The ETTO Principle: Efficiency-Thoroughness Trade-Off

Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.

'Hollnagel combines an accessible style with rigorous logic as he invites us to examine in new ways the socio-technical systems that have become so essential to our world. His observations of the ETTO Principle lead to insights about human and social performance variability and expose the limits of traditional bimodal analytical methods. Healthcare practitioners will find inspiration and greater understanding of the challenges of providing safe care in an underspecified and frequently intractable system. Bravo!' Rob Robson, Chief Patient Safety Officer, Winnipeg Regional Health Authority, Canada 'This is an impressive book, simultaneously bold and reasonable. Hollnagel, in his highly readable style, lays out a simple but profound principle - the tradeoff between thoroughness and efficiency - and uses it to cut through all kinds of sterile debates in order to provide valuable insights about human behavior.' Gary Klein, author of Sources of Power: How People Make Decisions 'With characteristic flair, Erik Hollnagel has cleverly captured in The ETTO Principle the pervasive problem of how we balance efficiency with thoroughness in our working life. Deftly blending material from decision science, accident analyses and risk management, he leads the reader through a fascinating series of adverse events, identifying the ETTO components to produce new insights into causal influences. Provocative reading for those interested in business efficiency and organisational safety.' Rhona Flin, University of Aberdeen, UK 'The ETTO principle resonates as a practical and workable premise from which to begin to address the complexity of healthcare. The specialized reductionist models that have been purported to apply to healthcare (Swiss Cheese, Root Cause Analysis) may be asking the wrong question. By biasing our view to the "retrospectoscope" we may chose not to look forward, at the complexity, context and trade offs in which modern healthcare occurs. We're using the ETTO Principle in our Patient Safety Investigation (PSI) curriculum. Clinicians will immediately recognize that they naturally adjust what they do to match the conditions by means of an efficiency-thoroughness trade-off (ETTO). My hope is that by framing patient safety investigations in this way, "sharp end" practitioners will be more likely to want to participate, especially if their intelligence is not insulted (from the get go) by overly simplistic accident causation models. Many thanks for this accessible, concise and useful text by a leader in the field.' Wrae Hill - Director Quality Improvement & Patient Safety - Interior Health , British Columbia, Canada 'Though relatively short, this book packs in a wealth of information and is very thought provoking...The book is highly recommended to anyone who wants to make a positive contribution to safety performance in their given sphere.' Health & Safety at Work , August 2010 'This author isn't afraid to identify some of the elephants in the room of safety and supports his position with technical references.' Safety WA, February 2014

Erik Hollnagel (PhD, Psychology) is Professor and Industrial Safety Chair at MINES ParisTech (France), Professor Emeritus at University of Linkoping (Sweden), and Visiting Professor at the Norwegian University of Science and Technology (NTNU) in Trondheim (Norway). Since 1971 he has worked at universities, research centres and industries in several countries and with problems from several domains, including nuclear power generation, aerospace and aviation, air traffic management, software engineering, healthcare, and land-based traffic. His professional interests include industrial safety, resilience engineering, accident investigation, cognitive systems engineering and cognitive ergonomics. Erik Hollnagel has published more than 250 papers and authored or edited 13 books, some of the most recent titles being Resilience Engineering Perspectives: Remaining Sensitive to the Possibility of Failure (Ashgate, 2008), Resilience Engineering: Concepts and Precepts (Ashgate, 2006), Joint Cognitive Systems: Foundations of Cognitive Systems Engineering (Taylor & Francis, 2005) and Barriers and Accident Prevention (Ashgate, 2004). He is Editor-in-Chief of the Ashgate Studies in Resilience Engineering series and, together with Pietro C. Cacciabue, Editor-in-Chief of the international journal Cognition, Technology & Work.

Accident investigation and risk assessment have for decades focused on the human factor, most notably in the form of human error. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for human error. This preoccupation with failure is near universal and can be found in all fields of application. One consequence of this has been a bias towards the study of performance failures, leading to a neglect of normal or error-free performance. The common, unspoken assumption is that failures and successes have different origins and that there therefore is little to be gained from studying the latter. Erik Hollnagel feels strongly that this assumption is false and that safety cannot be attained only by eliminating risks and failures. The akternative is to understand why things go right, and to find ways to support and amplify that. The aim of this book is to present a single, simple but powerful principle for human performance that can be used to understand both positive and negative outcomes. The ETTO Principle reflects the common trait that people in their work naturally adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that it is normal for people in work situations to adjust their performance by means of an efficiency-thoroughness trade-off (ETTO) - usually by sacrificing thoroughness for efficiency. The trade-off can be due to a lack of time, lack of resources, work and company pressures, lack of information, etc. The ability of people mutually to adjust their performance is the reason why things go right. Yet in some cases the adjustments may combine in an unforeseen way and lead to adverse outcomes. These outcomes are nevertheless due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle obviates the need for specialised theories and models of failure and human error' and offers instead a viable basis for more effective and just approaches to both reactive and proactive safety management.

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