Safety-II and Work-As-Done

This article is part of the series on behavioral design and the DUDUR method .
You can find explanations of the common concepts here: Concepts in the DUDUR method .

When we design solutions, procedures or systems, it is almost always based on an idea of how the work is done.
But there is a difference between the world we think people work in – and the one they actually find themselves in.
That's the difference between Work-As-Imagined and Work-As-Done.

The concepts originate from safety research and Erik Hollnagel's work with Safety-II (see From Safety-I to Safety-II – A White Paper , https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf ),
but they describe a pattern that is found everywhere: in leadership, change processes and especially in compliance.

Safety-I – when rules become more important than reality

The classic way of thinking about safety and quality is called Safety-I.
Here, safety is about the absence of errors:

“As few things as possible must go wrong.”

In the Safety-I logic, you look for deviations.
If an error occurs, the cause must be found, the procedure adjusted and controls tightened.
The idea is that if people just follow the rules, everything will be fine.

It's an approach that fits the world of compliance: SOPs, processes, checklists, and documentation requirements.
Where the rules are clear and reality resembles the manual.

The problem is that most organizations don't work like that.
They are complex, unpredictable and full of small adjustments that make everyday life coherent.

When we only design for what we think will happen – Work-As-Imagined – we risk overlooking how work actually succeeds.

Rules are static.

Reality is dynamic.

Safety-II – when we design for what works

Safety-II reverses the perspective.
Instead of seeing people as a risk, they are seen as a resource.
Safety and quality are not about avoiding mistakes, but about understanding why things go right 99% of the time.

“Safety is having as many things as possible go right.”

The point is simple:
People make work work – not in spite of the system, but because of their ability to adapt, prioritize, and use judgment.

In Safety-II, you learn not only from the exceptions, but from everyday life.
You design with reality – not against it.

Work-As-Imagined and Work-As-Done

Work-As-Imagined is how we believe work is done.
It's in manuals, procedures and PowerPoints.
It is orderly, stable and predictable.

Work-As-Done is how the work is actually done.
Here, people adjust, improvise and find solutions when the systems don't quite fit reality.

That doesn't mean they don't care about the rules.
On the contrary – they are trying to do the right thing.
But when the rules don't work in practice, you have to bend them a bit to make the work successful.

A classic example is passwords.

Work-As-Imagined says that we naturally use strong, unique passwords for each system.
In reality, most people reuse their password – otherwise they wouldn't be able to remember it.

If we design based on Work-As-Imagined, we create an e-learning course that teaches that passwords should not be reused.

But if we design from Work-As-Done, we ask: Why do people do it?
The answer is that the system is too heavy.

So the effective solution is not more learning, but fewer barriers – e.g. password managers, biometrics or single sign-on.

How to Detect Work-As-Done

It requires curiosity.
Instead of asking:

“Are you using the system?”

then ask:

“How do you do it in practice when you need to make it work?”

See what people actually do – not what they say they do.
Often it is precisely their work-arounds that keep the system alive.
They are not signs of resistance, but of responsibility.

Many people say “I didn't have time”, but really mean “it didn't make sense” or “I wasn't sure if it was okay”.
The friction is rarely visible – it is felt.

If you notice that people have found a smarter way to do something, acknowledge it.
Maybe it's not them who need to adjust – maybe it's the system that needs to change.

What Safety-II means for leadership and change

Safety-II is really about leadership.
About daring to let go of control and design based on reality instead of assumptions.

Three things make the difference:

1. Understand Work-As-Done before you decide anything.
   Ask what is already working and where everyday life is straining.
2. Design with, not against.
   Systems should support flexibility, not fight it.
   Variation is not dangerous – it's how work works.
3. Adjust instead of reform.
   Present changes as improvements to something that already works.
   Recognize what people are successful at.

Safety-I and Safety-II complement each other.
We still need rules when something needs to be safe.

But if we only design for the rules, we lose understanding of how the work is actually done.

It's not because people don't want to work after the procedure.

They try – but Work-As-Imagined just rarely matches Work-As-Done.

When we design solutions that are based on reality, we get more safety, greater quality and more engaged employees.

Because most people want to do the right thing – if only the system makes it possible.

Related articles

• The will-to-like reflex – why people actually want to do the right thing ( https://elearningspecialist.com/blog/posts/2025/november/vil-gerne-reflesen/ )
• The top-down reflex – when change starts in the wrong place ( https://elearningspecialist.com/blog/posts/2025/november/top-down-refleksen/ )
• Actorship – freedom to professionalism – Safety-II in practice ( https://elearningspecialist.com/blog/posts/2025/november/aktorskab-frihed-til-faglighed/ )

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