A tailor’s shop, somewhere downtown. A back room, two mirrors, a table covered with bolts of fabric, chalk and pins on a board. A man stands on a low platform, in a rough cut of light wool, and the tailor walks around him. He doesn’t just take measurements. He observes. He sees how the customer shifts his weight, how he holds his shoulders, whether the seam at the back pulls to one side. A chalk mark where it doesn’t yet sit right. Then the measuring tape again, then a stitch, then a fitting. Adjust. Try again.
What’s happening here isn’t fitting a suit. It’s a conversation between fabric, body, and habit. The tailor knows that no human stands exactly the way the pattern assumes. He knows the seams meant to sit centred will shift the moment the person moves. He plans for it. He builds in reserve at points where he knows the fabric needs room to settle. He isn’t surprised when the customer has to come back twice more. That’s his craft.
What does this workshop have to do with safety? That’s the question this magazine owes its name to. I made the case in the opening article Three Assumptions We Need to Leave Behind; in short: safety doesn’t arise when people adapt to systems, but when systems are designed so they can be adapted to people. Tailoring Safer Systems. Measure, draft, fit, wear, adjust. The cycle repeats, only with different material. And just as in tailoring, it isn’t a one-off act but a stance.
What this stance asks of us, in concept and tool, I want to lay out here. Three principles, each with a term you’ll recognise from the literature.
Measure, don’t assume
The tailor who doesn’t put down the measuring tape knows something that many safety departments treat as needless effort: that reality isn’t in the pattern.
Steven Shorrock and Claire Williams, in Human Factors and Ergonomics in Practice, frame the distinction that’s been at the centre of the human-factors tradition since Hollnagel so simply that it works as a test. Work-as-Imagined is the picture designers, auditors, and executives have of how work gets done. Work-as-Done is what people actually do. Between them there’s regularly a gap. The question isn’t whether the gap exists. It always does. The question is whether the organisation knows it.
Whoever doesn’t know it tailors into the assumption. They design procedures on the basis of what their model says. And the model says what’s convenient, what’s legible by audit standards, what sounds executive-ready. The procedure fits the assumption, not the practice. Within a short time, practice and procedure drift apart without anyone noticing, because no one ever measured how the fabric actually hangs.
What measuring actually means isn’t spectacular. It means observing. It means walking the floor: what the Lean tradition calls a Gemba Walk, and what the safety world circulates under terms like “operational learning visit”. It means shadowing across more than one shift. It means asking questions open enough that they don’t contain the answer: not “Do you stick to the procedure?”, but “When was the last time the procedure didn’t fit your situation, and what did you do instead?”
These questions regularly produce answers no one wants to hear. People describe workarounds that look like violations to compliance and look like the only way through to the system, on a day when a tool is missing, a stand-in is new, the plant has been moody since the update. The temptation is to read these answers as defect. And to close the case there. The work is to read them as finding.
Whoever measures accepts what they see. What they see is regularly not what’s in the pattern. That’s exactly why they’re there.
Measuring isn’t compliance on trial. It’s the willingness to see something that contradicts your own assumption.
Respect the fabric
Not every fabric can be tailored any way you like. Treat a soft knit like a firm wool and the seam won’t hold. The tailor knows the material’s properties before drafting the cut, and adapts the design to the fabric, not the other way around.
Transposed to organisations: context, culture, and history are the material with which a system is tailored. What works in an airline where Crew Resource Management has been embedded practice for decades doesn’t translate directly to an industrial organisation where hierarchies are lived differently and “Stop the Line” still has to be explained as a concept. What takes hold on a ward where the unit lead has built a reporting culture over years runs into nothing on another ward, where every report passes through two layers of HR before anyone gets to see it.
David Snowden’s Cynefin framework helps at this point. Simply put, it distinguishes between two kinds of problems: complicated and complex. Complicated problems are those where the link between cause and effect can be made visible with enough expertise: a machine, an accounting system, a construction plan. Best practices work here. Complex problems are those where cause and effect are only readable in hindsight, because the system shifts on every intervention. Culture, risk behaviour, learning capacity belong in this category. Best practices don’t work here. What worked in one organisation isn’t guaranteed to work in the next.
