The Safety of Work

Ep. 17 What did Heinrich really say?

Episode Summary

On this episode, we discuss what Heinrich really said. Drew is out this week, so in his stead, Carsten Busch helps me examine the topic at hand.

Episode Notes

Tune in to hear Carsten discuss his research into Heinrich’s work.

Topics:

Quotes:

“It’s interesting the way you go on to say that he wasn’t actually saying that you have to manage the three-hundred to prevent the one…”

“I think he would have liked to see himself, first and foremost, as a management advisor, because that is the audience for his book…”

“There’s a lot of talk about the Swiss Cheese model being linear...and it isn’t!”

 

Resources:

Carsten’s Paper on Heinrich

Feedback@safetyofwork.com

 

Episode Transcription

David: You're listening to the Safety of Work podcast episode 17. Today, we're asking the question, "What did Heinrich really say?" Let's get started.

Hey, everybody. My name's David Provan and I'm from the Safety Science Innovation Lab at Griffith University. Welcome to the Safety of Work podcast. If this is your first time listening, then thanks for coming. The podcast is produced every week and the show notes can be found at safetyofwork.com. In each episode, we ask an important question in relation to the safety of work or the work of safety, and we examine the evidence surrounding it.

You might've noticed that this introduction was a bit different that I didn't introduce Drew this week. No, it wasn't a mistake or a human error. He's not with us today. Instead, I'm joined by Carsten Busch.

Drew and I have decided that we're going to introduce some episodes into the podcast feed where we interview directly safety researchers about their work in a similar format to our usual episodes. Today, Carsten and I are asking the question, "What did Heinrich really say?"

Before we get started, Carsten, can you tell us a little bit about yourself, your background, and how you came to be at Lund undertaking this thesis on Heinrich's work?

Carsten: Yes, thank you for making me part of this fantastic podcast business of yours. I really am enjoying it. My background, going far back, I started as a mechanical engineer, or I was trained as one and was determined already on technical university. I'm not going to do this the rest of my life.

I got into safety, started working as a safety adviser, mostly in railway-related companies. I did a bit in law school in the middle and decided to move to Norway with my family where I continued in railways, and eventually ended up in police [...] now as an adviser for occupational safety in the police directorate. We are (so to speak) the head office of the Norwegian police force.

It’s a fascinating area because you have to rethink safety coming from an industrial and transport business. You have to rethink safety and risk because police are naturally much more risk-taking than other industries or other sectors. For many years, I have had an interest in the profession and what makes a safety adviser, I don't want to say good safety adviser, but a useful safety adviser, at least. Also, the formal competence, the theory, and so on. I'm rather active in the Dutch's Society of Safety Professionals. I do a quarterly book review there, where I look at recent and sometimes also a bit older literature, and try to encourage colleagues to read some more to get a deeper knowledge.

At some point a few years ago, I wanted to formalize and deepen my knowledge a bit, mostly around humans affectors because I've had education as a safety professional but it was rather technical, what we now might call [...] also. That's how I ended up in Lund. I was so lucky that my employer was willing to finance the participation. I started three years ago (I think), credited a year ago. In the past year, I've also been active as a tutor for new students for the program Youth Sectors and System Safety at the university. Fascinating program.

David: It's a great program. We recommend it to a number of people even as far away as Australia and New Zealand, if they can make the trip and do the work.

The title of your thesis was Heinrich's Local Rationality: Shouldn't 'New View' Thinkers Ask Why Things Made Sense To Him? What inspired this research and that somewhat provocative title? 

Carsten: Is it okay if I go a bit back in time, because why would Carsten start discussing Heinrich at all? After all, he wrote his main stuff in the 30s, and I was at [...] now. For me, Heinrich was actually the starting point in thinking critically about safety. I don’t know now if you've seen it at the time, but a few years ago, 2010–2011-ish, there were a lot of discussions on Heinrich on various forums, on LinkedIn, et cetera.

The interesting thing was that I had the old books from Heinrich at home. I bought a bunch of safety books many years ago. [...], normal accidents, and all that stuff. I have bought Heinrich on Amazon because I found many sold there classic text in safety. I want to have them, but I haven't actually read them.

Before I partook in these discussions on fora, I thought, "Let me have a read." So I read. I have two versions, 41 and 80, and then I concluded, "Wow! There are a lot of people arguing for Heinrich and arguing against Heinrich." I got a feeling that none of them have actually read Heinrich, which was quite a discovery for me.

I started in Lund and now I have several thesis topics. At one point, there was an assignment we had to make about cost and safety. I started drawing in Heinrich. I had already several times in the program, remarked people, “We're discussing Heinrich here, but we are discussing it in a cartoonish way. He said much deeper things, things that are much more nuanced than how we discuss some, so take care”. At some point, [...] said, "Why don't you do a thesis on Heinrich?" 

I was reluctant at first but I went that way. My initial thought was let me do a genealogy, where you look at what influenced Heinrich? How did his work develop over 40 or 50 years if he was effective? And how has his work influenced others after him? Of course, that's way too huge a topic for most thesis.

Reading a lot of his stuff and a lot of new literature, I thought there’s a mismatch there. You have Heinrich who wrote things from the 20s to the 50s. Then, you have the new authors who are really critical at times. The two don't quite match. Not fully at least. 

That was where I thought, "That's an interesting topic for a thesis. How do those two match?" Also, there were some questions I have about Heinrich's work for many years, like his focus on direct causes. Why does he focus on this middle domino, while we have been taught to focus on things more upstream, much more in the back underlying? Why did it make sense to him? 

Then, I had this topic. He said something, "Why did it make sense to him?" Some authors say things about him, and why does it make sense to them to speak like that? That's about my topic in a nutshell. The three subjects, Heinrich, new view, and why does it make sense?

David: Yeah, it's a captivating read. It's interesting because I've done quite a lot of safety study, and (as you said) a life's work of a man and probably a man who is the first big critical thinker in safety gets boiled down to triangles and dominoes as the enduring legacy. I'm really looking forward to the rest of this discussion.

I thought we might do it in two parts. I thought we might discuss first Heinrich ideas since you've been through most of the original text. I admit I haven't been through the original text, but I've read your thesis and got a few notes and questions to ask you. I wouldn't mind the second part being about the new view, some of the new view authors, how Heinrich's being characterized by them, some of that distance between maybe what he said and maybe how he’s being represented today, and see how far we get through that.

Where do you want to start? I suppose you'll be starting with the popular ratio? Should we start in the one and the 29? The 300 and the 88?

