The Missing Piece in the Safety 2 Debate: Agency

In the world of occupational health and safety, the conversation has increasingly shifted towards systemic and sociological factors that influence decision-making. Frameworks like Safety II and Human and Organizational Performance (HOP) encourage us to view incidents through a broader lens—one that examines the social and organizational systems surrounding workers that influence decision making rather than focusing solely on individual mistakes. While this perspective has its merits, it often downplays an equally crucial factor: agency, or the individual’s ability to make their own decisions.

To explore this, let’s start with a rather unexpected source of wisdom: Ricky from The Trailer Park Boys. In the very first episode, Ricky explains to the camera crew that their time in jail wasn’t his fault, but rather Julian’s, adding, “It doesn’t matter anyway, besides, the counsellors told me, it’s society’s fault, not my fault.” With his signature turn of phrase, Ricky captures a fundamental debate: to what extent are individual actions shaped by societal factors versus personal choices? This binary question—between the social environment and personal agency—forms the heart of what’s missing in modern safety discussions.

The Lens of Social Systems

The concept of society shaping behaviour is undeniable. Factors like socioeconomic status, ethnicity, gender, upbringing, and cultural norms undeniably play a significant role in shaping who we are and the decisions we make. For Ricky and his friend Julian, their life of petty crime is portrayed as a natural consequence of their upbringing and environment.

Similarly, in occupational safety, systemic factors undeniably influence worker behaviour. Whether it’s the availability of resources, operational design, the quality of safety leadership, or the organizational culture, these elements set the stage for decision-making. Safety II and HOP excel at identifying these systemic influences, particularly in complex environments where latent errors or “error traps” shows that failure is almost inevitable. This approach is especially powerful when analyzing large-scale disasters like Chernobyl or Three Mile Island, where individual actions are often the result of systemic breakdowns.

But What About Agency?

What these frameworks often underemphasize, however, is the role of agency—the ability of individuals to make their own choices, even within the constraints of their environment. Viktor Frankl’s Man’s Search for Meaning offers a powerful illustration of this idea. As a prisoner in Auschwitz, Frankl endured unimaginable suffering and deprivation, yet he argued that the ultimate freedom a person possesses is the ability to choose their attitude and response to any situation. He asserted that, even in the most extreme conditions, individuals can retain a measure of agency by refusing to become the “plaything of circumstance.” As he famously wrote, “Everything can be taken from a [person] but one thing: the last of human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”

How does this relate to occupational health and safety? Workers are not merely components of a system, nor are they entirely shaped by their environment. Despite external pressures, they retain the ability to make decisions—decisions that can have life-or-death consequences, like Viktor Frankl’s.

Consider a worker who has received comprehensive training, adequate supervision, and the proper safety equipment but chooses not to wear their fall harness. If they fall and suffer a fatal injury, the Safety II perspective might focus on designing systems that “fail safely.” This approach assumes the potential for failure and aims to mitigate its consequences through redundancies or by eliminating the risk of falling altogether.

While this philosophy emphasizes the need to account for all possible failures, it aligns with existing principles like redundancy and defense-in-depth strategies. However, in practice, safety-conscious organizations already strive to address risks comprehensively using the Hierarchy of Hazard Control. Even so, not all risks can be entirely eliminated due to limitations in feasibility or cost-effectiveness.

Ultimately, there will always be scenarios where adherence to specific practices—whether explicitly mandated or implicitly understood—relies on individual responsibility. Ensuring safety in such cases depends on workers making the right choices, as no system can fully substitute for personal accountability.

The Role of Agency in Risk Management

Risk is an inevitable aspect of any organization, and no system—no matter how advanced—can fully eliminate it. Safety II confronts this reality by emphasizing that systems are not inherently safe. Unlike Safety I, which often frames people as the source of problems, Safety II shifts the focus, arguing that people are the solution. Workers, through their resilience, adapt to challenges and create safety by identifying and addressing error traps, often improving their environments in the process.

Safety II posits that safety does not exist as an intrinsic property of systems but rather emerges from the continuous interaction of people, processes, and conditions. It emphasizes how individuals actively recognize trade-offs and work around rigid procedures to prevent harm and foster safety. This perspective highlights the critical role of individual agency in risk management. However, Safety II’s claim that “people are the solution” directly contrasts with Safety I’s view that “people are the problem,” creating a binary distinction between the two frameworks.

In reality, human behaviour exists on a spectrum. Workers are neither infallible automatons nor the sole creators of safety. Their decisions are shaped by a combination of systemic factors, situational pressures, and personal accountability. While systemic influences undeniably impact behaviour, it is equally important to acknowledge personal responsibility and the potential consequences of poor decisions. A balanced approach to occupational health and safety must consider both the systemic context and the agency of individuals, recognizing that the interplay between the two determines outcomes.

