety metrics should we use instead?
  如果我们这样做了，那么我们应该使用什么样的安全指标呢？

More injuries, fewer fatalities
更多的伤害，更少的死亡

• Executives or board members think that they can use injury or incident numbers and compare them across industries, or peers within an industry. But they can’t. Comparison between industries or business units is impossible because the measure says something about shifts, not about people or jobs.
  高管或董事会成员认为他们可以使用工伤或事故数据，并在不同行业或行业内的同行之间进行比较。但他们不能。行业或业务部门之间的比较是不可能的，因为该指标说明了转变，而不是人或工作。
• Not only that, the definitions of ‘incident’ and ‘injury’ is both variable and gameable. There is little consistency in what is registered as an injury and what isn’t. Supervisors, often in coordination with health & safety professionals, will make their call on whether to record a worker’s injury or not. And an organization’s reward system has a very strong role in helping push these determinations one way or another.
  不仅如此，“事故”和“伤害”的定义既多变又可玩。什么是受伤，什么不是，几乎没有一致性。监督员，通常与健康和安全专业人士协调，将决定是否记录工人的伤害。组织的奖励系统在帮助以某种方式推动这些决定方面发挥着非常重要的作用。
• Also, once you turn the number into a rate (like the total recordable incident frequency rate) it requires a denominator, which is a malleable choice.
  此外，一旦您将数字转换为速率（如总可记录事件频率），它就需要一个分母，这是一个可塑性的选择。
• Deriving trends or changes from the measure are meaningless because of its considerable lack of statistical power. With injury numbers relative to hours worked (i.e., injury rate or any other rate) as low as they are, the requirements of statistical significance are never met. In other words, managers or boards saying that they have seen a significant reduction in injury rate, or a significant difference between their injury rate and someone else’s injury rate, actually have no statistical basis for their claims. In addition, because of the low power, statistical variations in injury rates from year to year or between companies or business areas, are completely random and cannot be provably related to a manager’s or board’s actions or inactions. These variations, to put it simply, are way below the statistical noise level.
  从测度中得出趋势或变化毫无意义，因为它相当缺乏统计能力。由于相对于工作小时数的工伤数字（即工伤率或任何其他比率）如此之低，因此永远无法满足统计显著性的要求。换句话说，经理或董事会说他们看到工伤率显着降低，或者他们的工伤率与其他人的工伤率之间存在显着差异，实际上他们的索赔没有统计依据。此外，由于功效低，每年或公司或业务领域之间工伤率的统计变化是完全随机的，无法证明与经理或董事会的作为或不作为相关联。简单地说，这些变化远低于统计噪声水平。

Heinrich was wrong (well, he made part of it up)
海因里希错了（嗯，他编造了一部分）

Pursuing zero harm can be unsafe
追求零伤害可能是不安全的

• There were four fatal accidents for companies with zero safety.
  零安全性的公司发生了四起致命事故。
• There were zero fatal accidents for companies without zero safety.
  对于没有零安全性的公司来说，致命事故为零。

• There were 214 major injuries for companies with zero safety.
  零安全性的公司有 214 起重大伤害。
• There were 135 major injuries for companies without zero safety.
  没有零安全性的公司有 135 人重伤。

• There were 7 fatal or major accidents per billion turnovers for those with a Zero policy.
  对于拥有零保单的人来说，每 10 亿次营业额中有 7 起致命或重大事故。
• There were 6 major accidents per billion turnovers for those without zero safety.
  对于那些没有零安全性的人来说，每 10 亿次营业额中有 6 次重大事故。

Safety as the capacity to make things go well
安全是让事情顺利进行的能力

• Workarounds  解决方法
• Shortcuts  快捷方式
• Violations  违反
• Guidelines not followed  未遵循的准则
• Errors and miscalculations
  错误和误判
• Unfindable people or medical instruments
  找不到的人或医疗器械
• Unreliable measurements  测量不可靠
• User-unfriendly technologies
  对用户不友好的技术
• Organizational frustrations
  组织挫折
• Supervisory shortcomings
  监管缺陷

• People are the problem to control
  人是需要控制的问题
• We need to find out what people did wrong
  我们需要找出人们做错了什么
• We write or enforce more rules
  我们编写或执行更多规则
• We tell everyone to try harder
  我们告诉大家要更加努力
• We get rid of bad apples
  我们摆脱坏苹果

• Workarounds  解决方法
• Shortcuts  快捷方式
• Violations  违反
• Guidelines not followed  未遵循的准则
• Errors and miscalculations
  错误和误判
• Unfindable people or medical instruments
  找不到的人或医疗器械
• Unreliable measurements  测量不可靠
• User-unfriendly technologies
  对用户不友好的技术
• Organizational frustrations
  组织挫折
• Supervisory shortcomings
  监管缺陷

• Diversity of opinion and the possibility to voice dissent. Diversity comes in a variety of ways, but professional diversity (e.g., compared to gender and racial diversity) is the most important one in this context. Yet whether the team is professionally diverse or not, voicing dissent can be difficult. It is much easier to shut up than to speak up. I was reminded of Ray Dalio, CEO of a large investment fund, who has fired people for not disagreeing with him. He said to his employees: You are not entitled to hold a dissenting opinion…WHICH YOU DON’T VOICE.
  意见的多样性和表达不同意见的可能性。多样性有多种方式，但在这种情况下，职业多样性（例如，与性别和种族多样性相比）是最重要的一种。然而，无论团队在专业上是否多元化，表达异议都可能很困难。闭嘴比说出来容易得多。我想起了一家大型投资基金的首席执行官雷·达里奥（Ray Dalio），他因为没有不同意他的观点就解雇了人。他对他的员工说：你们没有资格持有不同意见......你不发声。
• Keeping a discussion on risk alive and not taking past success as a guarantee for safety. In complex systems, past results are no assurance for the same outcome today, because things may have subtly shifted and changed. Even in repetitive work (landing a big jet, conducting the fourth bypass surgery of the day), repetition doesn’t mean replicability or reliability: the need to be poised to adapt is ever-present. Making this explicit in briefings, toolboxes or other prejob conversations that address the subtleties and choreographies of the present task, will help things go well.
  保持对风险的讨论，而不是将过去的成功作为安全的保证。在复杂的系统中，过去的结果并不能保证今天的结果相同，因为事情可能已经发生了微妙的变化和变化。即使在重复性工作中（降落一架大型喷气式飞机，进行当天的第四次搭桥手术），重复并不意味着可复制性或可靠性：随时准备适应的需求是永远存在的。在简报、工具箱或其他职前对话中明确说明当前任务的微妙之处和编排，将有助于事情顺利进行。
• Deference to expertise. Deference to expertise is generally deemed critical for maintaining safety. Signals of potential danger, after all, and of a gradual drift into failure, can be missed by those who are not familiar with the messy details of practice. Asking the one who does the job at the sharp
  尊重专业知识。尊重专业知识通常被认为对于维护安全至关重要。毕竟，那些不熟悉练习中混乱细节的人可能会错过潜在危险和逐渐走向失败的信号。询问在夏普工作的人
  end, rather than the one who sits at the blunt end somewhere, is a recommendation that comes from High-Reliability Theory as well. Expertise doesn’t mean only front-line people. The size and complexity of some operations can require a collation of engineering, operational and organizational expertise, but high-reliability organizations push decision making down and around, creating a recognizable pattern of decisions ‘migrating’ to expertise.
  end 而不是坐在某个地方的钝端的那个人，也是来自 High-Reliability Theory 的建议。专业知识不仅仅意味着一线人员。某些运营的规模和复杂性可能需要对工程、运营和组织专业知识进行整理，但高可靠性组织将决策推向决策，从而形成一种可识别的决策“迁移”到专业知识的模式。
• Ability to say stop. Amy Edmondson at Harvard calls for the presence of ‘psychological safety’ a crucial capacity in teams that allow members to safely speak up and voice concerns. In her work on medical teams, too, the presence of such capacities was much more predictive of good outcomes than the absence of non-compliance or other negative indicators.
  能够说停止。哈佛大学的 Amy Edmondson 呼吁存在“心理安全”，这是团队中的一项关键能力，可以让成员安全地说出问题。在她在医疗团队的工作中，这种能力的存在比没有不依从或其他负面指标更能预测良好的结果。
• Broken down barriers between hierarchies and departments. A point frequently made in organizational research, and also in the sociological postmortems of big accidents, is that the totality of intelligence required to foresee bad things is often present in an organization but scattered across various units or silos. Get people to talk to each other-research, operations, production, and safety personnel-break down the barriers between them.
  打破层次结构和部门之间的障碍。在组织研究以及重大事故的社会学事后分析中经常提到的一个观点是，预见坏事所需的全部情报通常存在于组织中，但分散在各个部门或孤岛中。让人们相互交谈 - 研究、运营、生产和安全人员 - 打破他们之间的障碍。
• Don’t wait for audits or inspections to improve. This is one that quality guru
  不要等待审核或检查得到改进。这是质量大师

• Pride of workmanship, another of Deming’s points, is linked to the willingness and ability to improve without being prodded by audits or inspections. Teams that take evident pride in the products of their work (and the workmanship that makes it so) tended to end up with more good results. What can an organization do to support this? They can start by enabling their workers to do what they want to do and need to do, by removing unnecessary constraints and decluttering the bureaucracy surrounding their daily life on the job.
  对工艺的自豪感是 Deming 的另一个观点，它与在没有审计或检查催促的情况下改进自己的意愿和能力有关。对自己的工作成果（以及使之而来的工艺）感到自豪的团队往往最终会得到更好的结果。组织可以做些什么来支持这一点？他们可以从让员工做他们想做和需要做的事情开始，通过消除不必要的限制并整理围绕他们工作日常生活的官僚主义。