Carsten: We can start there, sure. That's the thing he is known for. I would say some of his brilliance is in these things. One of the things that struck me when I started studying Heinrich properly was that there's a lot of stuff that comes from him, but he didn't come with it, originally. His work was very much the best of what was around at that time. What he did and then [...] paraphrasing now while he, Heinrich, at that time, was a unified framework. He took bits and pieces from other authors. Louis de Blois was one very clear example. Louis de Blois was the first executive director of [...]. He wrote the book five years before Heinrich.

In that book, you'll see a lot of the concepts that Heinrich would make popular some years later. Like the sequence in an accident, it's not Heinrich. What Heinrich did was he took the concept, and 10 years later, he came with the dominoes. He had a very neat and appealing picture to it. The author made the biggest statement of what Heinrich made, which was, "88% of all accidents are caused by human failure on safe acts, et cetera." 

It was a common thinking at that time. What he basically did was add a ratio backed by some kind of study, which we can have a lot of comments about. He had this ratio, [...] It anchors in. It's very easy to remember. And the same with the famous triangle. That was actually (I think) an idea that was very much his own because I haven't found a lot about it in earlier safety literature years back. They're reacting to weak signals. I think that's pretty much Heinrich in a contribution, and a strong match towards more proactive safety management or accident prevention as they called it initially.

With a brilliant picture, a triangle, and numbers that are very easy to remember, you'll never forget [...] on the ratio because it's so neat.

David: I think (I supposed just for our listeners) that idea for the triangle and the ratio is 300 minors incidents and 29 serious incidents or 1 fatality or however it’s represented. My understanding from your thesis, it's 1928 paper where it emerges after a review of something like 75,000 accident reports.

It's interesting the way he goes and to say that he wasn't actually saying that you have to manage the 300 to prevent the 1. He was talking more about, "We should use those 300 as weak signals and the potential for other types of events to be occurring in our business." If we're not doing that, [...] from Heinrich, that we're often misdirecting our efforts and ignoring variable data. That could be straight out of HR literature from the 90s from [...]. 

Carsten: It's so recognizable because we all act if something really bad has happened, then we start to investigate. He turned it around and said, "We have a lot of small stuff here that might've been much worse, so why not act on that?" He calls it opportunities, which I think is a very beautiful way of phrasing it. He has 300 opportunities here which he can choose to do something with or not.

David: Yeah. I supposed if we keep moving through some of the things, and maybe I'll just throw some things that were really interesting to me from your thesis, that he started talking in 1923 about the indirect and hidden cause of accidents by the same events. He actually started talking about accident prevention being good business and this idea that good safety is good business. Was that in the literature before Heinrich started talking about it?

Carsten: Yes, quite a lot. There were several big studies in the early 20s. I think even a congressional study into safety and efficiency, and safety and cost. In a lot of our old, early 20th century safety literature, they already hinted at the hidden cost or intangible cost, as early as 15 of something, as far as I recall. Probably even before that.

Again, it wasn't anything new. The new thing Heinrich added was the ratio. He made it look much more scientific, which is the subtitle of his book—scientific approach. They actually look at first 100, then 1000, and then (I think) 5000 cases. They came at this average one before. Then he does the trick he mentioned, the 1:4 the whole time so people remember it. He made front page news with it, which is quite cool for a safety adviser, I think.

David: It's interesting. You mentioned in your thesis that he seemed to become somewhat of a celebrity within these safety sectors by the end of the 1920s. He was going all around and presenting all over the place. People at that time were traveling hundreds of miles to come and listen to him talk. That's similar to how we think in the modern day Sidney Dekker or Erik Hollnagel traveling around and talking about their ideas. It's quite amazing to think about that in the 1930s and pre World War II anyway.

You talked about prevention as well. I think there's a statement in there, I think it's from Heinrich, "Accident prevention is possible with knowledge (of course) and a will to act." You referred to Heinrich as being somewhat of an optimist in his belief that we could actually get better at safety management, and we could fix these hazards.

Carsten: Yeah, definitely. I compare him to self-help literature. One of the things that struck me when I really studied his work and besides his books, I dug out 750 papers that were hidden in vaults, on the Internet, et cetera. I think I got a quite rich source there. It's interesting to see that we think of him as a safety scholar or a safety worker, at least. I think he would have liked to see himself first and foremost as a management adviser. That's the audience for his book.

First of all, this is written for employers, for top executives. Then, he adds some authors for my benefit, but he addresses the top management. He discusses things like accident prevention, safety management in a really encouraging way. He says several times, "You can do this. This is simple. Just follow the principles you already follow for production, for quality, for other management." There was a growth for safety as well.

You can do this, prevent those accidents, because you can.

David: I suppose we believe maybe because of the ratios, the 88% of incidence being caused by the operator or the human. We form the assumption that that was his view where safety has to be solved. Interestingly, you talked a bit about how we really believe in the role of the employer and the executives that the safety needs—executive interest, support, and actions—knowledge of the accident facts and it needs an appropriate and effective action at all levels of the organization. He was quite holistic in his ideas about how a firm needs to run and approach safety management efforts.

Carsten: I think there's a lot of stuff he said that was lost in translation over the years. Maybe also in his own speech. I don't recall who said, I think it’s [...]. It's pretty hard to hear the rest after you heard a big statement about 88% of these stuff were caused by unsafe acts. Here, 88% causes unsafe acts. Practical [...] grow immediately and that let's fix that mode. Whatever comes after, it can’t be that interesting because we have 88% here.

David: Yeah. I'll think as we said earlier, maybe we've all written things in a certain way. We'll never know what kind of injury. We just need to ask and reason about the Swiss cheese model in his lifetime of work as well. 

A couple of lesser things that I didn't refer you, you made a subtle reference in your thesis to Heinrich's early suggestion for hierarchy of controls, where he preferred whole chapters in his early books on machine guarding and procedure revision rather than behavioral controls, which is kind of at odds with that 88%, which suggested that he did really think about ways to eliminate, isolate, and engineer out hazards in the workplace. He didn't have to rely on the operator. Could you find similar ideas around the hierarchy of controls in literature at that time? 

Carsten: Absolutely. In the past year, I acquired most of the literature that Heinrich listed in his bibliography. Those are safety books from the 1910s through the 1920s, and hints at hierarchy of controls are found in those already. There are some other authors (I don't recall them now) that put a lot of stress on procedure revision or a depth thing in the environment. Actually, if you go back to Frederick Taylor, the big bad guy in management science, he actually proposed first of all a [...] workplaces to facilitate that one best way. It's even there.