A Personal Example: When Agency is Fatal

Some safety professionals argue that organizations should aim to design error-free environments. However, this ideal isn’t always practical or achievable. The goal is not to create a perfect workplace but to take reasonable steps to minimize risks and protect employees. In many situations, following established procedures is the only realistic way to ensure safety. For instance, if workers are required to tie off after 10 feet of elevation and are provided with adequate training, information, and supervision, what justifies disregarding this requirement? While such behaviour might reflect a systems-level failure, it could also be a failure of personal agency. Ignoring the role of individual choices risks creating a dangerous precedent—one where accountability erodes, and responsibility is placed entirely on systems, leaving personal decision-making unexamined.

This emphasis on personal agency isn’t just theoretical for me—it’s deeply personal. Several years ago, I lost a family member in a tragic car accident. The driver of the other vehicle was speeding excessively and recklessly passed on the wrong side of the road, ultimately colliding head-on with my uncle’s car as he was driving home from visiting my wife and me. My uncle died in the crash. The driver survived but later took his own life, likely overcome by the guilt of causing someone else’s death.

If we were to analyse this incident solely through a systems lens, we could raise valid questions: Was the driver overworked or fatigued? Did societal norms around speeding influence his behaviour? Was the road design flawed, encouraging speeding and dangerous passing? Could stricter enforcement measures—such as more frequent speeding tickets or accountability programs from his employer—have prevented his actions?

These are important considerations, but they don’t erase the undeniable truth: the driver made a choice. He decided to speed and pass recklessly, fully aware of the risks. This is the essence of agency. By focusing exclusively on systemic factors, we risk absolving individuals of accountability. We could end up creating a world where no one is truly responsible for their actions—where systems are expected to be so flawless that personal responsibility becomes irrelevant. That is a dangerous mindset, one that overlooks the critical interplay between systems and individual decisions.

The Balance Between Systems and Agency

Occupational health and safety frameworks like Safety II and HOP have revolutionized how we think about accidents and risks, particularly in complex systems. But their utility is limited when applied to individual incidents where personal choices play a central role. To borrow a famous analogy, ‘If you give a boy a hammer, everything looks like a nail.’ In this case, the hammer is the systems-level analysis, and the nail is every workplace incident. While systemic analysis is invaluable, it shouldn’t be the sole lens through which we view safety.

In practice, investigations should start with a sociological and systems-level analysis. This involves identifying error traps, evaluating whether the organization provided adequate resources, processes, supervision, and training, and determining if these protocols were reasonable, practical, and effectively implemented. However, once these systemic factors have been thoroughly examined, attention must shift to individual choices and the motivations behind them.

These choices could arise from systemic error traps or reflect individual decisions. For example, imagine a scenario where a worker overturns a UTV on an embankment, resulting in a serious injury or fatality, while not wearing a helmet or seatbelt. This is not an uncommon occurrence in industries such as mining and wildland firefighting in British Columbia. If an investigation revealed that it was common practice to forgo helmets and seatbelts despite established procedures, this would point to a systemic issue, as frameworks like Safety II or HOP (Human and Organizational Performance) would emphasize. However, if the incident was an isolated case and not reflective of broader norms, it would suggest the worker made a personal decision to ignore safety protocols.

Unfortunately, incidents like these often leave unanswered questions. When workers are seriously injured or lose their lives, we cannot directly ask them why their decision made sense to them at the time. Such events may reveal systemic issues that tacitly allow or even encourage risky behaviour, or they might simply demonstrate the tragic consequences of an individual choice. Either way, these scenarios highlight the intricate relationship between systemic factors and personal accountability, reminding us that both must be considered in any safety analysis.

Conclusion: Why Agency Must Not Be Forgotten

Safety isn’t about creating a risk-free utopia—it’s about managing risk responsibly while acknowledging the limits of what systems can control. Laws, policies, and ethical norms are built on the premise of personal accountability. While Safety II and HOP provide valuable insights into systemic issues, they often overlook the fact that individuals retain the power—and responsibility—to make choices, even in high-pressure environments.

Ultimately, a balanced approach is needed. Systems shape behaviour, but they don’t remove personal accountability. Recognizing the importance of agency ensures that we don’t lose sight of the fundamental truth: safety is a shared responsibility, one that requires both robust systems and individuals who choose to act with care and responsibility.

Hayden Greenshields is the owner of Free Spirit Ventures Inc., a health and safety consulting firm located in Prince George, British Columbia. He is a consultant with over 18 years of experience as a safety professional within the oil & gas, construction and forestry industry. He can be reached at hayden@safetypays.ca or visit www.safetypays.ca for more information.