Discussion questions  问题讨论

1. Consider the list of capacities that make things go well in the example from this chapter (e.g. diversity of opinion, ability to say stop). Is there any capacity you are missing and that you are seeing (or would like to see) in your own organization?
   考虑本章示例中使事情进展顺利的能力列表（例如，意见的多样性、说停止的能力）。在您自己的组织中，是否有您缺少的以及您正在看到（或希望看到）的容量？
2. The safer your organization or industry becomes, the more inverse the correlation between injuries and accidents tends to become. Why is that, you think?
   您的组织或行业越安全，伤害和事故之间的相关性就越反比。你觉得这是为什么呢？
3. Does your organization believe that Heinrich was right? And if so, about what? Should you try to change that?
   您的组织认为 Heinrich 是对的吗？如果是这样，大约是什么？你应该尝试改变这一点吗？
4. Safety metrics can amount to a ‘Looking Good Index’ (or LGI). Who in your organization is trying to (make whom) look good, and for which stakeholders or what purposes? Does your organization measure or otherwise track the presence of capacities that make things go well? If not, what are the obstacles to them doing so?
   安全指标可以相当于“Looking Good Index”（或 LGI）。您的组织中谁在努力（让谁）看起来不错，为了哪些利益相关者或什么目的？您的组织是否衡量或以其他方式跟踪使事情进展顺利的能力的存在？如果不是，他们这样做的障碍是什么？
5. Does your organization have a Zero Harm policy or goal? Is it aware of the increased fatality risks associated with such a policy or goal? What might you do about that?
   您的组织是否有零伤害政策或目标？它是否意识到与此类政策或目标相关的死亡风险增加？您该怎么办？

Chapter 2：  第 2 章：

When the work done is not as you imagined：当完成的工作与你想家不一样时： Do learning teams
当完成的工作不如你想象的时：当完成的工作与你想家不一样时：做学习团队

＂When you are not getting the answers you need from your workers，it is not a problem with your workers．It is a problem with your question．＂
“当你没有从你的工人那里得到你需要的答案时，这不是你的 workers.It 问题，而是你的问题。”

－Betty Sue Flowers ${}^{19}$${}^{19}$^(19){ }^{19}
-贝蒂·苏·弗劳尔斯 ${}^{19}$${}^{19}$^(19){ }^{19}

Uncertainty is (and always has been) Uncertain
不确定性是（并且一直都是）不确定性

那就玄问做这项工作的工人。

You gotta talk（and listen！）to your workers
你必须和你的工人交谈（并倾听！

There is a better way
有更好的方法

Learning from workers is fast and accurate
向工人学习既快速又准确

Learning Teams are Easy，Don＇t Overthink Them
学习团队很容易，不要想太多

The Point of Learning Differently
不同的学习意义

The process of a learning team is captured in the following steps:
学习团队的流程通过以下步骤进行捕获：

1. Seek potential learning targets - There is no great mystery in the selection process for learning. Any near miss, close call, near the
   寻找潜在的学习目标 - 学习的选择过程并没有什么大的神秘之处。任何险些错过、险些打电话、靠近
   event or operational failure with the potential to create some type of harm certainly warrants deeper understanding. At the same time, any operational success is a great place to collect information. What learning does is allow the organization to understand the difference between work as planned and imagined and work as it is being done. Any place where there is operational pain, goal conflict, or misalignment is a place where learning can and should happen. Anytime something happens that places the organization in a position where the organization does not know what happened is where to start learning.
   可能造成某种类型伤害的事件或作失败当然需要更深入的理解。同时，任何运营成功都是收集信息的好地方。学习的作用是让组织了解按计划和想象的工作与按时完成的工作之间的区别。任何存在运营痛苦、目标冲突或错位的地方都是可以而且应该进行学习的地方。任何时候发生的事情使组织处于组织不知道发生了什么的位置，就是开始学习的地方。
   

   

2. Select or invite a group of workers to be a member of this learning review - Find people who know the work to be a part of the learning team. Select people who are interested in making the working environment better for both the organization and for the workers. If more people are needed, expand the team to include the people needed to understand the work. If special expertise is needed, bring those people into this learning activity as well. Who needs to be in the team is quite obvious and directly dependent on the work being done by the people doing the work. There will be no great mystery as to the membership in this learning activity.
   选择或邀请一组工作人员成为此学习评审的成员 - 查找了解工作的人员成为学习团队的一员。选择有兴趣为组织和员工提供更好的工作环境的人员。如果需要更多人员，请扩大团队以包括了解工作所需的人员。如果需要特殊的专业知识，也请让这些人参加这个学习活动。谁需要加入团队是显而易见的，并且直接取决于从事这项工作的人所做的工作。关于这项学习活动的成员不会有太大的神秘之处。
3. Schedule two meetings with a gap between meeting one and meeting two - Find a place to meet and schedule two meetings a day or
   安排两次会议，会议 1 和会议 2 之间有间隔 - 找个会议地点，每天安排两次会议，或者
   two apart to best prepare the group to both identify and solve the improvement target. The use of two meetings is almost entirely logistical - having two meetings allows the group to separate problem identification from solution generation. As we have discussed earlier, the biggest enemy of problem identification is the need to solve the problem immediately. Having two meetings makes it easy to simply put all solution ideas on the second day. This is a surprisingly simple way to keep the solution bias from destroying problem analysis.
   两个分开，以便为小组确定和解决改进目标做好最佳准备。使用两次会议几乎完全是后勤工作 - 召开两次会议可以让小组将问题识别和解决方案生成分开。正如我们之前所讨论的，问题识别的最大敌人是需要立即解决问题。召开两次会议可以很容易地在第二天提出所有解决方案想法。这是一种非常简单的方法，可以防止解决方案偏差破坏问题分析。
   

   

4. Spend meeting one in the identification and generation of the problem statement - The first meeting, in our opinion, is the most important meeting of the two meetings. Identifying the problem while having the luxury of discussing the problem without the burden of having to solve the problem allows much space for a deeper discussion of the problem and its origins within the organization. Don’t be surprised with the group’s identification of the problem not being in alignment with the problem organizational leadership may think they have - the problem statements rarely talk about the problem the group was formed to discuss. Learning teams tend to look up and out from the problem and often identify weaknesses in processes well before the problem had become knowable.
   花一次会议来识别和生成问题陈述 - 在我们看来，第一次会议是两次会议中最重要的一次会议。识别问题，同时可以自由地讨论问题，而不必承担解决问题的负担，这为组织内部对问题及其根源的深入讨论提供了很大的空间。不要对小组对问题的识别与组织领导层可能认为他们所面临的问题不一致而感到惊讶——问题陈述很少谈论小组成立时要讨论的问题。学习团队倾向于从问题中向上和向外看，并且通常在问题变得可知之前就发现流程中的弱点。
   

   

5. Take some soak time to think about what you identified as the problem - The gap between the first meeting and the second meeting not only serves as a clear division between problem identification and solution generation, this time also provides some time to review and think deeper about the problem. This soak time is normally very productive. Team members often will come to the second meeting and begin the discussion by talking about what was not talked about during the first meeting. This technique is both a way to separate the two meetings that also allows for the benefit of review of the topic.
   花一些时间思考一下您确定的问题是什么 - 第一次会议和第二次会议之间的差距不仅是问题识别和解决方案生成之间的明确划分，这段时间还提供了一些时间来回顾和更深入地思考问题。这个浸泡时间通常非常高效。团队成员通常会参加第二次会议，并通过谈论第一次会议期间没有讨论的内容来开始讨论。这种技术既是分隔两个会议的一种方式，也允许对主题进行审查。
   

   