David: You're laughing when you talk about Frederick Taylor. I studied under Sidney Dekker for four years or so. At one point, it might've been inspired by some of your early reading and thought I might do the same. Actually, when I read Scientific Management, I read some of the early work of Taylor through there. It is interesting to reflect on the version of what you think is the truth from what you read, the author's work versus when you go back and read in. I was so surprised when I read Taylor's, what was influencing him around that time. He was very much advocating for the work. He's very much trying to understand how to manage production lines so that workers would get a fair day's pay. 

When Frank Hubert and I went off and started doing time and motion studies, he said, "No. I don't want to be a part of this. This is suppressing the worker's rights. This is suppressing their ability to earn income and so on." He gave a very, very, small snippet of what you're able to do with Heinrich. The pair of going back to that original text and just trying to understand the context around when it was written and what the author was trying to achieve is vitally important, and we'll probably talk a bit about that in a little while.

We're going to talk about authors. There is another idea in there which you threw away. If you wanted to cherry pick, be selective in some of Heinrich's writing or maybe even broader than that, you can very much find in some of these contemporary ideas in his works. Particularly that idea that people are the solution.

I want to throw two quotes at you. One from Heinrich in 1931 which says, "In many cases, safety may be promoted by employee ingenuity and mechanical genius of work within the average planet in the revision of process and procedure." Another quote that I think was quoted in Bird’s or someone else's work, but I've got Heinrich in 1940 here that says, "He would prefer capable and experienced men who work under unsafe conditions, rather than incapable and inexperienced men who worked in safe conditions." These are really interesting quotes when we think about the popular interpretations of Heinrich's work.

Carsten: Especially the second one. It really jumped at me. I think this 1940 paper (it's included in the later books as a part of a chapter) was quite a groundbreaking work for him to look at that way. "I would rather have people," to cite in modern words, "that are able to adapt to the situation and handle it safely," which is a very modern definition of safety (I think) and work under different circumstances. Then that he would have to, let's say, cartoonish Taylorist variation where you build a workplace, you make it safe, you put in some monkeys there, and they’ll probably be fine because what can they do? We make it fool proof. Heinrich says that he would rather prefer the risk where you put capable people in uncertain circumstances.

David: Yeah, that's amazing. Even then, he knows that you're the fool if you think that you made something foolproof.

Let's move on to some of the authors. Like you said in the title about the new view and local rationality, you spend quite a bit in your thesis looking at some of your graphs and your thesis around your Google search, just a proliferation of Heinrich references in the safety literature, say between 2005 and 2010, just how much he’s been spoken about in the safety literature and by who he’s been spoken about.

Just for our listeners, you went through almost all of those references in all of the key authors that our listeners might know of—Dekker, Hollnagel, [...] and a long list of other minor authors—and actually look at the context in which they have quoted Heinrich's work and your thoughts on those quotations. Do you want to just start talking a little bit about how you saw Heinrich show up in the new view literature? How it made you feel having read quite a lot of the original texts?

Carsten: Yeah. If you'd look at the new view literature, it's probably hard to really define a book. Say, the work of Hollnager, Dekker, Woods, et cetera. Some of the authors that we would put in the new view don't speak of Heinrich at all. David Woods for example, [...]. Not a word. Neither does James Reason. James Reason refers at one point [...] Bird’s triangle, but that's about it.

The situation is like that until early 2010s. The only new view author who actually spends some time on Heinrich is Erik Hollnagel. He started (I think) in the early 2000s when Hollnagel started developing his various stages in excellence models like linear, the dominoes, the archetypes of the linear, and the accident model, and he goes to the pathological (I think) where he [...] the Swiss cheese, and then the systemics models, like from [...]. He has these different categories. He uses Heinrich constantly over the next 20 years from 1999 or 2000 until today. He refers to that and it's not even detrimental.

Then, something interesting starts in the early 2010s. There seems to be some interest by some new view authors in Heinrich. A good example and maybe the most typical example is Sidney Dekker who has written three versions of  Field Guide to Understanding Human Error. The first two can do without any Heinrich. In the third, there are two pages where he thrashes the pyramid. We always had a feeling of what was this? Why did this happen? For me, that doesn't really fit into the book. That was one of the questions that also triggered my study. What's happening here? Why? Why did you do so?

I asked Sidney, and he said, "One explanation is move to Australia, contact the mining industry where these symbols were very much communicated and also misused.” That’s clear. A lot of Heinrich's works were misused for whatever reason.

David: Yeah. I think we might be to blame a little bit because of being down in Australia and having Sidney come down and discover that. I think, absolutely, the triangle is an artifact that appears in company safety reports all the time. I think if my reflections on your thesis and one possible explanation might've been Professor Hopkins. He's also very prominent within Australian literature. He talked a lot about near misses, weak signals, and the need to learn from those.

I think the Australian industry puts together Hopkins' calls for a reporting culture and the need to learn from all those instances with the nice picture of a triangle. Every single company has in its corporate safety reports particularly in that period 10 years ago, were testing themselves to see what their ratios look like and whether they had a reporting culture [...]. 

Carsten: [...] where they are in benchmark, et cetera. And it’s not the only Australia. At the end of last year, I did a huge study of [...] papers and literature. The British and the UK’s [...] for years they had the triangle in their report, but [...] now.

David: Yeah. I think we're done, like you've mentioned, with triangles, with icebergs. You mentioned the D&B and their Loss Control Model. You mentioned DuPont and behavioral safety. You mentioned all of these models that came through the early 2000s. All had some kind of representation of a ratio model of the unsafe acts to near misses to fatalities or whatever that looked like. 

You, including your thesis discussion, I think from Jean Christophe La Coze, it's about how safety models endure and the characteristics of these models that endure. They're somewhat simple, memorable, and generalizable across different situations. I think it's a perfect example of each type of model.

Carsten: That's their strength, and because they're also simple, people find it easy to adapt them through their own goals also, and then only get the most shallow version of the message (the real message), and take the Swiss cheese [...]. I think it's a brilliant example because there's a lot of talk about the Swiss cheese model as being linear.

Even in the first description, Reason writes about these holes that are moving over the place, changing in size, opening and closing, and their feedback loops. If you look at the picture, you'll see some areas in the row, an arrow going through them and another arrow stopping, and [...] make sense and give your own explanation. Losing all the author's richness in the model just because of the easy, understandable, picture which is the strength and the curse of the picture. 

