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Sense-making framework 
applied to safety methodology
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15th May 2009
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Organisational strategic consulting company Deloitte has extended the Cynefin sense-making framework as a strategic tool to help the mining industry to better understand and deal with the challenges associated with health and safety.

The Cynefin framework, originally developed by Professor Dave Snowden and published in the Harvard Business Journal, 
assists in identifying different kinds of issues, defined by their varying cause and effect relationships.

The framework allows leaders to diagnose and understand situations, and then to act in contextually appropriate ways. Understanding the context in which a problem arises will allow better decision-making and will avoid further problems resulting from applying solutions that are not contextually relevant.

“The mining industry, in terms of safety, has improved a lot over the past few years. 
“A lot of attention has been given to the issue,” says Deloitte mining consultant Nicolaas Herholdt. “However, the sense is that the mining industry has pla-
teaued in terms of further 
improvements. 
“The Cynefin framework allows one to see why certain approaches are only 
effective within certain parameters, and how different solutions can be applied to further improve safety.”

Essentially, the Cynefin framework divides the world into two main components: that of order, where cause and effect are clearly linked to predictable outcomes, and unorder, where cause and 
effect are present, but not 
immediately discernible nor predictable.

Each of these elements can be further split into two classes. According to the framework, ‘order’ consists of the simple and the complicated, while ‘unorder’ consists of the complex and the chaotic.

Simple Order – the Domain of Best Practice

Simple ordered problems or situations are the easiest to diagnose and to solve. The solution to the problem is obvious and requires very little debate.

It is within this domain that best practices can be applied with confidence. For example, it is easy to determine that to avoid head injury, hard hats should be worn on site. Should a head 
injury occur involving someone not wearing a hard hat, it can 
easily be determined that the hard hat would have prevented it.

Complicated Order – the Domain of Experts

Complicated problems may contain multiple correct solutions, as the relationship between cause and effect increases in complexity. Although there is a definite, clear relationship between cause and effect, not everyone can see this. 
It is, therefore, the domain of 
experts, who will diagnose the problem and find the solution. It may take time to find the solu-
tion, but a solution does exist.

An example of a complicated problem may be the failure of a piece of machinery. The operator may not know how to fix it or where the problem lies, but a technician with the right set of skills would, after analysis, discover the cause of the problem and solve it.

Complex Unorder – the Domain of Pattern Emergence

In this domain, correct answers cannot be ferreted out through accurately categorising or analysing the problem. Cause and effect relationships are not discernible in real time, only retro-
spectively.

In this situation, leaders first need to probe the system to prompt the emergence of under-
standable patterns and take 
appropriate action. Solutions require a fundamental shift in thinking, from fail-safe 
approaches that are expensive and totalitarian, to safe-fail 
experimentation with multiple, low-risk, cheap experiments 
designed for acceptable failure.

The use of experimentation to probe complex issues runs contrary to the traditional intolerance of failure. However, those who allow patterns to emerge 
before acting will discern many opportunities for innovation.

Chaotic Unorder – the Domain of Rapid Response

In this domain, analysing the problem or attempting to categorise it is pointless. The relationship between cause and effect is impossible to determine because it is constantly in flux, and so no manageable patterns exist.

A leader must first act decis-
ively to establish some order, then sense where stability is present, or where it is absent, and then 
respond by working to transform the situation from chaos to complex, where patterns can be identified.

Typically, people are more open to novelty and directive leadership in this context than in the other contexts.

In Mining

Using the Cynefin framework, Deloitte carried out research and case studies throughout the industry. A key issue that was identified in mining safety is the apparent mismatch between the nature of most unaddressed 
issues in the current safety landscape and the nature of the 
majority of intervention methods 
being used to counter these.

There appears to be a trend to attempt to solve complex 
unordered problems using simple 
ordered solutions. In essence, in contrast to the array of complex problems in the mining safety 
industry, only a predominantly 
ordered set of solutions exists.

When incidents do occur, often the first instinct is to create new rules to prevent reoccurrence. There are so many potential permutations in the way that accidents can take place that, if rules were devised to prevent every permutation, adherence would soon become impossible.

In any case, given the nature of complex problems and the ability to see only the cause and 
effect relationship in hindsight, it is pointless to attempt to apply an appropriate rule because it is not known which rule should be applied.

“Based on our research, we have identified that many safety 
initiatives are focused on the 
simple and complicated domains, and many of the unsolved problems are found in the complex 
domain,” said Deloitte in a mining safety report published in 2009.

Deloitte recommends a multi-
faceted approach to handling safety in mining. In the case of simple problems, the application of best practices and rules is perfectly appropriate.

However, an overemphasis on compliance can be counter-
productive, resulting in scenarios 
involving deliberate under-
reporting or inaccurate root cause analysis.

When problems of a complex nature occur, or where experimen-
tation is required, the company recommends setting up simple rules to establish the boundaries for seeking solutions, as well as establishing platforms for rigorous and open debate, which is valuable in the development of new ideas and insights into safety 
dilemmas.

Deloitte suggests a shift in mindset, from a focus on safety, 
to a focus on the overall high quality of mining.

Edited by: Shannon de Ryhove
 
 
 
 
 
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SIMPLE ORDERS
Many complex ordered problems are given simple ordered solutions, and it simply is not effective
 
SIMPLE ORDERS Many complex ordered problems are given simple ordered solutions, and it simply is not effective
 
 
Facts
Negative attitudes associated with safety
Fatalism:
Many adopt the view that mining is inextricably dangerous and that fatalities are inevitable and unavoidable, no matter how much effort is put into preventing them. When this mindset is prevalent, it is unlikely that safety interventions will succeed.

Negativity:
Safety is often seen as disruptive to business, and as something that seeks to penalise and assign blame. People can be of the perception that they are being watched so that they can be caught and punished.

Policing:
Linked to the negativity, safety is generally viewed as a law enforcement element. Terms associated with safety roles, such as ‘safety officer’, ‘safety inspection’ and ‘conducting investigations’, all have ties to law enforcement, invoking images of punishment.