The ESReDA Cube model

The ESReDA Cube model was created by the ESReDA Project Group on Dynamic Learning and published in 2015. Originally the Cube consisted of a 3x3x4 matrix (hence the name “Cube”) with three systemic dimensions representing a) the level of learning, b) the stakeholders involved and c) the work organization where the problem lies. The idea was to use the Cube as an aid to identify and categorize accident factors more systematically.

The Cube was developed to provide the ability to optimize, adapt and innovate sustainable change beyond the level of intervening in the actual accident process itself. Intervention does not only focus on eliminating or mitigating causal factors which were disclosed during the investigation of the sequence of events. Causal factors are answering questions dealing with the what and how, while understanding the why of an occurrence requires additional information about conditions, context, assumptions and simplifications. Such information can only be derived from a diagnosis of the system itself. Applying the Cube enables an investigator to disclose the origin of contributing factors to different phases and states of a system. This can be as early as in the conceptual design, up to operations, both in normal and in safety critical states. In short: The Cube enables an investigator to analyse an event in the context of the system in which it occurs. The purpose of the Cube is to enlarge the scope of recommendations to the system and not restrict recommendations to the sequence of events under scrutiny.

Since its publication the Cube has been utilized in the post-investigation analysis of several accidents and, based on these results, developed further. The original publication introducing

the model is available free to download on the ESReDA website46. The publication includes a

more detailed description of the thoughts and theories behind the Cube than is presented in this paper, and several examples of the use of the Cube.

46_{https://www.esreda.org/projectcasestudy/dynamic-learning-as-the-follow-up-from-accident-}

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The Cube was developed further based on the thought that the model itself and the guidelines to use it need a more simplistic form that will allow to use the Cube more intuitively. The result is a 3x3x3 matrix, see Figure 1a.

Figure 1a. The ESReDA Cube 2.0. A model with three dimensions and 27 individual cells that represent different possibilities to improve safety.

Figure 1b. The Cube may be sliced into planes. If sliced into horizontal planes, each plane represents a different organizational or societal level where safety may be improved. Slicing vertically (different aspects of work organization) or in-depth (levels of learning) is also possible, depending on the objectives of the analysis.

During the development process it was identified that the systematicity of the Cube may be utilized from several viewpoints. These viewpoints will be discussed in detail in the upcoming ESReDA book on Foresight in Safety (estimated to be published in 2019), and here we will concentrate on only one of them: the intriguing thought that the Cube may be used to create (on-going investigation) or analyse (post-investigation) the recommendations that are generated by the accident investigation results.

In the example figure 1b above, the stakeholder dimension has been cut into three levels. The levels represent different organizational and societal levels, not unlike those presented by Rasmussen and Svedung (2000).

Stakeholders involved (y-axis)

1. MICRO level. Organisations, teams or individuals. 2. MESO level. Industry sectors

3. MACRO level. Governments, agencies, authorities and society

The stakeholder levels must be explicitly defined before the analysis. There may be more than three levels, if needed.

Once the stakeholders have been identified, the factors that enabled the accident to happen may be divided into three categories of work organization. In the original publication there was a fourth category of context, but in the further development of the Cube it was identified that context is best written into the narrative of the accident due to its specific impact on the accident sequence. This does not mean that context, the operations environment, should be excluded from the analyses. Careful consideration should be given to the possibility of

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existing accident factors that are not included in the three levels of work organization presented below.

Work organization (x-axis)

1. STRUCTURE is about the (re)design of the system architecture: hardware, technology, functionality, organizational scheme (static)

2. PROCESS is about the actions and decisions made in both actual and formal operational conditions (dynamic)

3. CULTURE is about the values, norms and behaviour (inherent/abstract)

The first step of the analysis is to place the accident factors into the grey 3x3 matrix presented in figure 2.

Figure 2. Identified accident factors (x) may be divided according to stakeholder and work organization.

When all the accident factors have been identified, it is time to start thinking about the lessons learned: what can be learned from the accident. How deep have we learned and what lessons have possibly remained unlearned? The depth of the Cube (z-axis) represents the depth of learning, expressed by its rate of change: optimize, adapt or innovate.

Level of learning (z-axis)

1. RULES, single-loop learning: react, improve, optimize 2. INSIGHTS, double-loop learning: adapt, renew 3. PRINCIPLES, triple-loop learning: develop, innovate

More information on single-, double- and triple-loop learning may be found from the original ESReDA Cube publication (2015) and Stoop (2018).

The task at hand is to take the identified accident factors (step 1, figure 3) one-by-one, and think what are the lessons learned (step 2, figure 3) from that factor on the x-, y- and z-levels. What can different stakeholders learn from it? On what levels can learning occur? Can the learning involve different parts of work organization? Take one accident factor and place all the things that may be learned from it into the cells of another empty ESReDA Cube. After this has been done, do the same to all the other accident factors. The results will be a Cube full of lessons learned.

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The final step (step 3, figure 3) is to use the full Cube to generate or evaluate the recommendations. You must learn something before you can recommend improvements. Slice the Cube into three planes. Do this first from one direction, then later on from the other two, and target your recommendations to a) different levels of stakeholders, b) different parts of work and c) different levels of learning.

Figure 3. Use of the ESReDA Cube. Utilizing identified and categorized accident factors to formulate precisely targeted recommendations.

The ESReDA Cube may also be used to assess the quality of a former investigation and thus to improve the investigation process itself. It can also assist in tracking which recommendations have been addressed, and with those that have been addressed, could result in a post-implementation reclassification, becoming evidence of good practice to be shared with the safety management communities. Additionally, for those recommendations that were not implemented, the researcher could investigate what the reasons were behind, triggering another research thread. What were the obstacles? Where was the governance bottleneck, etc.?