David: Yeah, exactly. That's the curse, to try to shrink down the curse, make something simple enough so that it's understandable and usable, but obviously then the flip side is all of the nuance context gets lost in the simplification.

What are the other things that we haven't spoken about in relation to Heinrich's work that you think is useful for people to understand in a sense of what he was saying?

Carsten: That's a pretty big question. 

David: We didn't really touch on proximal causes and why does it make sense for him to focus on proximal causes to the incident. That's pretty essential.

Carsten: It is very essential. As I said, this was one of the things that have really bucked me for years. I was thinking it would be cool to just talk to him about it. That is impossible, so I did the next best thing and read a lot of his stuff. What I found out, we know his domino model very well. Again, it's easy. You have this picture where he picks out the middle domino, the direct cause, the unsafe X or unsafe conditions. If you fix the stuff afterwards, it doesn't happen. That seems to be very much focused on direct causes, and it is if you stop reading there. If you then progress to the next section, then it shows that there are actually much more thought behind it.

Heinrich started speaking about underlying causes. One thing he is very clear about since the 1940 paper we mentioned, not in the early versions, but since 1940, he's quite consequent in saying, "If you find unsafe X, the thing to do then is to find reasons for this unsafe X," I posted it on LinkedIn this morning, but I can’t recall what he said. It's something like, “because you can maybe fix the unsafe X, but to have a lasting effect, you need to address the reasons there, too." 

Why did people do that? Example, in a prediction pressure, I think he mentioned that as one of the examples. Then his advice is, "Don't focus on the behavior, the unsafe X, but go against that X and do something about restructuring the process or do something about the physical environment. It eliminates this unsafe X in the future or at least reduces possibility."

David: That’s almost exactly the idea that the behavior of the operator is a symptom of the functioning of [...].

Carsten: Yes. He never said anything about it. It's a logical conclusion. The reason for him, and he actually spelled it out when I read his books for the first time in 2010 or whatever, I must have missed it but you always miss a lot the first time around. It explains that his aim is a practical aid for managers. That's why he emphasized the direct solution—the simple solution—over the more deeper understanding. He said, "If the simple solution doesn't work, doesn't help enough, you have to go deeper. Sometimes it means going deep up to the management level because maybe you need bigger funding." 

He said that those are the rare cases because mostly you can fix it much easier. He is a very practical man. That's why he chose, "Okay, stop there. Only go further if necessary."

David: I really like that advice for action because we can get caught up on our own heads in safety quite a lot in organizations today. I like it quite a bit. I was going to start with it, I don't think I mentioned it. It wasn't in the podcast, it was in your thesis from him in 1931, which is something like, "It's time to stop talking. [...] and go to work."

Carsten: Yeah. I think it's the closing word from the summary of his book. It's four pages which is a lot of, what I said, optimistic. You can do this and now roll up your sleeves and go to work.

David: Good advice, too. Good advice to safety practitioners. I think also, one of the other things we didn't touch on was that Heinrich was probably one of the very early advocates of the professionalization of safety. This idea that I mentioned [...] to science, but it's not being recognized or treated scientifically today. He said that in 1928 and talked about what he thought safety management needed as a scientific and a professional discipline.

With that as a backdrop, do you want to talk a little bit about that? Maybe some practical takeaways from what you learned during your research that might apply to the safety profession today.

Carsten: There are two important lessons that I really want my colleagues, my peers over the world to remember. The first one is try to take the local rationality perspective as much as you can. Of course, it's not a method. It's an approach. It's an attitude, to understand behavior and events. Makes sense of the events. Why did it make sense for the people to do such and so. I applied to something completely different. I applied it to safety literature.

I think it's a great approach also there. It suspends a judgment. I don't take sides. I'm not for Heinrich or against Heinrich. He wrote brilliant stuff, you quote some. He also wrote some stuff that makes me cringe about ancestry. I really still don't understand why he did that or what he meant. He doesn't explain but it makes me feel very, very, awkward reading it.

But I'm still curious. I want to find out why it made sense for him to write this down in that way? What did he mean by that? That leads your mind open to learn something. You can always reject the [...]. This is not useful or this is outdated or plainly wrong. That's one lesson. Local rationality as much as possible in any setting.

I think it's also very liberating for you because if I've spoken with hundreds of safety people, I don't understand my management, they seemed to be living on another planet, and yes, they do. That's what local rationality is. They are not safety advisers. They're top management in their ivory towers, and they have different perceptions of reality here. Yes, try to take that view. It will actually help you do a better job. That's one.

The other one is if you can try to find primary sources and do not rely on hearsay because as I hopefully have shown, a lot gets lost in translation. And also in translation by people who are trying to convey the message as clearly as possible or as original as possible because it might [...]. It's influenced by my thoughts. It's not a good source either, probably. It's a bias source.

David: It's both sage-like advice for a safety professional to seek to understand why things make sense to people and go straight to the source. Whether that's a piece of literature or whether that's a person at the frontline of the organization. I think that's great advice.

Carsten, look, not everyone likes to read a whole thesis. I don't know if anyone read mine. Even my family, I don't think has read mine, even though it's a great source because most of them are publicly available including yours. Do you have any plans to make this content about Heinrich more accessible to the world? Or any other projects you are currently working on that you want to tell us?

Carsten: Those who don't like to read, I have to disappoint, firstly because I am now in the process of writing a book on Heinrich's work, trying to present who he was, which I think is an important part of trying to understand why he wrote what he wrote. Then about his work and discuss the main themes in his work. I'll also discuss some of the criticisms of his work. That's work in progress until next year, I think. It's going to be a lot to read. 

If I have time for those who don't like to read, I really planned to do a really short version, some kind of webinar or something put out on the net. I can't promise when it's finished. The material is there. I just need to find some hours to do it. I prioritize the book for now.

David: That's good. They can always do what Sidney Dekker seems to start to do which is record his books—his audio books. Some people might want to listen to your voice for seven or eight hours rather than read the text.

Carsten: Yeah. I hate reading aloud and I hate hearing my own voice. I need someone who has a sexy voice to do this. James Earl Jones or something like that.

David: They don't have to listen to it. Carsten, thank you. Thank you so much for taking the time to organize and coordinating this halfway around the world.

Carsten: It’s my pleasure. Thank you for inviting me.

David: I really appreciate you coming. It's really interesting in some of our listener’s feedback about how they find the interview approach. Drew and I planned to do quite a number of these interviews. 