6. Spend the second meeting reviewing the problem statement and start generating solutions ideas - The second meeting not only allows for the review period as discussed in step 5 but also allows the group to go through a review process as a natural function of getting back on topic. This review process further helps to define the problem statement more acutely. The most powerful part of the second meeting is the defined time, set aside to generate creative and potentially effective solution ideas. This second meeting uses the identified problem as a springboard for a multitude of solution ideas - some of which the workers will have been thinking about for years - that will improve the organization’s ability to do work.
   利用第二次会议回顾问题陈述并开始产生解决方案想法 - 第二次会议不仅允许第 5 步中讨论的审查期，还允许小组完成审查过程，作为回到主题的自然功能。此审查过程进一步有助于更敏锐地定义问题陈述。第二次会议最有力的部分是确定的时间，留出时间来产生创造性和可能有效的解决方案想法。第二次会议将已发现的问题作为大量解决方案想法的跳板 - 其中一些想法是员工们已经考虑了多年 - 这将提高组织的工作能力。
7. Have the learning team prioritize the solution ideas - It is normal to have many great solutions offered up during a learning opportunity like a learning team. Many of the solutions will be effective. One way to encourage a continued sense of engagement is to allow the group to propose a prioritized list of solutions. Have the group determine which solutions should be fixed first, second, and third - Often this periodization is done by asking the group to identify the solutions into one of three lists: long-term implementation, mid-term implementation, and immediate implementation. Normally the organization selects a mix of these solutions. Using the team to help prioritize the solutions is a very effective method to help determine the next steps for this improvement strategy.
   让学习团队确定解决方案想法的优先级 - 在学习团队等学习机会中提供许多出色的解决方案是正常的。许多解决方案将是有效的。鼓励持续参与感的一种方法是允许小组提出一个优先的解决方案列表。让小组确定哪些解决方案应该首先、第二个和第三个 - 通常，这种分期是通过要求小组将解决方案确定为以下三个列表之一来完成的：长期实施、中期实施和立即实施。通常，组织会选择这些解决方案的组合。让团队帮助确定解决方案的优先级是帮助确定此改进策略的后续步骤的一种非常有效的方法。
8. Micro-experiment these solutions in a safe-to-learn, safe-to-fail environment - One of the most beneficial aspects of learning teams is the ability to prototype solutions on a small scale, collect data about the prototype and then move to more effective and sustainable solutions. To allow testing to happen with any hope of success the organization has to make it both a safe-to-learn and safe-to-fail environment. Provide the space, time and resources for these groups to experiment with ideas to improve the work context and conditions. Many of the greatest solutions start with masking tape and cardboard prototypes that eventually turn to fully engineered improvements. This process also
   在安全学习、安全失败的环境中对这些解决方案进行微实验 - 学习团队最有益的方面之一是能够小规模地构建解决方案原型，收集有关原型的数据，然后转向更有效和可持续的解决方案。为了让测试在有希望的情况下进行，组织必须使其成为一个安全学习和安全失败的环境。为这些小组提供空间、时间和资源，让他们尝试各种想法，以改善工作环境和条件。许多最出色的解决方案都是从遮蔽胶带和纸板原型开始的，最终转变为完全工程化的改进。此过程还
   is fun and exciting for the group, not a small benefit in honoring the expertise and skill the workers have for doing work in your organization.
   对团队来说既有趣又令人兴奋，对于表彰员工在您的组织中工作所拥有的专业知识和技能来说，这是一个不小的好处。
9. Present information to leadership - Finally, when the information and improvement begin to take shape, it is time to tell the stories of this learning voyage. These stories are very impactful and important - think of this activity as teaching the improvement story to the leaders so that they call tell this same story to their direct line reporting and their peers. Giving your leadership a story to tell is one of the most important tools to create change - a very important way to do safety in a different way.
   向领导层展示信息 - 最后，当信息和改进开始形成时，是时候讲述这次学习之旅的故事了。这些故事非常有影响力和重要性 - 将这个活动看作是向领导者传授改进故事，以便他们打电话向他们的直接下属和同事讲述同样的故事。给你的领导层一个故事是创造变革的最重要工具之一，也是以不同的方式实现安全的非常重要的方式。
10. Do it again on a new problem or operational curiosity - Perhaps the best part of doing worker-centric learning teams is these teams can multiply themselves. Once the organization realizes the power and effectiveness of this type of learning, the organization will soon realize the power of tapping into the expertise that lives within the organization all of the time. Tell stories of success knowing that these stories will breed more stories of success.
    针对新问题或作好奇心再做一次 - 也许以员工为中心的学习团队最好的部分是这些团队可以自我倍增。一旦组织意识到这种学习方式的力量和有效性，组织将很快意识到利用组织内一直存在的专业知识的力量。讲述成功的故事，知道这些故事会孕育出更多的成功故事。

Change happens through learning
通过学习实现改变

Discussion questions  问题讨论

1. Why is the idea that your organization may be able to prevent accidents by preventing short cuts or creative adaptations by workers, a crap idea?
   为什么您的组织可以通过防止工人走捷径或创造性地适应来防止事故的想法是一个废话？
2. How large do you reckon the gap between work-as-imagined and work-as-done is in your organization? Does it differ per area? Are your leaders aware of the gap between work-asimagined and work-as-done? Do they see operational learning from workers about work-as-done as a challenge to their leadership and a threat to their need for control?
   您认为您的组织中“想象中的工作”和“按时完成的工作”之间的差距有多大？每个地区都不同吗？您的领导者是否意识到想象中的工作和已完成的工作之间的差距？他们是否将员工关于“已完成工作”的作学习视为对他们领导力的挑战和对他们控制需求的威胁？
3. Are there cases from your own organization where it sort-of stumbled upon a spontaneous Learning Team? Did it recognize and capitalize on the opportunity for learning and improvement, or did it let the moment pass?
   你自己的组织有没有偶然发现一个自发的学习团队的案例？它是否认识到并利用了学习和改进的机会，还是让这一刻过去了？
4. What would you need to do in your organization to make learning teams an effective standard technique for understanding and improving real work?
   您需要在组织中做些什么才能使学习团队成为理解和改进实际工作的有效标准技术？
5. If you were to organize Learning Teams not to investigate an incident, but rather to look into normal, everyday successful work, which practical trigger(s) could you use for setting up such a Learning Team?
   如果您组织学习团队不是为了调查事件，而是为了调查正常的、每天的成功工作，那么您可以使用哪些实际触发因素来建立这样的学习团队？

Chapter 3  第 3 章

When things go wrong：当事情怡错时， Do investigations differently
When things goes wrong：当事情怡错时，以不同的方式进行调查

－Change how you define what you want
- 改变你定义你想要的东西的方式
－Change how you learn from yourself and others
– 改变你向自己和他人学习的方式
－Change how you respond to failure and success．
– 改变你对失败和成功的反应方式。

Not everything went right
并非一切都顺利

• In this case study, you can see this event as a failure; a tank lost containment and leaked for almost two full days.
  在此案例研究中，您可以将此事件视为失败;一个储罐失去了控制并泄漏了近整整两天。
• In this case study, you can see this event as a success; a tank lost containment and the process safety design was ready and able to manage the loss of containment to a secondary containment system with zero loss of product to the environment.
  在本案例研究中，您可以将此事件视为成功;储罐失去了密封性，工艺安全设计已准备就绪，能够管理二级密封系统的密封性损失，而不会对环境造成零产品损失。
• In this case study, you can see this event as both a failure and a success - a successful failure. A telltale, a purposefully designed weakness to give an early indication of tank erosion functioned as designed and leaked into a secondary containment system giving the organization an early indicator of a potential catastrophic tank failure.
  在本案例研究中，您可以将此事件视为失败和成功 - 成功的失败。一个明显的、故意设计的弱点，用于提供储罐腐蚀的早期迹象，按设计运行并泄漏到二级安全壳系统中，为组织提供潜在灾难性储罐故障的早期指标。

Investigations learn; Corrective actions fix
调查学习;纠正措施修复

Except for one…  除了一个...

Traditional Investigations are often limited by Administrative Requirements
传统调查通常受到管理要求的限制

The benefits of investigating differently
以不同方式进行调查的好处

Investigating differently
以不同的方式进行调查

• Things go wrong all the time in our daily operations. In most instances, workers detect and correct problems in real-time. Failure happens all the time; all the components for an unwanted outcome live in your organizational system and processes as a part of daily work. An organization can learn from typical work much better than from waiting for an event.
  在我们的日常运营中，事情总是出错。在大多数情况下，工作人员会实时检测并纠正问题。失败一直在发生;作为日常工作的一部分，导致意外结果的所有组成部分都存在于您的组织系统和流程中。组织可以从典型工作中学习，而不是从等待事件中学习。
• Events are the unexpected combination of normal work contexts. Don’t look for some type of special deviation to explain why an event happened. Instead, look at the work as it is done when it does not fail. Learn how this work is done when it does not fail to better understand the conditions present when the work fails.
  事件是正常工作环境的意外组合。不要寻找某种类型的特殊偏差来解释事件发生的原因。相反，当工作没有失败时，就要看它已经完成。了解在工作失败时如何完成这项工作，以更好地了解工作失败时出现的条件。
• Investigations learn/Corrective actions fix. There is a huge difference between learning and fixing. Learning always must happen before fixing. Too often organizations do investigations to fix problems. Investigating to fix problems will ensure the organization will not learn enough about the work to truly understand what happened. It is much better to see the corrective actions as a product of the learning analysis. Your organization must learn before it can act.
  调查学习/纠正措施修复。学习和修复之间存在巨大差异。在修复之前，必须先学习。组织经常进行调查来解决问题。调查以解决问题将确保组织不会对工作了解得足够多，无法真正了解发生了什么。将纠正措施视为学习分析的产物要好得多。您的组织必须先学习，然后才能采取行动。
• Investigations answer the “how” question, not the “why” question. When an event happens, there is a desperate need to answer the “why” question. Many organizations are so fixated on the “why” question they use a stairstep process of asking the why question many times. Our organization desperately wants to understand “why something bad happened.”
  调查回答的是 “如何” 的问题，而不是 “为什么” 的问题。当事件发生时，迫切需要回答 “为什么” 的问题。许多组织非常关注 “为什么” 问题，他们使用阶梯式流程多次询问 为什么 问题。我们的组织迫切希望了解 “为什么会发生坏事”。

• Tell the story of the conditions necessary to have the failure that happened. Complex systems are made up of many separate parts that are tightly coupled together. Identifying the individual parts of the event, the conditions present for the event to happen helps to illustrate the complex nature of an event. Traditional investigations tend to put preferential treatment on the combination of all the individual parts of an event. This is evident in traditional investigation timelines, highlighting process deviation and root cause analysis.
  讲述发生失败所需的条件。复杂系统由许多紧密耦合在一起的独立部分组成。确定事件的各个部分，以及事件发生的条件有助于说明事件的复杂性。传统调查倾向于优先考虑事件的所有单独部分的组合。这在传统的调查时间表中很明显，突出了流程偏差和根本原因分析。

