Quantum Safety: A Powerful Method for Understanding and Preventing Adverse Workplace Incidents

Cover
Half Title
Title Page
Copyright Page
Table of Contents
List of Figures and Tables
Foreword
Preface
Author
Acknowledgments
Chapter 1 Newtonian Safety and the New View Refraction
	1.1 Newtonian Safety
	1.2 New Views
		1.2.1 The First New View: Behaviour Based Safety
		1.2.2 Safety II
		1.2.3 Safety Differently
		1.2.4 Safety III
	1.3 The New View Landscape
	1.4 Moving into the Quantum World
	References
Chapter 2 Let’s Talk about Complexity
	2.1 Different Types of Systems
	2.2 Systems, Complexity and Emergence
	2.3 Complexity Law and Order
	References
Chapter 3 The Lilypond: A New Conceptual Model to Understand Safety Performance in the Modern, Complex Workplace
	3.1 The View from Above
		3.1.1 Outcome Representation
		3.1.2 A Non-monochrome World
	3.2 Below the Surface of the Lilypond
		3.2.2 An Intricate Ecosystem
		3.2.3 Interactions
		3.2.4 Hierarchies
	References
Chapter 4 Understanding the Lilypond Model, Organisational Safety Performance and the Performance Continuum
	4.1 Human Factors Taxonomies
	4.2 The Continuum of Human & Organisational Performance
		4.2.1 The Philosophical Realm
		4.2.2 The Organisational Realm
		4.2.3 The Personal Realm
	4.3 Using the Continuum of Human & Organisational Performance
	References
Chapter 5 A Different School of Quantum Safety: Moving into the Experimental World
	5.1 The Organisational Realm
	5.2 The Personal Realm
	5.3 Creating your Continuum Profile
	References
Chapter 6 The Human Performance Foxtrot
	6.1 Systems Soliloquy
	6.2 Systems Dance Partner
	6.3 Partners on the Dance Floor
	6.4 Dancing the Foxtrot
	6.5 Understanding the Dance
	6.6 Why We Need to Embrace Our Partner
	References
Chapter 7 The Just Culture: Why It Isn’t Just and How It Could Be
	7.1 Leaving Blame
	7.2 Revisiting the Idea of Justice
	7.3 Just Culture for the Modern Complex Workplace
		7.3.1 Safety I and Safety II
		7.3.2 Learn Not Blame
		7.3.3 Systems Thinking
		7.3.4 Civility and Respect
	7.4 A New Model
	References
Chapter 8 Learning from Everything
	8.1 An Adverse Event in Healthcare
		8.1.1 Adopting a Just Culture
		8.1.2 Reason’s Classical Just Culture
		8.1.3 Dekker’s Restorative Just Culture
		8.1.4 Just Culture in Quantum Safety
	8.2 An Adverse Event in Rail
		8.2.1 Reason’s Classical Just Culture
		8.2.2 Dekker’s Restorative Just Culture
		8.2.3 Just Culture in Quantum Safety
	References
Chapter 9 Beneath the Surface of the Lilypond: Understanding Causation in Complex Systems
	9.1 Causation within the Lilypond
	9.2 Understanding Different Types of Human Work
	9.3 When Causation and Complexity Meet
	9.4 Adaptive Behaviours within the Lilypond
	9.5 Developing Causal and Non-causal Variation
	References
Chapter 10 Learning When We Don’t Dock in the Bay
	10.1 Causal Variation in Practice
		10.1.1 The Plan
		10.1.2 The Event
		10.1.3 The Climate
		10.1.4 The Significance
		10.1.5 The Action
	10.2 Investigating Using Causal Variation Analysis (CVA)
	10.3 The Wakashio Grounding
		10.3.1 The Plan: Wakashio
		10.3.2 The Event: Wakashio
		10.3.3 The Climate: Wakashio
		10.3.4 The Significance: Wakashio
		10.3.5 The Action: Wakashio
	References
Chapter 11 Continual Coaching: Moving from Outcome to Process
	11.1 How Learning Opportunities Are Utilised Currently
		11.1.1 Responding to Adverse Events
		11.1.2 Specific Feedback
		11.1.3 Post Event Briefing
	11.2 Facilitated Learning and Improvement Conversations
		11.2.1 Adaptations
		11.2.2 Interactions
		11.2.3 Decisions
	References
Chapter 12 The Way Ahead: Developing a Roadmap with Quantum Safety
	12.1 Institutions and Doctrines
	12.2 Cats and Watermelons
	12.3 Safety Management System: The Babushka Edit
	12.4 Rituals and Routines
	12.5 The Quantum Safety Roadmap
	References
Index