There you go. Like Carsten says, direct with the source rather than two of us commentating on researcher work, where we can introduce some direct conversations with the researchers themselves.

That's it for this week. We hope you find this episode thought-provoking and ultimately useful in shaping the safety work in your own organization. Please join us in our discussion on LinkedIn or send any comments, questions, or ideas of future episodes directly to us at feedback@safetyofwork.com.David: You're listening to the Safety of Work podcast episode 17. Today, we're asking the question, "What did Heinrich really say?" Let's get started.

Hey, everybody. My name's David Provan and I'm from the Safety Science Innovation Lab at Griffith University. Welcome to the Safety of Work podcast. If this is your first time listening, then thanks for coming. The podcast is produced every week and the show notes can be found at safetyofwork.com. In each episode, we ask an important question in relation to the safety of work or the work of safety, and we examine the evidence surrounding it.

You might've noticed that this introduction was a bit different that I didn't introduce Drew this week. No, it wasn't a mistake or a human error. He's not with us today. Instead, I'm joined by Carsten Busch.

Drew and I have decided that we're going to introduce some episodes into the podcast feed where we interview directly safety researchers about their work in a similar format to our usual episodes. Today, Carsten and I are asking the question, "What did Heinrich really say?"

Before we get started, Carsten, can you tell us a little bit about yourself, your background, and how you came to be at Lund undertaking this thesis on Heinrich's work?

Carsten: Yes, thank you for making me part of this fantastic podcast business of yours. I really am enjoying it. My background, going far back, I started as a mechanical engineer, or I was trained as one and was determined already on technical university. I'm not going to do this the rest of my life.

I got into safety, started working as a safety adviser, mostly in railway-related companies. I did a bit in law school in the middle and decided to move to Norway with my family where I continued in railways, and eventually ended up in police [...] now as an adviser for occupational safety in the police directorate. We are (so to speak) the head office of the Norwegian police force.

It’s a fascinating area because you have to rethink safety coming from an industrial and transport business. You have to rethink safety and risk because police are naturally much more risk-taking than other industries or other sectors. For many years, I have had an interest in the profession and what makes a safety adviser, I don't want to say good safety adviser, but a useful safety adviser, at least. Also, the formal competence, the theory, and so on. I'm rather active in the Dutch's Society of Safety Professionals. I do a quarterly book review there, where I look at recent and sometimes also a bit older literature, and try to encourage colleagues to read some more to get a deeper knowledge.

At some point a few years ago, I wanted to formalize and deepen my knowledge a bit, mostly around humans affectors because I've had education as a safety professional but it was rather technical, what we now might call [...] also. That's how I ended up in Lund. I was so lucky that my employer was willing to finance the participation. I started three years ago (I think), credited a year ago. In the past year, I've also been active as a tutor for new students for the program Youth Sectors and System Safety at the university. Fascinating program.

David: It's a great program. We recommend it to a number of people even as far away as Australia and New Zealand, if they can make the trip and do the work.

The title of your thesis was Heinrich's Local Rationality: Shouldn't 'New View' Thinkers Ask Why Things Made Sense To Him? What inspired this research and that somewhat provocative title? 

Carsten: Is it okay if I go a bit back in time, because why would Carsten start discussing Heinrich at all? After all, he wrote his main stuff in the 30s, and I was at [...] now. For me, Heinrich was actually the starting point in thinking critically about safety. I don’t know now if you've seen it at the time, but a few years ago, 2010–2011-ish, there were a lot of discussions on Heinrich on various forums, on LinkedIn, et cetera.

The interesting thing was that I had the old books from Heinrich at home. I bought a bunch of safety books many years ago. [...], normal accidents, and all that stuff. I have bought Heinrich on Amazon because I found many sold there classic text in safety. I want to have them, but I haven't actually read them.

Before I partook in these discussions on fora, I thought, "Let me have a read." So I read. I have two versions, 41 and 80, and then I concluded, "Wow! There are a lot of people arguing for Heinrich and arguing against Heinrich." I got a feeling that none of them have actually read Heinrich, which was quite a discovery for me.

I started in Lund and now I have several thesis topics. At one point, there was an assignment we had to make about cost and safety. I started drawing in Heinrich. I had already several times in the program, remarked people, “We're discussing Heinrich here, but we are discussing it in a cartoonish way. He said much deeper things, things that are much more nuanced than how we discuss some, so take care”. At some point, [...] said, "Why don't you do a thesis on Heinrich?" 

I was reluctant at first but I went that way. My initial thought was let me do a genealogy, where you look at what influenced Heinrich? How did his work develop over 40 or 50 years if he was effective? And how has his work influenced others after him? Of course, that's way too huge a topic for most thesis.

Reading a lot of his stuff and a lot of new literature, I thought there’s a mismatch there. You have Heinrich who wrote things from the 20s to the 50s. Then, you have the new authors who are really critical at times. The two don't quite match. Not fully at least. 

That was where I thought, "That's an interesting topic for a thesis. How do those two match?" Also, there were some questions I have about Heinrich's work for many years, like his focus on direct causes. Why does he focus on this middle domino, while we have been taught to focus on things more upstream, much more in the back underlying? Why did it make sense to him? 

Then, I had this topic. He said something, "Why did it make sense to him?" Some authors say things about him, and why does it make sense to them to speak like that? That's about my topic in a nutshell. The three subjects, Heinrich, new view, and why does it make sense?

David: Yeah, it's a captivating read. It's interesting because I've done quite a lot of safety study, and (as you said) a life's work of a man and probably a man who is the first big critical thinker in safety gets boiled down to triangles and dominoes as the enduring legacy. I'm really looking forward to the rest of this discussion.

I thought we might do it in two parts. I thought we might discuss first Heinrich ideas since you've been through most of the original text. I admit I haven't been through the original text, but I've read your thesis and got a few notes and questions to ask you. I wouldn't mind the second part being about the new view, some of the new view authors, how Heinrich's being characterized by them, some of that distance between maybe what he said and maybe how he’s being represented today, and see how far we get through that.

Where do you want to start? I suppose you'll be starting with the popular ratio? Should we start in the one and the 29? The 300 and the 88?

Carsten: We can start there, sure. That's the thing he is known for. I would say some of his brilliance is in these things. One of the things that struck me when I started studying Heinrich properly was that there's a lot of stuff that comes from him, but he didn't come with it, originally. His work was very much the best of what was around at that time. What he did and then [...] paraphrasing now while he, Heinrich, at that time, was a unified framework. He took bits and pieces from other authors. Louis de Blois was one very clear example. Louis de Blois was the first executive director of [...]. He wrote the book five years before Heinrich.