Discussion questions  问题讨论

1. If you were to ask your own organization why it does investigations, what do you think the answer would be? Should you try to change that?
   如果你问你自己的组织为什么要进行调查，你认为答案会是什么？你应该尝试改变这一点吗？
2. Do you have any examples of ‘successful failures’ in your own organization that were mostly hailed as a success and that inspired further improvements?
   在你自己的组织中，是否有任何 “成功的失败 ”的例子，这些例子大多被誉为成功，并激发了进一步的改进？
3. Why is thinking in terms of ‘root causes’ not very helpful?
   为什么从“根本原因”的角度思考不是很有帮助？
4. In what sense are the administrative and policy apparatus (and perhaps the politics) surrounding and driving investigations in your organization actually limiting learning and improvement?
   从什么意义上说，围绕和推动您组织中调查的行政和政策机构（也许还有政治）实际上限制了学习和改进？
5. What is the link between investigating differently and acknowledging the difference between work-as-imagined and work-asdone?
   以不同的方式进行调查与承认按想象工作和按原样工作之间的区别之间有什么联系？

Chapter 4
当脑从太多时，清理你的栓客僚
When there＇s too much compliance： Declutter your safety bureaucracy
第 4 章 当脑从太多时，清理你的栓客僚 当合规性过多时：整理您的安全官僚机构

What is safety clutter?
什么是安全杂物？

• Signs on stairs instructing workers to ‘maintain 3 points of contact,’ which were
  楼梯上的标志指示工人“保持 3 个接触点”，它们是

• Duplicate labels warning users that a hot tap will issue hot water taken from hazardous area warning labels, or labels on-site toilets that use grey (storm) water for flushing that say ‘not for drinking’;
  重复标签警告用户热水龙头会发出从危险区域取来的热水警告标签，或使用灰色（雨水）冲水的现场马桶贴上“不得饮用”的标签;
• Risk assessments for travel to be done on a seven-page form, independent of whether such travel was to a remote, risk-filled country on another continent or to a neighboring city in the same state.
  旅行风险评估以七页的表格形式进行，无论此类旅行是前往另一大洲的偏远、充满风险的国家，还是前往同一州的邻近城市。

Where does safety clutter come from?
安全杂物从何而来？

“The largest source of growth in rules and regulations is the private sector. We tend to blame the government for bureaucracy’s drag on our productivity, but the dollars locked up by businesses in complying with selfimposed red tape are double those associated with government regulations.” ${}^{29}$${}^{29}$^(29){ }^{29}
“规则和法规增长的最大来源是私营部门。我们倾向于将官僚主义拖累我们的生产力归咎于政府，但企业为遵守自我强加的繁文缛节而锁定的资金是与政府法规相关的资金的两倍。 ${}^{29}$${}^{29}$^(29){ }^{29}

These disorders cause persistent and severe pain, lost work time, reduction or loss of the worker’s normal functional capacity both in work tasks and in other of life’s major activities, loss of productivity, and significant medical expenses. Where preventive action or early medical intervention is not provided, these disorders can result in permanent damage to musculoskeletal tissues, causing such disabilities as the inability to use one’s hands to do even the small tasks of daily life (e.g., lifting a child), permanent scarring, and arthritis. ${}^{33}$${}^{33}$^(33){ }^{33}
这些疾病会导致持续和严重的疼痛、工作时间的损失、工人在工作任务和其他生活主要活动中的正常功能能力减少或丧失、生产力损失和大量的医疗费用。在没有提供预防措施或早期医疗干预的情况下，这些疾病可导致肌肉骨骼组织永久性损伤，导致诸如无法用手完成日常生活中的小任务（例如，举起孩子）、永久性疤痕和关节炎等残疾。 ${}^{33}$${}^{33}$^(33){ }^{33}

The safety and health of our Nation’s workforce is a priority for my Administration. Together we will pursue a comprehensive approach to ergonomics that addresses the concerns surrounding the ergonomics rule repealed today. We will work with Congress, the business community, and our Nation’s workers to address the important issues. ${}^{34}$${}^{34}$^(34){ }^{34}
我们国家劳动力的安全和健康是本届政府的首要任务。我们将共同寻求一种全面的人体工程学方法，以解决围绕今天废除的人体工程学规则的担忧。我们将与国会、商界和我们国家的工作人员合作，解决这些重要问题。 ${}^{34}$${}^{34}$^(34){ }^{34}

How to sit at your desk
如何坐在办公桌前

CHAIR  椅子

1. Is the chair easily adjusted from a sitting position?
   椅子从坐姿可以轻松调节吗？

1. Is your chair high enough so that your elbows are just above the height of the desk (note: to determine elbow height relax your shoulders and bend your elbows to about 90 degrees)?
   您的椅子是否足够高，以至于您的肘部刚好高于桌子的高度（注意：要确定肘部高度，请放松肩膀并将肘部弯曲约 90 度）？
2. Are your elbows by your sides and shoulders relaxed?
   您的肘部放在身体两侧和肩膀是否放松？
3. Are your knees at about hip level, i.e., thighs parallel to the floor (may be slightly higher or lower depending on comfort)?
   您的膝盖是否与臀部齐平，即大腿与地板平行（根据舒适度，可能会略高或略低）？
4. Is there adequate legroom beneath your desk?
   您的办公桌下方是否有足够的腿部空间？
5. Do you require a footrest?
   您需要脚踏板吗？

1. When sitting and looking straight ahead, are you looking at the top one-third of your screen?
   当您坐着直视前方时，您是否正在看屏幕的顶部三分之一？
2. Is your screen at a comfortable reading distance (i.e., approximately an arm’s length away from your seated position)?
   您的屏幕是否处于舒适的阅读距离（即，距离您的坐姿大约一臂之遥）？
3. Can you easily adjust and position your screen?
   您可以轻松调整和定位屏幕吗？
4. Are all the characters on the display legible and the image stable (i.e., not flickering)?
   显示屏上的所有字符是否清晰易读且图像稳定（即不闪烁）？
5. Do light reflections on your screen cause you discomfort you may need to adjust the angle of your screen)?
   屏幕上的光反射会引起您的不适吗，您可能需要调整屏幕的角度）？
6. Do you wear bifocal glasses during computer work?
   您在计算机工作时戴双焦点眼镜吗？
7. Do you have dual monitors at your workstation?
   您的工作站上有双显示器吗？

KEYBOARD  键盘

1. Is your keyboard positioned close to the front edge of your desk (approximately $60-70\mathrm{mm}$$60-70\mathrm{mm}$60-70mm60-70 \mathrm{~mm} from the edge)?
   您的键盘是否靠近桌面的前边缘（大约 $60-70\mathrm{mm}$$60-70\mathrm{mm}$60-70mm60-70 \mathrm{~mm} 从边缘开始）？
2. Is the keyboard sitting directly in front of your body when in use?
   使用时，键盘是否直接位于您的身体前方？
3. Does it sit slightly raised up?
   它是否略微抬起？
4. If the keyboard is tilted, are your wrists straight, not angled, when typing?
   如果键盘倾斜，打字时手腕是否伸直，而不是倾斜？
5. Are the keys clean and easy to read?
   按键是否干净且易于阅读？

MOUSE/LAPTOP  鼠标/笔记本电脑

1. Are your mouse and mouse pad directly beside the end of the keyboard, on your preferred side?
   您的鼠标和鼠标垫是否直接位于键盘末端的一侧？
2. Do you use a laptop computer for extended periods of time at a desk?
   您是否长时间在办公桌前使用笔记本电脑？
3. Is the screen raised so that the top of the screen is at eye level?
   屏幕是否升高，使屏幕顶部与眼睛齐平？
4. Do you use an external keyboard and mouse?
   您是否使用外部键盘和鼠标？

DESK LAYOUT  桌面布局

1. Are all the items that you are likely to use often within easy reach?
   您可能经常使用的所有物品都触手可及吗？
2. Is there sufficient space for documents and drawings?
   是否有足够的空间放置文档和图纸？
3. If most of your work requires typing from source documents, do you require a document holder?
   如果您的大部分工作都需要从源文档中键入，您是否需要一个文档支架？
4. If you use a document holder, is it properly located close to your monitor and adjustable?
   如果您使用文件架，它是否正确放置在靠近显示器的位置并且可以调节？
5. Is your workstation set out to prevent undue twisting of your neck and back?
   您的工作站是否旨在防止颈部和背部过度扭动？

• Get rid of the regulation and get rid of the regulator if you can. Tell the state to stay away.
  如果可以的话，摆脱监管和监管。告诉州政府远离。
• Then give everything a price, or, rather, let the markets set a price for everything, including injury.
  然后给所有东西一个价格，或者更确切地说，让市场为所有东西设定价格，包括伤病。
• Abolish the state’s worker compensation scheme and outsource injury compensation to the private insurance market instead.
  废除该州的工人赔偿计划，将伤害赔偿外包给私人保险市场。
• Allow the burgeoning of a consultancy market where someone will come up with a ‘how-to-sit-at-your-desk-checklist’ and sell it to you by sowing fear about what it might cost you if you don’t buy it.
  允许咨询市场的蓬勃发展，有人会提出一个 “如何坐在你的办公桌前的清单 ”，并通过散播对如果你不买它可能会让你付出什么代价的恐惧来推销给你。
• Then responsibilize your workers to do their self-regulatory work by plodding through that checklist every time they go sit at a desk, and implicitly or explicitly warn them of making ‘poor choices’ when working at their stations.
  然后，让你的员工负责做他们的自我监管工作，每次他们坐在办公桌前时都要仔细阅读该清单，并含蓄或明确地警告他们在工作岗位上工作时要做出 “糟糕的选择”。
• Then hold your workers accountable for compliance with your new rules through this arduous four-page long process that will allow you to pass the buck back to the worker when it turns out that they got RSI after all.
  然后，通过这个艰巨的四页长过程，让您的工人负责遵守您的新规则，这将允许您在证明他们最终获得了 RSI 时将责任转嫁给工人。