The most common mistake in safety programmes I work with is mixing these two up. A proven concept from a best-practice collection gets sold as a universal solution, draped over an organisation made of different fabric. And everyone’s surprised when the seam doesn’t hold. What the organisation needed wasn’t the solution. It was the diagnosis: what kind of fabric is in front of us?
Respecting the fabric doesn’t mean finding everything fine as it is. It means checking the cut against the material before reaching for the scissors. Whoever skips that builds a safety programme that fits the quarterly report, not the practice.
Build adjustment in
A good cut has give. The tailor doesn’t pull the fabric so tight that it tears at the first breath. He knows the body changes, the day changes, the fabric settles after the first few wearings. He builds that in. Where he leaves room, where he doesn’t, is craft. Eliminate the give, bind yourself to the exact measurement, and you get a garment that fits exactly once. Not the next moment.
Erik Hollnagel’s work has circled this insight in safety language for years. In FRAM (the Functional Resonance Analysis Method), he argues against linear incident models that read variation as defect. Variation, Hollnagel writes, isn’t the opposite of function. It’s a condition of function. Complex socio-technical systems work because their components (people, tools, procedures) are flexible enough to respond to conditions that aren’t in the plan. When the plan tries to switch off this variation, it switches off adaptive capacity at the same time.
In practice this means: a good procedure describes not only the intended path, but makes visible the conditions under which it holds. It knows the assumptions it makes, and it knows the places where it will break if those assumptions fail. A good procedure is aware of its limits. More than that: a good system keeps resources free that aren’t tied to the plan (slack in the staffing plan, time in the shift, room in the communication), because without these no adjustment is possible. What looks like inefficiency is the precondition for the system to make it through the day on which reality departs from the plan. And it departs. Every day.
Building adjustment in means giving the system permission to adjust. Not afterwards, in the case of damage, but beforehand, in the design. It means shaping room deliberately rather than tolerating it by default. And it means making visible what otherwise stays hidden: that the workarounds no one admits to are often the last adjustments an over-standardised system still allows.
What tailoring isn’t
Off-the-rack sits in the warehouse waiting for someone it fits. It’s efficient, it’s cheap, it’s clean in the reporting. It’s a complete solution as long as the measurement is right. When it isn’t, it becomes the source of a quiet compromise: the person adapts to the suit, holds their shoulders differently, breathes shallower, moves as if they belonged in the pattern. For a while, this goes well.
Safety from the compliance catalogue works on exactly this logic. It comes with finished procedures, standardised KPIs, audit templates that fit everything because they look at nothing. The problem isn’t that it’s structured. The problem is that it takes its own description of the system for the system. When reality departs from it (and it does), no adjustment is provided for in the catalogue. What remains is the admonition to please stick to the procedure.
In contrast stands the tailor who doesn’t put down the measuring tape. Who knows he’ll have to come back twice. Who respects the give in the fabric. Who doesn’t finish the cut today, but draws it in conversation with what’s in front of him. Who accepts that the end product isn’t perfect on the first attempt, and that adjustment is part of the craft, not an admission of error.
This is what Tailoring Safer Systems means. Shape room rather than eliminate it. Make adjustment visible so the system can learn from it. This is harder work than a dense catalogue. It’s also the only thing that works under conditions where the next measurement is already a different one.
Sources
- Steven Shorrock & Claire Williams (Eds.) – Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World, CRC Press 2017
- Erik Hollnagel – FRAM: The Functional Resonance Analysis Method – Modelling Complex Socio-technical Systems, Ashgate 2012
- David J. Snowden & Mary E. Boone – A Leader’s Framework for Decision Making, Harvard Business Review, November 2007
- Erik Hollnagel – Safety-II in Practice, Routledge 2018