In that book, you'll see a lot of the concepts that Heinrich would make popular some years later. Like the sequence in an accident, it's not Heinrich. What Heinrich did was he took the concept, and 10 years later, he came with the dominoes. He had a very neat and appealing picture to it. The author made the biggest statement of what Heinrich made, which was, "88% of all accidents are caused by human failure on safe acts, et cetera." 

It was a common thinking at that time. What he basically did was add a ratio backed by some kind of study, which we can have a lot of comments about. He had this ratio, [...] It anchors in. It's very easy to remember. And the same with the famous triangle. That was actually (I think) an idea that was very much his own because I haven't found a lot about it in earlier safety literature years back. They're reacting to weak signals. I think that's pretty much Heinrich in a contribution, and a strong match towards more proactive safety management or accident prevention as they called it initially.

With a brilliant picture, a triangle, and numbers that are very easy to remember, you'll never forget [...] on the ratio because it's so neat.

David: I think (I supposed just for our listeners) that idea for the triangle and the ratio is 300 minors incidents and 29 serious incidents or 1 fatality or however it’s represented. My understanding from your thesis, it's 1928 paper where it emerges after a review of something like 75,000 accident reports.

It's interesting the way he goes and to say that he wasn't actually saying that you have to manage the 300 to prevent the 1. He was talking more about, "We should use those 300 as weak signals and the potential for other types of events to be occurring in our business." If we're not doing that, [...] from Heinrich, that we're often misdirecting our efforts and ignoring variable data. That could be straight out of HR literature from the 90s from [...]. 

Carsten: It's so recognizable because we all act if something really bad has happened, then we start to investigate. He turned it around and said, "We have a lot of small stuff here that might've been much worse, so why not act on that?" He calls it opportunities, which I think is a very beautiful way of phrasing it. He has 300 opportunities here which he can choose to do something with or not.

David: Yeah. I supposed if we keep moving through some of the things, and maybe I'll just throw some things that were really interesting to me from your thesis, that he started talking in 1923 about the indirect and hidden cause of accidents by the same events. He actually started talking about accident prevention being good business and this idea that good safety is good business. Was that in the literature before Heinrich started talking about it?

Carsten: Yes, quite a lot. There were several big studies in the early 20s. I think even a congressional study into safety and efficiency, and safety and cost. In a lot of our old, early 20th century safety literature, they already hinted at the hidden cost or intangible cost, as early as 15 of something, as far as I recall. Probably even before that.

Again, it wasn't anything new. The new thing Heinrich added was the ratio. He made it look much more scientific, which is the subtitle of his book—scientific approach. They actually look at first 100, then 1000, and then (I think) 5000 cases. They came at this average one before. Then he does the trick he mentioned, the 1:4 the whole time so people remember it. He made front page news with it, which is quite cool for a safety adviser, I think.

David: It's interesting. You mentioned in your thesis that he seemed to become somewhat of a celebrity within these safety sectors by the end of the 1920s. He was going all around and presenting all over the place. People at that time were traveling hundreds of miles to come and listen to him talk. That's similar to how we think in the modern day Sidney Dekker or Erik Hollnagel traveling around and talking about their ideas. It's quite amazing to think about that in the 1930s and pre World War II anyway.

You talked about prevention as well. I think there's a statement in there, I think it's from Heinrich, "Accident prevention is possible with knowledge (of course) and a will to act." You referred to Heinrich as being somewhat of an optimist in his belief that we could actually get better at safety management, and we could fix these hazards.

Carsten: Yeah, definitely. I compare him to self-help literature. One of the things that struck me when I really studied his work and besides his books, I dug out 750 papers that were hidden in vaults, on the Internet, et cetera. I think I got a quite rich source there. It's interesting to see that we think of him as a safety scholar or a safety worker, at least. I think he would have liked to see himself first and foremost as a management adviser. That's the audience for his book.

First of all, this is written for employers, for top executives. Then, he adds some authors for my benefit, but he addresses the top management. He discusses things like accident prevention, safety management in a really encouraging way. He says several times, "You can do this. This is simple. Just follow the principles you already follow for production, for quality, for other management." There was a growth for safety as well.

You can do this, prevent those accidents, because you can.

David: I suppose we believe maybe because of the ratios, the 88% of incidence being caused by the operator or the human. We form the assumption that that was his view where safety has to be solved. Interestingly, you talked a bit about how we really believe in the role of the employer and the executives that the safety needs—executive interest, support, and actions—knowledge of the accident facts and it needs an appropriate and effective action at all levels of the organization. He was quite holistic in his ideas about how a firm needs to run and approach safety management efforts.

Carsten: I think there's a lot of stuff he said that was lost in translation over the years. Maybe also in his own speech. I don't recall who said, I think it’s [...]. It's pretty hard to hear the rest after you heard a big statement about 88% of these stuff were caused by unsafe acts. Here, 88% causes unsafe acts. Practical [...] grow immediately and that let's fix that mode. Whatever comes after, it can’t be that interesting because we have 88% here.

David: Yeah. I'll think as we said earlier, maybe we've all written things in a certain way. We'll never know what kind of injury. We just need to ask and reason about the Swiss cheese model in his lifetime of work as well. 

A couple of lesser things that I didn't refer you, you made a subtle reference in your thesis to Heinrich's early suggestion for hierarchy of controls, where he preferred whole chapters in his early books on machine guarding and procedure revision rather than behavioral controls, which is kind of at odds with that 88%, which suggested that he did really think about ways to eliminate, isolate, and engineer out hazards in the workplace. He didn't have to rely on the operator. Could you find similar ideas around the hierarchy of controls in literature at that time? 

Carsten: Absolutely. In the past year, I acquired most of the literature that Heinrich listed in his bibliography. Those are safety books from the 1910s through the 1920s, and hints at hierarchy of controls are found in those already. There are some other authors (I don't recall them now) that put a lot of stress on procedure revision or a depth thing in the environment. Actually, if you go back to Frederick Taylor, the big bad guy in management science, he actually proposed first of all a [...] workplaces to facilitate that one best way. It's even there.