Freedom in a frame
框架中的自由

• Rangers internalized certain common professional values;
  Rangers 内化了某些共同的职业价值观;
• Rangers shared a sense of joy at taking, and being given, responsibility;
  流浪者队对承担和被赋予责任感到高兴;
• Rangers had a ‘neutral competency’ themselves, allowing them to master their work and their areas of responsibility;
  Rangers 本身就具有“中立能力”，这使他们能够掌握自己的工作和责任领域;
• There was only ‘soft’ and distant oversight by their employing agency;
  他们的雇佣机构只有“软”和远程的监督;
• A rotation system kept the rangers from going entirely native or being captured by local interests in their work areas;
  轮换制度使护林员不会完全成为本地人或被他们工作区域的当地利益所俘虏;

• The rotation system also ensured the sharing and distribution of novel solutions across different jurisdictions over time. ${}^{36}$${}^{36}$^(36){ }^{36}
  轮换制度还确保了随着时间的推移在不同司法管辖区之间共享和分发新颖的解决方案。 ${}^{36}$${}^{36}$^(36){ }^{36}

• Don’t order more than necessary and avoid planning beyond the situation you can foresee;
  不要订购不必要的订单，并避免超出您可以预见的情况进行计划;
• Subordinates are justified in modifying or even changing the task assigned, as long as it supports the higher commander’s intent (he called this Auftragstaktik, or ‘Assignment tactics’)
  下属有理由修改甚至更改分配的任务，只要它支持上级指挥官的意图（他称之为 Auftragstaktik，或“分配策略”）
• Look for those with Verantwortungsfreudligkeit, who have willingness and a joy at taking responsibility for others and for the work they need to jointly accomplish. They like taking ownership and take pride in doing so.
  寻找那些拥有 Verantwortungsfreudligkeit 的人，他们愿意并乐于为他人和他们需要共同完成的工作负责。他们喜欢拥有所有权，并为此感到自豪。

• Hate their work  讨厌他们的工作
• Avoid responsibility and need constant direction
  逃避责任，需要持续的指导
• Have to be controlled, forced and threatened to deliver work
  必须被控制、被迫和威胁才能交付工作
• Need to be supervised at every step
  每一步都需要监督
• Have no incentive to work. They have no ambition and need to be externally motivated to achieve goals.
  没有工作动力。他们没有雄心壮志，需要外部激励来实现目标。

• Most people like their work
  大多数人都喜欢他们的工作
• There is such a thing as intrinsic motivation
  有一种东西叫做内在动机
• People’s needs and organizational needs can overlap
  人们的需求和组织的需求可以重叠
• Most people like to take responsibility, initiative and ownership if given the opportunity
  如果有机会，大多数人都喜欢承担责任、主动性和主人翁意识
• Most people are capable of solving problems creatively and imaginatively
  大多数人都能够创造性地和想象力地解决问题
• Talent gets underutilized a whole lot.
  人才没有得到充分利用。

• Autonomy-the ability to control and direct your work-what, when and with whom
  自主性 - 控制和指导您的工作的能力 - 什么、何时以及与谁合作
• Mastery-the ability to develop your knowledge and skills and expertise, getting better at what you do
  精通 - 发展您的知识和技能以及专业知识的能力，让您的工作变得更好
• Purpose-the answer to ‘why’: the sense that you’re part of something larger than you are accomplishing together with other people.
  目的 - “为什么”的答案：感觉你是比你与他人一起完成的更大的事情的一部分。

How to reduce your safety clutter
如何减少安全杂乱

• Most of your safety clutter is self-imposed. Your organization wrote it. That means that your organization has the power to change it.
  您的大部分安全杂物都是自我强加的。您的组织编写了它。这意味着您的组织有能力改变它。
• A lot of safety clutter is the result of knee-jerk reactions to (badly investigated) incidents (see Chapter 3 about how you can do this better and prevent the writing of yet another rule in response to the latest event).
  很多安全混乱都是对（调查不善的）事件的下意识反应的结果（参见第 3 章，了解如何更好地做到这一点并防止为应对最新事件而编写另一条规则）。
• Resolve that for each new rule you put in, you take at least one (or better still, two or three) out.
  解决 对于您输入的每个新规则，您至少删除一个（或者更好的是，两个或三个）。
• More internal rules do not equal better legal protection.
  更多的内部规则并不等于更好的法律保护。
• The more self-imposed rules you have, the more likely you will be found out of compliance. The more rules you have, in other words, the easier you may get into trouble.
  您自我强加的规则越多，您被发现不合规的可能性就越大。换句话说，您拥有的规则越多，您就越容易遇到麻烦。
• You can start decluttering by asking your people ‘what’s the stupidest thing we’re asking you to comply with to work here today?’ You’ll learn a lot if you’re open to the answers. Engaging with those who do the work, and with how they actually get work done, is key to decluttering.
  你可以通过问你的员工'我们要求你今天在这里工作遵守的最愚蠢的事情是什么'来开始整理。如果你对答案持开放态度，你会学到很多东西。与从事工作的人互动，以及他们如何实际完成工作，是整理的关键。
• If you want to take a serious stab at decluttering, make sure you’ve only got operational people in the room. No safety people or lawyers. They can have their say (if at all) later.
  如果您想认真尝试整理，请确保您的房间里只有作人员。没有安全人员或律师。他们可以在以后发表意见（如果有的话）。
• You can safely declutter by making sure that only rules directly traceable to a regulation, law or government requirement are on your books.
  您可以通过确保只有可直接追溯到法规、法律或政府要求的规则在您的账簿上来安全地整理。
• You can safely declutter by microexperimenting (see Chapter 7).
  您可以通过微实验安全地整理（参见第 7 章）。

Discussion questions  问题讨论

1. Are there any rules or policies in your organization that you are supposed to follow and that you wouldn’t even have known about if it weren’t for some occurrence?
   您的组织中是否有任何您应该遵守的规则或政策，如果不发生某些情况，您甚至不会知道这些规则或政策？
2. Do you consider your organization ‘cluttered’ with rules, policies and procedures? Where do you think it all comes from? And to what extent do safety requirements contribute to all this clutter?
   您是否认为您的组织被规则、政策和程序“杂乱无章”？你认为这一切从何而来？安全要求在多大程度上导致了所有这些混乱？
3. Why can safety clutter be dangerous? Is your organization aware of these dangers?
   为什么安全杂物会很危险？您的组织是否意识到这些危险？
4. How is it possible that government deregulation has caused greater safety clutter inside your organization?
   政府放松管制怎么可能在你的组织内部造成更大的安全混乱？
5. How would you introduce the idea of ‘Freedom in a Frame’ into your own organization? What would be the frame and what would be the freedom?
   您将如何将“框架中的自由”理念引入您自己的组织？框架是什么，自由是什么？

Chapter 5  第 5 章

When your safety people are dejected： Empower them differently
当您的安全人员感到沮丧时：以不同的方式赋予他们权力

The fun police  有趣的警察

• thinks they’re better than everyone else, but
  认为他们比其他人都好，但是
• doesn’t understand what real work is;
  不明白什么是真正的工作;
• takes away the fun from being at the frontline;
  带走了在前线的乐趣;
• has lots of petty rules to dish out and no clue;
  有很多琐碎的规则要制定，却毫无头绪;
• comes and tries to record and report stuff that is easily made up, hidden or manipulated.
  来并试图记录和报告容易编造、隐藏或纵的东西。

• Optic compliance. People do as if they care about the rules. They will comply-or they make their behavior ‘look’ like they are complying-when they know someone is watching; when they know they are under surveillance. Otherwise they’ll just do what they need to do to get on with things. This optic compliance, creating the impression for others that the rules are fine, workable, unproblematic and adhered to.
  光学合规性。人们就像他们关心规则一样。当他们知道有人在看着时，他们会遵守——或者他们让他们的行为“看起来”像是在遵守;当他们知道自己受到监视时。否则，他们只会做他们需要做的事情来继续做事。这种视觉上的合规性，给其他人留下了规则很好、可行的、没有问题并且得到遵守的印象。
• Resignation. People get resigned when the become learned helpless; when they have started to realize that there’s nothing they can do to change the situation they’re in. They cannot influence the tasks they’re assigned to accomplish; they can’t stop nonsensical rules
  辞职。当人们变得博学无助时，人们就会无奈;当他们开始意识到他们无法改变他们所处的状况时。他们无法影响他们被分配完成的任务;他们无法阻止荒谬的规则

• Cynicism. People become cynical when they stop believing that any of the actions or rules made by others will make any difference, or that they are truly for their benefit. They’ve been fed so much nonsense or been given so many broken promises, that they wonder whether any of it can be trusted anymore. Intriguingly, Arendt found that people under totalitarianism simultaneously believe everything and believe nothing. One the one hand, they have to believe everything, just to keep a glimmer of hope alive among their resigned, optic compliance. But at the same time, weary and jaundiced as they’ve become, they’ve learned to no longer believe anything. Cynicism sits at the heart of the paradox.
  玩世不恭。当人们不再相信他人制定的任何行动或规则会带来任何影响，或者他们真的是为了自己的利益时，他们就会变得愤世嫉俗。他们被灌输了太多的废话，或者被灌输了那么多违背的承诺，以至于他们想知道这些是否还能被信任。有趣的是，阿伦特发现，极权主义下的人们同时相信一切，什么都不相信。一方面，他们必须相信一切，只是为了在他们无奈的、表面上的顺从中保持一丝希望。但与此同时，尽管他们已经变得疲惫和黄疸，但他们已经学会了不再相信任何事情。犬儒主义是这个悖论的核心。

