When a dramatic event occurs, the responses organisations provide always depend on the human factor. On those who decide, or who have delegated their decision-making power to tools or procedures. On those who accept and perpetuate habits, “cultures”. But also on those who decide to change them. And in a situation of failure, in the face of crisis, how do we change?
In April, a group of change management practitioners (The Change Leaders) took on a collective reflection on ways to “face crises”, drawing on shared experience and practice. Perhaps because of the spirit of the times, which attaches great importance to “personal development” and “quality of life”, or because of the participants’ sensibilities, individual “resilience” was discussed at length. How to “absorb” shocks, how to “live with” them as calmly as possible.
We brought a different, more operational approach to this work, with concepts and practices drawn from the new approaches to safety – in industry, healthcare, conflict… wherever life and death are at stake. So as not merely to accept.
Experiencing crises differently
At the end of the 1970s, and particularly after the Three Mile Island nuclear accident in 1979, many companies and researchers explored the place of the “human factor” in accidents in our increasingly complex systems, both technologically and humanly. From this still-ongoing ferment emerged, in particular, two especially fruitful approaches: High Reliability Organisations and Resilience Engineering. Two approaches which, despite academic discussions about their similarities and differences, seem to me to belong to the same “paradigm shift”.
The workshop we facilitated on this subject aimed precisely to raise awareness of this deep conflict between the fundamentals of the usual approaches and those of the “new views”. And to consider avenues for change. For ourselves, but also for our organisations.
Five case studies made it possible to become aware of the “reflexes” we may have when faced with an accident. Very human reflexes which, when the people concerned are in decision-making positions, lead to organisational responses with major impacts.
And you, what would you do:
- If your son died in hospital, after collapsing one morning at home;
- When two aircraft (an airliner and a cargo plane) collide in mid-air;
- After a rocket carrying astronauts explodes on take-off;
- When fighter jets shoot down allied helicopters over uncertain territory;
- When a train sets off one night with no driver and no passengers, crashes into a building at the end of the line, and a maintenance worker is found on board?
This role-play aimed to introduce participants to new conceptual and practical contributions, and invited them to look back at the cases, after the fact, through these new lenses – a few examples of which follow.
Hindsight bias
Do you know the character of “Captain Hindsight” in the cartoon South Park? This superhero is known for turning up at accidents: a house fire, for example, where he arrives to explain to the victims how they should have acted to avoid the accident – to their great satisfaction…
Hindsight bias is very widespread, and most often unintentional. A reflex.
After the accident, past decision-making is analysed in the light of what is known afterwards, and not in the light of what the actors knew about the situation at the time of the decision. It then becomes easy to determine what the actors should have done. Ah, that wretched “human factor”, which a good “root cause analysis” can flush out!
Because the management practices of our technological and human systems still rely heavily on a Newtonian-Cartesian tradition (on this subject, there is no rivalry between the continental and Anglo-Saxon traditions). Fundamentals that took shape at the beginning of the last century in Taylorism… and which still deeply permeate many practices, even methods presented as “modern”.
This reasoning rests on the principle of linear causality: the final effect is generated by an initial cause, which acts in cascade. Or possibly by several, whose accumulation causes the accident (this is the “Swiss cheese model”). In these approaches, combined effects are not taken into account at all – let alone emergence.
And the inclusion of cognitive factors, in the 1980s, led practitioners and thinkers of these classic approaches to enrich the list of possible causes with a taxonomy of “human errors”… Always that wretched “human factor” that must be distrusted…
90% of accidents are due to human factors?
Try it on your favourite search engine, and you will find many illustrations of this great classic of traditional safety. Including in the most recent applications of the discipline: cybersecurity.
Because for followers of mechanistic thinking, man is a machine like any other. More fragile, less reliable. Particularly when the human factor is at the end of the chain – what is called the sharp end. Where the action takes place, where the effect of the whole applies. As opposed to what characterises the organisation: its culture, its standards, its management – the blunt end.
By describing this safety continuum, the promoters of the new approaches to safety chose, unlike the traditionalists, to show that the hunt for human error was neither moral nor effective. Because in a complex sociotechnical system (and even the most complex programs have a human origin), the “human factor” is everywhere.
One can look for the “bad apples”. Those that will spoil the rest of the barrel. On convenient criteria. Looking for culprits, encouraging people to inform on others… any approach that leads to the concealment of deviations from the norm, whether trivial or serious. To protect some, at the expense of others. And it is true that, most often, the “culprit” is at the “sharp” end: where the action takes place, closest to the ground.
But if one is steeped in Foucault’s obsessions with domination, it is also possible to reverse the burden of accusation and look for the guilt of the human factor at the other end: no longer that of the operator, but that of the manager, the shareholder, the legislator. Simply changing the culprit.
One can also – and this is our preference – try to understand how situations escape a “control” that is by nature imperfect and impossible, because of cognitive overload, conflicting priorities, insufficient or unsuitable skills… so as to be able to act modestly, and above all without looking for culprits.
Setting about putting the “human factor” in a position to act collectively in the face of the unexpected. Because an individual weakness only leads to disaster if the system is not reliable. In this approach, human error is not the cause of a system’s failures. It is its symptom. That changes everything in terms of action.
The point is therefore not to build ever higher walls, which an unexpected wave may submerge, or to add layers of protection, which an improbable combination of independent events will render useless, but to organise the system’s responsiveness and develop its learning capacity. To prepare for tomorrow’s hazard – the one that will surprise us. To be ready not to be ready…
Learning from successes
Because the traditional approach to safety rests on another model of conviction, or of cognitive habits: the belief that a serious accident is an incident that “succeeded”.
From then on, any safety approach based on this old paradigm rests on the pursuit of “zero defects”, even when the “defect”, or the deviation from the rule, has no negative consequences.
Tracking down the slightest deviation, even when justified by circumstances, ruling out initiatives that depart from the norm, even when they “save the system”, means choosing the paradigm of total control. It means giving in to the intoxication of hubris, to the fantasy of omniscience and omnipotence.
It also means devoting all one’s time, all one’s energy, all one’s cognitive capacity, to errors, failures and faults.
But how can the improvement in a system’s safety be measured by counting the number of adverse events? Or, more poetically, how can one be happy by devoting oneself exclusively to one’s failures?
The choice of the new approaches to safety is also to learn from human abilities to face the uncertain, the unknown, the unexpected. Including when they override standards, by showing initiative. Accepting deviations – as long as the intention is good. A delicate exercise in tact practised by organisations seeking a “just culture”.
It means abandoning the immoral and ineffective fantasy of total control, by showing humility. Not standing rigidly “straight in one’s boots”, as the French saying goes, but managing the trade-offs between safety and efficiency. Navigating in balance between three ridgelines: that of disaster, that of economic collapse and that of human capacities.
To the five cases studied in our participatory workshop, a sixth could be added, accessible to all thanks to the film “Sully”, by Clint Eastwood, starring Tom Hanks. Based on a true story.
After the accident, would you decide to punish the man who did not follow procedures, at the cost of the aircraft – or to learn, in order to promote and spread them, the skills and behaviours that enabled him to save the passengers’ lives?
At a time when our societies and companies face complex challenges, at the edge of the chaos of living systems, all these questions are particularly pressing.
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