David: You're laughing when you talk about Frederick Taylor. I studied under Sidney Dekker for four years or so. At one point, it might've been inspired by some of your early reading and thought I might do the same. Actually, when I read Scientific Management, I read some of the early work of Taylor through there. It is interesting to reflect on the version of what you think is the truth from what you read, the author's work versus when you go back and read in. I was so surprised when I read Taylor's, what was influencing him around that time. He was very much advocating for the work. He's very much trying to understand how to manage production lines so that workers would get a fair day's pay. 

When Frank Hubert and I went off and started doing time and motion studies, he said, "No. I don't want to be a part of this. This is suppressing the worker's rights. This is suppressing their ability to earn income and so on." He gave a very, very, small snippet of what you're able to do with Heinrich. The pair of going back to that original text and just trying to understand the context around when it was written and what the author was trying to achieve is vitally important, and we'll probably talk a bit about that in a little while.

We're going to talk about authors. There is another idea in there which you threw away. If you wanted to cherry pick, be selective in some of Heinrich's writing or maybe even broader than that, you can very much find in some of these contemporary ideas in his works. Particularly that idea that people are the solution.

I want to throw two quotes at you. One from Heinrich in 1931 which says, "In many cases, safety may be promoted by employee ingenuity and mechanical genius of work within the average planet in the revision of process and procedure." Another quote that I think was quoted in Bird’s or someone else's work, but I've got Heinrich in 1940 here that says, "He would prefer capable and experienced men who work under unsafe conditions, rather than incapable and inexperienced men who worked in safe conditions." These are really interesting quotes when we think about the popular interpretations of Heinrich's work.

Carsten: Especially the second one. It really jumped at me. I think this 1940 paper (it's included in the later books as a part of a chapter) was quite a groundbreaking work for him to look at that way. "I would rather have people," to cite in modern words, "that are able to adapt to the situation and handle it safely," which is a very modern definition of safety (I think) and work under different circumstances. Then that he would have to, let's say, cartoonish Taylorist variation where you build a workplace, you make it safe, you put in some monkeys there, and they’ll probably be fine because what can they do? We make it fool proof. Heinrich says that he would rather prefer the risk where you put capable people in uncertain circumstances.

David: Yeah, that's amazing. Even then, he knows that you're the fool if you think that you made something foolproof.

Let's move on to some of the authors. Like you said in the title about the new view and local rationality, you spend quite a bit in your thesis looking at some of your graphs and your thesis around your Google search, just a proliferation of Heinrich references in the safety literature, say between 2005 and 2010, just how much he’s been spoken about in the safety literature and by who he’s been spoken about.

Just for our listeners, you went through almost all of those references in all of the key authors that our listeners might know of—Dekker, Hollnagel, [...] and a long list of other minor authors—and actually look at the context in which they have quoted Heinrich's work and your thoughts on those quotations. Do you want to just start talking a little bit about how you saw Heinrich show up in the new view literature? How it made you feel having read quite a lot of the original texts?

Carsten: Yeah. If you'd look at the new view literature, it's probably hard to really define a book. Say, the work of Hollnager, Dekker, Woods, et cetera. Some of the authors that we would put in the new view don't speak of Heinrich at all. David Woods for example, [...]. Not a word. Neither does James Reason. James Reason refers at one point [...] Bird’s triangle, but that's about it.

The situation is like that until early 2010s. The only new view author who actually spends some time on Heinrich is Erik Hollnagel. He started (I think) in the early 2000s when Hollnagel started developing his various stages in excellence models like linear, the dominoes, the archetypes of the linear, and the accident model, and he goes to the pathological (I think) where he [...] the Swiss cheese, and then the systemics models, like from [...]. He has these different categories. He uses Heinrich constantly over the next 20 years from 1999 or 2000 until today. He refers to that and it's not even detrimental.

Then, something interesting starts in the early 2010s. There seems to be some interest by some new view authors in Heinrich. A good example and maybe the most typical example is Sidney Dekker who has written three versions of  Field Guide to Understanding Human Error. The first two can do without any Heinrich. In the third, there are two pages where he thrashes the pyramid. We always had a feeling of what was this? Why did this happen? For me, that doesn't really fit into the book. That was one of the questions that also triggered my study. What's happening here? Why? Why did you do so?

I asked Sidney, and he said, "One explanation is move to Australia, contact the mining industry where these symbols were very much communicated and also misused.” That’s clear. A lot of Heinrich's works were misused for whatever reason.

David: Yeah. I think we might be to blame a little bit because of being down in Australia and having Sidney come down and discover that. I think, absolutely, the triangle is an artifact that appears in company safety reports all the time. I think if my reflections on your thesis and one possible explanation might've been Professor Hopkins. He's also very prominent within Australian literature. He talked a lot about near misses, weak signals, and the need to learn from those.

I think the Australian industry puts together Hopkins' calls for a reporting culture and the need to learn from all those instances with the nice picture of a triangle. Every single company has in its corporate safety reports particularly in that period 10 years ago, were testing themselves to see what their ratios look like and whether they had a reporting culture [...]. 

Carsten: [...] where they are in benchmark, et cetera. And it’s not the only Australia. At the end of last year, I did a huge study of [...] papers and literature. The British and the UK’s [...] for years they had the triangle in their report, but [...] now.

David: Yeah. I think we're done, like you've mentioned, with triangles, with icebergs. You mentioned the D&B and their Loss Control Model. You mentioned DuPont and behavioral safety. You mentioned all of these models that came through the early 2000s. All had some kind of representation of a ratio model of the unsafe acts to near misses to fatalities or whatever that looked like. 

You, including your thesis discussion, I think from Jean Christophe La Coze, it's about how safety models endure and the characteristics of these models that endure. They're somewhat simple, memorable, and generalizable across different situations. I think it's a perfect example of each type of model.

Carsten: That's their strength, and because they're also simple, people find it easy to adapt them through their own goals also, and then only get the most shallow version of the message (the real message), and take the Swiss cheese [...]. I think it's a brilliant example because there's a lot of talk about the Swiss cheese model as being linear.

Even in the first description, Reason writes about these holes that are moving over the place, changing in size, opening and closing, and their feedback loops. If you look at the picture, you'll see some areas in the row, an arrow going through them and another arrow stopping, and [...] make sense and give your own explanation. Losing all the author's richness in the model just because of the easy, understandable, picture which is the strength and the curse of the picture. 

David: Yeah, exactly. That's the curse, to try to shrink down the curse, make something simple enough so that it's understandable and usable, but obviously then the flip side is all of the nuance context gets lost in the simplification.

What are the other things that we haven't spoken about in relation to Heinrich's work that you think is useful for people to understand in a sense of what he was saying?

Carsten: That's a pretty big question. 