A traditional safety role
传统的安全角色

• Safety management involves a strong focus on barriers, restrictions, standardization and compliance.
  安全管理涉及对障碍、限制、标准化和合规性的高度关注。
• Incidents, accidents and near misses are believed to be the result of workers ignoring those barriers. It’s because workers bust the restrictions, because they’re being noncompliant.
  事故、事故和未遂事故被认为是工人忽视这些障碍的结果。这是因为工人违反了限制，因为他们不遵守规定。
• The way to govern safety, then, is to centralize it. Don’t allow workers to do their own thing, don’t permit them to improvise, don’t let them
  因此，管理安全的方法是集中化它。不允许工人做自己的事情，不允许他们即兴发挥，不要让他们

• You have to keep workers on the straight-andnarrow. You need to restrict the bandwidth of what you want them to do; and of what you allow them to do.
  你必须让工人保持笔直和狭窄。您需要限制您希望他们执行的作的带宽;以及你允许他们做什么。

• Checking compliance with policy and procedures
  检查对政策和程序的遵守情况
• Workplace risk assessments
  工作场所风险评估
• Hazard analysis  危害分析
• Develop or inform company policies
  制定或告知公司政策
• Conduct safety campaigns
  开展安全活动
• Write procedures  编写过程
• Give instructions  给出指示
• Investigate injuries and incidents and accidents
  调查伤害、事件和事故
• Physical inspections  物理检查
• Audits of workplace behavior
  工作场所行为审计
• Record, report and tally deviances
  记录、报告和统计偏差

• Reactive: Because of the inevitable gap between work as imagined and work as done, there is a constant need for reactive activities to ‘correct’ work as actually done. Safety people have to explain incidents;
  反应性：由于想象中的工作和已完成的工作之间不可避免地存在差距，因此始终需要反应性活动来“纠正”实际完成的工作。安全人员必须解释事件;
  others expect them to explain them in terms of non-compliance and deviances. They all react by reminding workers of the barriers and procedures already in place, or by inventing new ones to add to the compliance burden.
  其他人则希望他们用不合规和越轨行为来解释它们。他们的反应都是提醒员工已经存在的障碍和程序，或者发明新的障碍和程序来增加合规负担。
• Distant: Safety people become wrapped up in the ‘work of safety,’ or all the safety management activities that are performed at a distance and separate from the core functioning of workers at the frontline. That means that there’s no guiding principle for all that work of safety coming from how work is actually done (and what is required to make that work safe).
  疏远：安全人员被卷入“安全工作”中，或所有在远距离进行的安全管理活动中，与一线工人的核心职能分开。这意味着所有安全工作都没有指导原则，这些工作来自工作的实际完成方式（以及确保工作安全所需的条件）。
• Fragmented: The work of safety gets driven by a hodgepodge of legal, organizational and other compliance requirements, reactions to incidents or other bad news, or the inspired thought of a leader who wants another poster campaign because her or his peers have one as well. Initiative-fatigue is a common condition, and of course also contributes to cynicism and resignation.
  碎片化：安全工作受到法律、组织和其他合规要求、对事件或其他坏消息的反应，或者领导者想要另一场海报活动的启发性想法的驱动，因为她或他的同事也有海报活动。主动疲劳是一种常见情况，当然也会导致愤世嫉俗和无奈。
• Defensive: All the work of safety becomes so disconnected from the safety of actual frontline work that it begins to resemble a bulwark against risks and threats that don’t even come from the frontline. Rather, a lot of the work of safety (ticking boxes, doublechecking, documenting) is about managing another threat: that of legal or other liabilities. These will not affect the workers,
  防御性：所有安全工作都与实际前线工作的安全脱节，以至于它开始像一个堡垒，抵御甚至不是来自前线的风险和威胁。相反，许多安全工作（勾选框、仔细检查、记录）都是关于管理另一个威胁：法律或其他责任。这些不会影响 worker，
  but those higher up in the organization. The work of safety is a defensive mechanism to help them stay clear of trouble.
  而是那些在组织中更高层的人。安全工作是一种防御机制，可以帮助他们远离麻烦。

• Covert work systems. Work-as-done (the kinds of things that need to be done to really make operations happen) gets hidden from view when the work is subjected to formal scrutiny (audits, inspections, management visits). During those moments of intense surveillance, very little real work is actually going on, and will resume when surveillance is gone. This is, literally, the optic compliance we talked about above.
  隐蔽的工作系统。当工作受到正式审查（审计、检查、管理层访问）时，已完成的工作（真正使运营发生需要完成的工作类型）被隐藏起来。在那些严密监控的时刻，实际上几乎没有真正的工作在进行，当监控消失时，它们会继续进行。从字面上看，这就是我们上面谈到的 optic 合规性。
• Role retreat. If initiative and innovation are discouraged, one response is to stick strictly to the requirements and specifications of one’s role. People refuse going the extra mile, and will be less willing to collaborate across roles or team boundaries.
  角色撤退。如果不鼓励主动性和创新，一种应对措施是严格遵守自己角色的要求和规范。人们拒绝加倍努力，并且不太愿意跨角色或跨团队边界进行协作。
• Renaming and manipulation. If incidents or injuries give rise to bureaucratic over-
  重命名和作。如果事故或伤害导致官僚主义过度
  reaction by the organization, the strategy is to not have them. This is accomplished by calling incidents or injuries something else, or finding other ways to not have evidence of them show up. Interestingly, there are few limits to the creativity that people show here. If only such creativity to be channeled into more productive safety uses…
  组织的反应，策略是没有他们。这是通过将事件或伤害称为其他原因，或寻找其他方法来不显示它们的证据来实现的。有趣的是，人们在这里展示的创造力几乎没有限制。如果能够将这种创造力引导到更有成效的安全用途中......

• Remain ignorant of work-as-done. The fluency and smoothness with which work is done efficiently and safely (even if it’s not done as imagined) is the result of workers applying and combining expertise and experience. They iron out inconsistencies, contradictions, goal conflicts, resource limitations, tools and procedures that aren’t fit for the task, and more. Remaining ignorant of the deep cognitive and collaborative commitments that workers make to ‘make work work,’ is a safe strategy for those wanting to uphold the relevance of centralized safety control.
  保持对已做工作的无知。高效、安全地完成工作的流畅性和流畅性（即使没有按照想象完成）是工人应用和结合专业知识和经验的结果。他们消除了不一致、矛盾、目标冲突、资源限制、不适合任务的工具和程序等等。对于那些希望维护集中安全控制相关性的人来说，对员工为“让工作正常运转”而做出的深刻认知和协作承诺一无所知是一种安全的策略。
• Discounting. Problems and issues with frontline work that fall outside of ‘work-asimagined’ are discounted or rationalized away so that they once again align with existing plans, production goals and models of risk. Workers are told to ‘try harder,’ or ‘care more.’ Because the plan is perfect, the
  贴现。超出“想象工作”的一线工作问题和问题被打折扣或合理化，以便它们再次与现有计划、生产目标和风险模型保持一致。员工被告知要“更加努力”或“更关心”。因为计划是完美的，
  organization immaculate. People (workers) have to stop being a problem that gets in the way of the smooth execution of work-asimagined.
  组织完美无暇。人（工人）必须停止成为阻碍工作顺利执行的问题。

You are looking at the person responsible for your safety
您正在查看负责您安全的人

Focus on the safety of work, not the work of safety ${}^{42}$${}^{42}$^(42){ }^{42}
注重工作安全，而不是工作安全 ${}^{42}$${}^{42}$^(42){ }^{42}

• You can’t do everything by the book and still get work done in time. This is why we have work-to-rule actions or strikes. Follow all the rules for a change, and everything comes to a grinding halt. The point is not that full compliance is impossible (though it generally is); the point is to know what matters and what doesn’t matter in a particular setting.
  你不能按部就班地做所有事情，但仍然能按时完成工作。这就是我们推出按规则工作作或警示的原因。遵循所有规则进行更改，一切都会陷入停顿。关键不是完全遵守是不可能的（尽管通常是不可能的）;关键是要知道在特定环境中什么重要，什么不重要。
• You can’t keep doing work super-cheaply and still do it safely in the long run. Tools will start breaking, parts won’t work.
  从长远来看，你不能继续以超级便宜的方式做工作，并且仍然安全地做。工具会开始损坏，零件不会工作。
• You can’t run back-to-back shifts and then add some overtime just to meet production demands and think that that doesn’t increase risk somewhere along the line.
  你不能连续轮班，然后增加一些加班时间，只是为了满足生产需求，并认为这不会增加生产线上某个地方的风险。

The face of safety differently
不同的安全面貌

Build a bridge from the old ideas to the new ideas
搭建从旧想法到新想法的桥梁

The change is in how we see the workers
变化在于我们看待工人的方式

1. The levels of trust, communication, shared accountability, and reporting will increase. Worker engagement increases.
   信任、沟通、共同责任和报告的水平将提高。员工敬业度提高。
2. The safety team’s job becomes easier. Knowing more about operations makes you smarter and more effective.
   安全团队的工作变得更加轻松。更多地了解运营会让您更聪明、更高效。

A Philosophical Shift from Seeking Deviation to Assuring Capacity
从寻求偏差到确保能力的哲学转变

