What the motorcycle manufacturing industry can tell us about why motorcycles crash.

Considering mechanical failure accounts for so few accidents nowadays you would have thought that the way bikes are built and the way they are ridden wouldn’t have much of a connection. You would be wrong in this assumption however because bikes are built and bikes are ridden in what are commonly known as ‘systems’ and how systems work and sometimes fail to work is critical to our understanding of accident causation.

According to http://www.businessdictionary.com a system is:

1) A set of detailed methods, procedures and routines created to carry out a specific activity, perform a duty, or solve a problem.

2) An organized, purposeful structure that consists of interrelated and interdependent elements (components, entities, factors, members, parts etc.). These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system, in order to achieve the goal of the system.

All systems have (a) inputs, outputs and feedback mechanisms, (b) maintain an internal steady-state (called homeostasis) despite a changing external environment, (c) display properties that are different than the whole (called emergent properties) but are not possessed by any of the individual elements, and (d) have boundaries that are usually defined by the system observer. Systems underlie every phenomenon and all are part of a larger system. Systems stop functioning when an element is removed or changed significantly. Together, they allow understanding and interpretation of the universe as a meta-system of interlinked wholes, and organize our thoughts about the world.

Although different types of systems (from a cell to the human body, soap bubbles to galaxies, ant colonies to nations) look very different on the surface, they have remarkable similarities. At the most basic level, systems are divided into two categories: (1) Closed systems: theoretical systems that do not interact with the environment and are not influenced by its surroundings. Only the components within the system are significant. (2) Open systems: real-world systems whose boundaries allow exchanges of energy, material and information with the larger external environment or system in which they exist. Example: a company–even if there are separate departments in one organization, the workers share data and interact with each other on a daily basis. Different systems methodologies (such as systems dynamics and systems thinking) classify systems differently.

As you can imagine the above description can be applied to a motorcycle manufacturing plant as easily as it can be applied to road transport so it seems odd that the two have entirely different approaches to the way that they ensure successful outcomes (safety for transport, quality for manufacturing). That similar systems can have different approaches to the way successful outcomes are assured (or not as the case may be) is largely down to the fact that originally both systems had exactly the same approach, but that a significant event occurred in one of them that caused it to diverge from the existing method. This divergence led to a superior method of outcome assurance for manufacturing, but sadly this superior method was not adopted by road transport who decided to stick with the old inferior method instead.

The significant event that caused the divergence was the post war reconstruction of the Japanese manufacturing base that was driven by the efforts of a chap called W. Edwards Deming. Many in Japan credit Deming as the inspiration for what has become known as the Japanese post-war economic miracle of 1950 to 1960, when Japan rose to become the second most powerful economy in the world, all founded on the ideas Deming taught. Essentially Deming encouraged the Japanese to view their manufacturing facilities through four ‘lenses’ which are, an appreciation of what a system is and how it functions, an understanding of variation, an understanding of psychology and finally an understanding of epistemology or the theory of knowledge. With just these four foundations in place an entirely new way of ensuring outcomes was created and one which eventually led to the Japanese domination of motorcycle manufacturing. This new thinking was called systems thinking for quality and it’s thanks to Deming and his ideas that we all ride round on bikes that go well, stop well, handle well and which don’t leak oil.

One of the most profound actions made by Deming during his time in Japan was to take the old way of thinking that ‘all the problems in a system were down to the shortcomings of the people within the system’ and flip it to the idea that it was the variation in the system that was actually causing the problems. All the people were doing was managing that variation in the best way they knew how. Deming famously quoted “85 percent of a worker’s effectiveness is determined by his environment and only minimally by his own skill”. The understanding that it was variation that was the problem to control and not the people was an idea that was so radical, but so true that it literally changed the world.

Consider now the road transport system that stuck with the old methods of outcome assurance where it’s still an established ‘fact’ that 85 percent of system safety is determined entirely by a driver or rider’s own attitudes and behaviours. Fix the attitudes and behaviours so the thinking goes and you will make the system safe as a matter of course.

This gives us a clear distinction between the old view that people are a problem to control and the new view that says variation is the problem to control.

It has taken a long time for the extremely effective methods used in manufacturing to find their way into industries that had stuck with the old ‘behaviourist’ ideals and methods, but this is changing rapidly as more and more non-manufacturing industries buy in to the ideas. To go along with this expansion the old name of ‘systems thinking for quality’ just wasn’t up to explaining what the new ideas were all about as people still got confused with the idea that quality and safety were just two different names for the same thing. In truth there is no functional difference between a scrap part and a dead rider as both are unwanted outcomes from the system that produced them. A couple of years ago a resilience engineer called Professor Erik Hollnagel coined the term ‘Safety II’ to give this new view an easily remembered handle that would help differentiate it from any old and existing methods.

Shorn of any association with quality, Safety II is a comprehensive set of concepts that are based on Deming’s original philosophy, but that have been updated to reflect the huge body of knowledge that has been acquired in the years since Deming first started his work in Japan.

Safety II is based upon the idea that safety must be considered in the context of the overall system, not isolated individuals, parts, events or outcomes.
“In a system, everything is connected to something; nothing is completely independent.”

Principle 1. Field expert Involvement
The people who do the work are the specialists in their work and are critical for system improvement.
“We need to understand people as part of the system, and understand the system with the people.”

Principle 2. local rationality
People do things that make sense to them given their goals, understanding of the situation and focus of attention at that time.
“Trying to understand why and how things happen as they do requires an inside perspective.”

Principle 3. Just culture
People usually set out to do their best and achieve a good outcome.
“Assuming goodwill and adopting a mindset of openness, trust and fairness is a prerequisite to understanding how things work, and why things work in that way.”

Principle 4. Demand & pressure
Demands and pressures relating to efficiency and capacity have a fundamental effect on performance.
“Systems respond to demand, so understanding demand is fundamental to understanding how the system works.”

Principle 5. Resources & constraints
Success depends on adequate resources and appropriate constraints.
“Any attempt to understand human work needs to consider resources and constraints carefully.”

Principle 6. Interactions & flows
Work progresses in flows of inter-related and interacting activities.
“When looking at an organisation as a system, it is necessary to see the flows of work from end to end through the system, and the interactions that make up these flows.”

Principle 7. Trade-off’s
People have to apply trade-offs in order to resolve goal conflicts and to cope with the complexity of the system and the uncertainty of the environment.
“The efficiency-thoroughness trade-off has implications for understanding systems because it underlies all forms of work.”

Principle 8. Performance variability
Continual adjustments are necessary to cope with variability in demands and conditions. Performance of the same task or activity will vary.
“Performance variability is both normal and necessary, and it is mostly deliberate. Without performance variability, success would not be possible.”

Principle 9. Emergence
System behaviour in complex systems is often emergent; it cannot be reduced to the behaviour of components and is often not as expected.
“As systems become more complex, we must remain alert to the positive and negative emergent properties of systems and system changes.”

Principle 10. Equivalence
Success and failure come from the same source – ordinary work.
“When wanted or unwanted events occur in complex systems, people are often doing the same sorts of things that they usually do – ordinary work.”

Although the word work is used in these foundation principles of Safety II you can simply replace them with the terms riding or driving and the whole thing still makes perfect sense.

By taking the methodologies that are used so successfully to produce the bikes we ride and applying them to the environment in which we ride them will lead to significant advances in the overall safety of the system just as it led to the advances in manufacturing quality.

For a more thorough explanation of the thinking behind the Safety II paradigm there is an excellent paper that has been produced by Eurocontrol, the European air traffic control agency. From Safety-I to Safety-II: A White Paper


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