David: We didn't really touch on proximal causes and why does it make sense for him to focus on proximal causes to the incident. That's pretty essential.

Carsten: It is very essential. As I said, this was one of the things that have really bucked me for years. I was thinking it would be cool to just talk to him about it. That is impossible, so I did the next best thing and read a lot of his stuff. What I found out, we know his domino model very well. Again, it's easy. You have this picture where he picks out the middle domino, the direct cause, the unsafe X or unsafe conditions. If you fix the stuff afterwards, it doesn't happen. That seems to be very much focused on direct causes, and it is if you stop reading there. If you then progress to the next section, then it shows that there are actually much more thought behind it.

Heinrich started speaking about underlying causes. One thing he is very clear about since the 1940 paper we mentioned, not in the early versions, but since 1940, he's quite consequent in saying, "If you find unsafe X, the thing to do then is to find reasons for this unsafe X," I posted it on LinkedIn this morning, but I can’t recall what he said. It's something like, “because you can maybe fix the unsafe X, but to have a lasting effect, you need to address the reasons there, too." 

Why did people do that? Example, in a prediction pressure, I think he mentioned that as one of the examples. Then his advice is, "Don't focus on the behavior, the unsafe X, but go against that X and do something about restructuring the process or do something about the physical environment. It eliminates this unsafe X in the future or at least reduces possibility."

David: That’s almost exactly the idea that the behavior of the operator is a symptom of the functioning of [...].

Carsten: Yes. He never said anything about it. It's a logical conclusion. The reason for him, and he actually spelled it out when I read his books for the first time in 2010 or whatever, I must have missed it but you always miss a lot the first time around. It explains that his aim is a practical aid for managers. That's why he emphasized the direct solution—the simple solution—over the more deeper understanding. He said, "If the simple solution doesn't work, doesn't help enough, you have to go deeper. Sometimes it means going deep up to the management level because maybe you need bigger funding." 

He said that those are the rare cases because mostly you can fix it much easier. He is a very practical man. That's why he chose, "Okay, stop there. Only go further if necessary."

David: I really like that advice for action because we can get caught up on our own heads in safety quite a lot in organizations today. I like it quite a bit. I was going to start with it, I don't think I mentioned it. It wasn't in the podcast, it was in your thesis from him in 1931, which is something like, "It's time to stop talking. [...] and go to work."

Carsten: Yeah. I think it's the closing word from the summary of his book. It's four pages which is a lot of, what I said, optimistic. You can do this and now roll up your sleeves and go to work.

David: Good advice, too. Good advice to safety practitioners. I think also, one of the other things we didn't touch on was that Heinrich was probably one of the very early advocates of the professionalization of safety. This idea that I mentioned [...] to science, but it's not being recognized or treated scientifically today. He said that in 1928 and talked about what he thought safety management needed as a scientific and a professional discipline.

With that as a backdrop, do you want to talk a little bit about that? Maybe some practical takeaways from what you learned during your research that might apply to the safety profession today.

Carsten: There are two important lessons that I really want my colleagues, my peers over the world to remember. The first one is try to take the local rationality perspective as much as you can. Of course, it's not a method. It's an approach. It's an attitude, to understand behavior and events. Makes sense of the events. Why did it make sense for the people to do such and so. I applied to something completely different. I applied it to safety literature.

I think it's a great approach also there. It suspends a judgment. I don't take sides. I'm not for Heinrich or against Heinrich. He wrote brilliant stuff, you quote some. He also wrote some stuff that makes me cringe about ancestry. I really still don't understand why he did that or what he meant. He doesn't explain but it makes me feel very, very, awkward reading it.

But I'm still curious. I want to find out why it made sense for him to write this down in that way? What did he mean by that? That leads your mind open to learn something. You can always reject the [...]. This is not useful or this is outdated or plainly wrong. That's one lesson. Local rationality as much as possible in any setting.

I think it's also very liberating for you because if I've spoken with hundreds of safety people, I don't understand my management, they seemed to be living on another planet, and yes, they do. That's what local rationality is. They are not safety advisers. They're top management in their ivory towers, and they have different perceptions of reality here. Yes, try to take that view. It will actually help you do a better job. That's one.

The other one is if you can try to find primary sources and do not rely on hearsay because as I hopefully have shown, a lot gets lost in translation. And also in translation by people who are trying to convey the message as clearly as possible or as original as possible because it might [...]. It's influenced by my thoughts. It's not a good source either, probably. It's a bias source.

David: It's both sage-like advice for a safety professional to seek to understand why things make sense to people and go straight to the source. Whether that's a piece of literature or whether that's a person at the frontline of the organization. I think that's great advice.

Carsten, look, not everyone likes to read a whole thesis. I don't know if anyone read mine. Even my family, I don't think has read mine, even though it's a great source because most of them are publicly available including yours. Do you have any plans to make this content about Heinrich more accessible to the world? Or any other projects you are currently working on that you want to tell us?

Carsten: Those who don't like to read, I have to disappoint, firstly because I am now in the process of writing a book on Heinrich's work, trying to present who he was, which I think is an important part of trying to understand why he wrote what he wrote. Then about his work and discuss the main themes in his work. I'll also discuss some of the criticisms of his work. That's work in progress until next year, I think. It's going to be a lot to read. 

If I have time for those who don't like to read, I really planned to do a really short version, some kind of webinar or something put out on the net. I can't promise when it's finished. The material is there. I just need to find some hours to do it. I prioritize the book for now.

David: That's good. They can always do what Sidney Dekker seems to start to do which is record his books—his audio books. Some people might want to listen to your voice for seven or eight hours rather than read the text.

Carsten: Yeah. I hate reading aloud and I hate hearing my own voice. I need someone who has a sexy voice to do this. James Earl Jones or something like that.

David: They don't have to listen to it. Carsten, thank you. Thank you so much for taking the time to organize and coordinating this halfway around the world.

Carsten: It’s my pleasure. Thank you for inviting me.

David: I really appreciate you coming. It's really interesting in some of our listener’s feedback about how they find the interview approach. Drew and I planned to do quite a number of these interviews. 

There you go. Like Carsten says, direct with the source rather than two of us commentating on researcher work, where we can introduce some direct conversations with the researchers themselves.

That's it for this week. We hope you find this episode thought-provoking and ultimately useful in shaping the safety work in your own organization. Please join us in our discussion on LinkedIn or send any comments, questions, or ideas of future episodes directly to us at feedback@safetyofwork.com.