Engaging safety people in Safety Differently
以不同的方式让安全人员参与安全

• Start with the fundamentals - build competency on this new way of doing work. Don’t start at the conclusion - start at the beginning and ensure your safety team has the opportunity to develop these ideas so they can better put these ideas into practice. The biggest mistake that can be made is to assume a level of familiarity that is not there.
  从基础开始 - 培养这种新工作方式的能力。不要从结论开始 - 从头开始，确保您的安全团队有机会发展这些想法，以便他们能够更好地将这些想法付诸实践。可能犯的最大错误是假设不存在的熟悉程度。
• Allow time for discussion and disagreements. Diversity of thought makes you stronger and makes your transition more effective. It is normal for some initial pushback on these ideas so leave some space in your organization for people to talk about how they are feeling and what they are
  留出时间进行讨论和分歧。思想的多样性使您更强大，使您的过渡更有效。最初对这些想法的一些抵制是正常的，因此请在您的组织中留出一些空间让人们谈论他们的感受和他们是什么
  thinking. Seek places where diverse ideas live in the organization.
  思维。寻找组织中存在不同想法的地方。
• Know that your safety team members will develop at their own rate. Not everyone learns at the same rate. Some of your team will jump on these ideas in a short amount of time. Other members of your team may need some more time to think about these ideas. There is no one right way - both of these groups are right and will move at their own rate.
  知道您的安全团队成员将按照自己的速度发展。并非每个人都以相同的速度学习。您的一些团队会在短时间内接受这些想法。您团队的其他成员可能需要更多时间来思考这些想法。没有一条正确的路 - 这两个群体都是正确的，并且会以自己的速度前进。
• Ensure a peer-support group. Nothing is more comforting than knowing you have some fellow professionals also on the journey. The best resource for difficult questions is the group itself. The combined experience this group represents means there probably is not a question or a problem that some members of the safety team will not have some experience handling.
  确保有一个对等支持小组。没有什么比知道您有一些专业人士也在旅途中更令人欣慰的了。解决难题的最佳资源是小组本身。该小组所代表的综合经验意味着安全团队的某些成员可能没有一些处理经验的问题或问题。
• Encourage micro-experimentation. Encourage safety professionals to try new, worker-engaged ideas in a safe to fail environment. If these new ideas work repeat them. If these new ideas fail - stop, learn, and move on. The ability to try ideas and gather information about that experiment is how progress is made. The time it takes to try an idea will end up saving you time in the end.
  鼓励微实验。鼓励安全专业人员在安全失败的环境中尝试新的、工人参与的想法。如果这些新想法有效，请重复它们。如果这些新想法失败了 - 停下来，学习，然后继续前进。尝试想法和收集有关该实验的信息的能力就是取得进展的方式。尝试一个想法所需的时间最终会节省您的时间。
• Provide protection from the small group that will resist this change. There will be
  为抵制此更改的一小群人提供保护。将会有
  people who want to submarine this new safety for reasons that never really make much sense when queried. This is normal and sometimes these naysayers will exercise power and force over the safety professionals. Be alert to this idea and be ready to provide some type of protection.
  那些想要潜入这种新安全性的人，其原因在被询问时从来没有多大意义。这是正常的，有时这些反对者会对安全专业人员行使权力和武力。警惕这个想法并准备好提供某种类型的保护。
• Build-in shared accountability for the diffusion of these ideas. Accountability counts - and nothing is stronger than a sense of shared accountability for the success of any new idea. Talk about the roles that leadership, the workers, and the safety professionals have in doing Safety Differently.
  对这些思想的传播建立共同的责任。问责制很重要 - 没有什么比对任何新想法的成功都有共同的责任感更强大的了。谈谈领导层、工人和安全专业人员在以不同的方式开展安全工作中的作用。
• Tell stories of success during this transition. Talk about what you have learned. Discuss the events that did not happen because of the work you have done. Be your own press agent. If you don’t talk about the success with each other and with the rest of your organization, those stories will not be told. Remember, our organization is used to talking about how safety occasionally fails not how safety normally succeeds.
  讲述此过渡期间的成功故事。谈谈你学到了什么。讨论由于您所做的工作而没有发生的事件。成为您自己的新闻代理。如果你不与彼此和组织的其他成员谈论成功，这些故事就不会被讲述。请记住，我们的组织习惯于谈论安全偶尔会失败，而不是安全通常如何成功。
• Remember this is fun, exciting and is good for the organization. Don’t lose the joy that comes with making the world a better place. Get caught trying your best.
  请记住，这很有趣、令人兴奋，对组织有好处。不要失去让世界变得更美好的快乐。尽力而为。

When the safety team is frustrated, help them
当安全团队感到沮丧时，帮助他们

Discussion questions  问题讨论

1. Why is the way you see workers so fundamental to making any changes that may be needed in the role or orientation of safety people-for example away from being (seen as) the safety police?
   为什么您看待工人的方式对于在安全人员的角色或方向上做出任何可能需要的改变如此重要——例如，远离（被视为）安全警察？
2. Is there any evidence of optic compliance, resignation and cynicism around safety rules and policies in your organization? What is responsible for that, you think?
   是否有任何证据表明您的组织中存在对安全规则和政策的遵守、顺从和愤世嫉俗的态度？您认为是什么造成了这种情况？
3. What would it take for safety people in your organization to make the philosophical (and practical) shift from seeking deviation to assuring capacity? Who else would need to be on board, and how would that happen?
   您组织中的安全人员需要做些什么才能从寻求偏差到确保能力的理念（和实践）转变？还有谁需要加入，这将如何实现？
4. What is the difference between the ‘work of safety’ and the ‘safety of work’ in your organization? Are the right people aware of that difference?
   您组织中的“安全工作”和“工作安全”有什么区别？合适的人是否意识到这种差异？
5. What stickers, posters or slogans do you have in your organization that all seem to suggest that workers are the problem and that they need to take responsibility for their safety? What might you do about that?
   您的组织中有哪些贴纸、海报或口号似乎都表明工人是问题所在，他们需要对自己的安全负责？您该怎么办？

Chapter 6  第 6 章

When you need to help your leaders
当您需要帮助领导者时

You never know what will trigger a shift in thinking in a leader. Different people realize this new way of thinking in different ways. Knowing what will be the catalyst for new thinking in any learner, not just at the leadership level, is a mystery that we are constantly trying to discover.
你永远不知道什么会触发领导者的思维转变。不同的人以不同的方式实现这种新的思维方式。知道什么会成为任何学习者新思维的催化剂，而不仅仅是在领导层，这是我们一直在努力发现的一个谜团。

Spend your limited resource allotment on setting leadership up to be successful
将您有限的资源分配用于培养领导力以取得成功

When leaders push back - become instructive, not offended
当领导者反击时 - 变得有教贲意义，而不是被冒犯

What about looking at how badly we managed safety in the past?
看看我们过去在安全管理方面有多糟糕呢？

When you need to help leaders to succeed remember these ideas
当您需要帮助领导者取得成功时，请记住这些想法

1. Meet your leadership team where they are in this process. Don’t assume leaders already know this information - most likely leaders will not have been exposed
   在这个过程中，你会见你的领导团队。不要假设领导者已经知道这些信息——很可能领导者不会被暴露
   to many of these ideas.
   对其中许多想法。
2. Help your leaders move their definition of safety from the old view, safety as an outcome, to the newer view of seeing safety as a capacity. This seemingly simple change is fundamental to every other change that will happen.
   帮助您的领导者将他们对安全的定义从旧观点（安全即结果）转变为将安全视为一种能力的新观点。这个看似简单的变化对于将要发生的所有其他变化来说都是基础。
3. Build sufficient time for presenting these new ideas, discussing these new ideas, and pushing back on these new ideas. Don’t allow the fear of a busy schedule to shorten the amount of time you spend in creating successful change. No matter how hard your leadership team will try to shorten the schedule, and they will try to shorten the schedule, staying true to the rule of more time being the better option.
   留出足够的时间来展示这些新想法、讨论这些新想法并反对这些新想法。不要让对繁忙日程的恐惧缩短您花在创造成功变革上的时间。无论您的领导团队会多么努力地缩短时间表，他们也会尝试缩短时间表，坚持更多时间是更好的选择。
4. Allow the opportunity to practice this new way of responding to operational failure. Use case studies, other peer leaders from other organizations, and discussion time to help build competency in responding differently.
   让有机会练习这种应对运营故障的新方法。利用案例研究、来自其他组织的其他同行领导者和讨论时间来帮助培养以不同方式做出响应的能力。
5. Build expertise at the leadership level create a path for your leaders to be experts in this new way of thinking. Tell these leaders the organization needs them to be experts in operational reliability and safety.
   在领导层积累专业知识，为您的领导者创造一条道路，让他们成为这种新思维方式的专家。告诉这些领导者，组织需要他们成为运营可靠性和安全方面的专家。
6. Help recognize and reinforce leadership peer groups within your organization-
   帮助识别和加强组织内的领导同行群体 -
   your leader’s co-workers are not the people they lead; your leadership’s coworkers are their fellow leaders. Change is less scary when change is shared among peers. There is strength (and confidence) in numbers.
   你领导的同事不是他们领导的人;领导层的同事是他们的领导同事。当同龄人之间分享变化时，变化就不那么可怕了。人多力量（和信心）是有的。
7. Tell stories of success - don’t underestimate the power of the many small successes that are happening in your organization all the time.
   讲述成功的故事 - 不要低估组织中一直在发生的许多小成功的力量。
8. And finally, know that your leaders will move forwards and backwards in leading the organization towards this new way of thinking and responding - it takes a while to change years of experience.
   最后，要知道你的领导者在带领组织走向这种新的思考和回应方式方面会不断前进和后退——改变多年的经验需要一段时间。

