Labels and Accidents

7 Mar

Organisations, projects and people who operate in dynamic, high risk environments constantly need to update their understanding of a situation. The reason is that dynamic, high risk environments constantly change and they continually surprise.

Fighting a fire, building a hospital or managing diverse projects are all environments where plans and expectations become derailed by reality. Scanning an environment for even the smallest deviation in plans and expectations can ensure that small incidents do not explode into catastrophes. However, one of the biggest barriers to scanning and updating a dynamic, high risk environment are the techniques we turn to simplify our world and make it more manageable- plans and labels. This article discusses how plans and labels can turn a dynamic situation into a potentially dangerous situation.

Weick and Sutcliffe (2007) comment that “unexpected events audit resilience”. If an organisation, project or person is not able to continually update their understanding of a dynamic, risky and sometimes dangerous situation, then small deviations to plans and expectations can be left unchecked to blow up into major, brutal audits (Weick et al, 2007). Labels and plans are essentially methods of simplifying complex situations and accounting for complex situations. Labels and plans funnel a variety of perspectives and channel them into specific terms. Of course, this process has huge benefits. But the downside is that labels and plans smooth out nuanced interpretations of events. And smoothing out nuanced interpretations standardises individual perspectives, making updating far more difficult to achieve. This can leave small deviations in expectations and plans neglected.

An example is from NASA and the 1986 Challenger disaster. When maintenance and checks were carried out on the shuttle, expected events were categorised as “in family” and unexpected events “out of family”. During a series of checks, previously unexpected events (out of family) in the form of burn marks were being categorised as “in family”, an acceptable risk. The definition of safety was being stretched to fit a specific label. The unexpected was being explained away and labelled as safe. Once this process of stretching the boundary of labels has begun, it becomes incredibly difficult to move back (Vaughan, 1997 and see Weick, 2009).

A remedy is an open culture which promotes multiple perspectives on dynamic situations. Each person, professional and expert has a slightly different way of making sense of events. This is the result of experience. Seeking multiple perspectives provides variety. Variety in interpreting the deviation of expectancies and plans, and variety in how to respond to these deviations. This sounds like it could be chaotic, but it should be cultural rather than a complex data collection process.

If reporting is encouraged (as opposed to only labelling), then when a deviation is noticed it is feedback to a project manager (for example) along with an interpretation of its potential consequences. Nuanced feedback highlights emergent risks, and increases safety. It also draws, when shared, everyone’s attention to a new detail. Previously this detail may have been explained away by the majority of frontline staff.  Now it is a significant event with potentially large consequences.

Implementing this type of culture can be achieved by changing the method of reporting. There are numerous high risk, dynamic environments where constant feedback based on focused attention is essential to safety and success. The methods these environments employ have to be sufficiently detailed, but sufficiently lean, to feedback and share detail fast and effectively. Vitally, the methods allow expertise to be expressed in a nuanced way. They do not smooth over experienced sense making with standardised labels. These methods of reporting increase safety, increase organisational variety to tackle unexpected events, and allow expertise to express itself.

Reading

Weick, K. Sutcliffe, K. (2007) Managing the Unexpected: Resilient Performance in an Age of Uncertainty. Jossey-Bass.

Weick, K. (2009) Making Sense of the Organization, Volume 2: The Impermanent Organization. John Wiley & Sons

Vaughan, D. (1997) The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University of Chicago Press.

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