• Take everything out. This condition, which we formally called the ‘local ownership condition,’ was the one in which we removed all the safety processes, procedures, checklists and rules that were not specifically required by state or federal law. In this condition, we wanted to create completely open conditions for grass-roots safety to germinate and grow. We took everything out, made no suggestions about what to do instead, and left the stores with only one rule: ‘don’t hurt anyone.’
  把所有东西都拿出来。我们正式称之为“本地所有权条件”，在这种条件下，我们删除了州或联邦法律没有明确要求的所有安全流程、程序、检查表和规则。在这种情况下，我们希望为基层安全创造完全开放的条件，使其发芽和生长。我们把所有东西都拿出来了，没有提出任何建议，离开商店时只有一条规则：“不要伤害任何人”。
  at Woolworths were instrumental in making the microexperiment happen, as well as stakeholders at the regulator and other partner organizations. You can watch the experiment in the free documentary film ‘Safety Differently’ on YouTube.
  在实现微实验方面发挥了重要作用，监管机构和其他合作伙伴组织的利益相关者也发挥了重要作用。您可以在 YouTube 上的免费纪录片“Safety Different”中观看实验。
• Take everything out and retrain according to Safety Differently. This condition, which we formally called the ‘ownership and engagement condition’, was driven by deliberate change management, which included training sessions for store workers and managers. These were modeled on the ideas of Safety Differently: see people as a resource to harness, not as a problem to control. Don’t tell people what to do but ask what they need to be successful, and stop counting negatives as a measure of your progress. Instead, identify and support the positive capacities in your people and teams that make things go well. We wanted this condition in there to see whether there were any radical differences between how people organized safety for themselves when left entirely to their own devices, and how they did so when actively instructed or inspired along new lines. In this condition, too, workers and managers were empowered to take out what they didn’t think was useful.
  把所有东西都拿出来，根据 Safety Different 进行再培训。我们正式称之为“所有权和参与度条件”，是由深思熟虑的变更管理驱动的，其中包括对商店员工和经理的培训课程。这些都是以 Safety Different（不同安全）的理念为蓝本的：将人视为需要利用的资源，而不是需要控制的问题。不要告诉人们该做什么，而是询问他们需要什么才能成功，并停止将消极因素作为衡量您进步的标准。相反，识别并支持您的员工和团队的积极能力，这些能力使事情顺利进行。我们希望将这个条件放在那里，看看人们在完全由自己的设备组织安全时，与在积极指导或启发新路线时如何组织安全之间是否存在根本差异。在这种情况下，工人和管理人员也被授权去掉他们认为没有用的东西。
• Control condition. This condition was literally our control. It involved a group of stores that were comparable to the stores in the other two conditions, but we changed nothing in them. They kept doing what they had been doing. Head office stayed in control of safety. It kept sending down its safety packs and expecting compliance in return. Managers or workers were not given any more leeway.
  控制条件。这种情况实际上是我们的控制。它涉及一组与其他两种条件下的商店相当的商店，但我们没有改变它们中的任何内容。他们继续做他们一直在做的事情。总部一直控制着安全。它不断发送安全包，并期望得到回报。经理或工人没有更多的回旋余地。

Bigger Worries  更大的担忧

Results  结果

Freedom In a Frame
框架中的自由

A Whoopee Prize  Whoopee 奖

Can you do your own micro-experiment?
你能做自己的微实验吗？

1. Find two or more groups (sites, teams, locations) that are comparable because they do similar work and have a similar makeup. To the extent that you can control it, make sure that these groups will remain relatively stable for the duration of the experiment (e.g., no management shakeups, no radical changes of leadership). If there are such changes along the way, you may have a harder time attributing any results to what you did, as opposed to what was done to the group by those other factors.
   查找两个或多个组（站点、团队、位置），因为它们从事相似的工作和相似的构成。在您可以控制的范围内，确保这些小组在实验期间保持相对稳定（例如，没有管理层变动，没有领导层的根本变动）。如果在此过程中有这样的变化，你可能更难将任何结果归因于你所做的，而不是那些其他因素对团队所做的。
2. Study what you can change or take out. Is there unnecessary bureaucratic clutter? Is there overlap? A typical case of overlap would be procedures that a contractor uses, which do almost the same as those the lead organization uses, but people working for the contractor (which is working for the lead organization) have to do both. Are there rules that nobody believes in? You can find this out by asking what people consider to be the stupidest thing they have to do every day to be allowed to work on a particular site or project. It’s a great question to ask, and you’ll surely get enlightening answers.
   研究你可以改变或删掉什么。是否有不必要的官僚主义混乱？有重叠吗？重叠的一个典型情况是承包商使用的程序，这些程序的作用与牵头组织使用的程序几乎相同，但为承包商工作的人（为牵头组织工作）必须同时做这两件事。有没有人相信的规则吗？您可以通过询问人们认为他们每天必须做的最愚蠢的事情才能被允许在特定站点或项目上工作来了解这一点。这是一个很好的问题，你肯定会得到有启发性的答案。
3. Do a small pilot. This might involve just talking to people, testing your idea through a thought experiment, or testing it live with a group of people. You can learn a lot from these small pilots (e.g., you might learn that
   做一个小试点。这可能只涉及与人交谈，通过思想实验测试你的想法，或者与一群人一起现场测试它。您可以从这些小型飞行员那里学到很多东西（例如，您可能会学到这一点
   the thing you wanted to take out is not at all what frustrates people the most).
   你想拿掉的东西根本不是让人最沮丧的）。
4. Reserve the time to let the change(s) take effect. Don’t think you can do a microexperiment inside of a few weeks, though you might see some immediate effects (as we observed in the micro-experiment above: the previously mandatory safety work was abandoned as soon as they were no longer required in the ownership conditions). Other effects will take more time to become visible.
   请预留时间让更改生效。不要以为你可以在几周内做一个微实验，尽管你可能会看到一些立竿见影的效果（正如我们在上面的微实验中观察到的那样：以前的强制性安全工作一旦所有权条件不再需要，就被放弃了）。其他效果需要更多时间才能显示。
5. Measure the changes. You can do that by using safety indicators and measures you are already using, but you might also want to think about additional measures to take that are more positive than that (e.g., leadership perception, empowerment and locus of control, happiness at work). Think about what you’ve read in chapter 1: what capacities are needed to make things go well?
   衡量变化。您可以通过使用您已经在使用的安全指标和措施来做到这一点，但您可能还需要考虑采取比这更积极的其他措施（例如，领导感知、授权和控制点、工作幸福感）。想想你在第 1 章中读到的内容：需要什么能力才能让事情顺利进行？
6. Collate the findings, celebrate the successes and communicate them to others in the organization, so they are inspired to take your experiences onboard. They may even be inspired to do their micro-experiments to innovate and improve an area of their work.
   整理调查结果，庆祝成功并将其传达给组织中的其他人，以便他们受到启发，将您的经验纳入其中。他们甚至可能受到启发进行微实验，以创新和改进他们的工作领域。

Sustaining these new ideas and newly changed leaders
维持这些新想法和新更换的领导者

Change is best understood by seeing how change makes our organization different.
通过了解变化如何使我们的组织与众不同，可以最好地理解变化。

Discussion questions  问题讨论

1. When it comes to doing safety differently, has your organization’s leadership been largely missing from that conversation? Or have they been driving it? What are the reasons for that, you think?
   当谈到以不同的方式进行安全工作时，您的组织的领导层是否在很大程度上没有参与其中？还是他们一直在驾驶它？您认为这是什么原因？
2. How can you support your leaders in making these safety differently ideas their own? Have they pushed back on them before? What happened then?
   您如何支持您的领导者将这些不同的安全理念变成自己的理念？他们以前有没有反击过他们？然后发生了什么？
3. Can you think of a viable micro-experiment in your organization or unit? What would you compare or test, how would you do that, and what would you hope to find or demonstrate?
   您能想到在您的组织或单位中可行的微实验吗？你会比较或测试什么，你会怎么做，你希望找到或证明什么？
4. What needs to be in place or change in your organization to make safety differently not only a viable, but sustainable way of doing safety?
   您的组织中需要采取哪些措施或做出哪些改变，才能使安全不仅成为一种可行且可持续的安全方式？
5. What have you missed in this book? What would you like, or need, to discuss more of?
   你在这本书中错过了什么？您希望或需要更多地讨论什么？

About the Authors  作者简介

Made in United States  美国制造
North Haven, CT  康涅狄格州北黑文
28 October 2024  28 10月 2024

SIDNEY  西德尼

DEKKER | CONKLIN DO SAFETY DIFFERENTLY
戴克 |康克林以不同的方式执行安全

• Safety: From outcome to capacity.
  安全性：从结果到容量。
• When the work done is not as you imagined: Do learning teams.
  当完成的工作不如您想象的那样时：做学习团队。
• When things go wrong: Do investigations differently.
  当出现问题时：以不同的方式进行调查。
• When there is too much compliance: Declutter your safety bureaucracy.
  当合规性过多时：整理您的安全官僚机构。
• When your safety people are dejected: Empower them differently.
  当您的安全人员感到沮丧时：以不同的方式赋予他们权力。
• When you need to help your leaders succeed.
  当您需要帮助领导者取得成功时。

PRE-ACCIDENT INVESTIGATION MEDIA SANTA FE, NEW MEXICO
事故前调查 媒体 新墨西哥州圣达菲