Engineers as the agents of evolution
Process is no substitute for paying attention
As Weick has pointed out, to manage the unexpected we need to be reliably mindful, not reliably mindless. Obvious as that truism may be, those who invest heavily in plans, procedures, process and policy also end up perpetuating and reinforcing a whole raft of expectations, and thus investing in an organisational culture of mindlessness rather than mindfulness.
There’s been a lot of ink expended on examinations of the causes of the Challenger disaster, whose anniversary passed quietly by yesterday, but are we really the wiser for it?
How do we give meaning to experience in the midst of crisis?
Instead people strive to create a view of it by establishing a common framework into which events can be fitted to makes sense of the world, what Weick (1993) calls a process of sensemaking. And what is true for individuals is also true for the organisations they make up. In return people also use an organisation to make sense of what’s going on, especially in situations of uncertainty, ambiguity or contradiction.
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
What you pay attention to dictates what you’ll miss
The point that the great detective was making was that the absence of something was the evidence which the Scotland Yard detective had overlooked. Holmes of course using imagination and intuition did identify that this was in fact the vital clue. Such a plot device works marvelously well because almost all of us, like detective Gregory, fail to recognise that such an absence is actually ‘there’ in a sense, let alone that it’s important.
In June of last year I gave a short three day course on system safety at UNSW@Canberra, and this year they’ve asked me back to run it again!
Anyone who wants a good understanding of the theory and practice of system safety and how to manage safety risk, as well as an overview of modern risk theory, would find the course of interest and, I hope, useful.
There’s currently planned two course dates. The first is the original three day form, for those of us who are time poor, while the second is five days. Dates are as follows:
- 16-18 Jun - 3 day short course.
- 14-18 July – 5 day course.
John Adams has an interesting take on the bureaucratic approach to risk management in his post reducing zero risk.
The problem is that each decision to further reduce an already acceptably low risk is always defended as being ‘cheap’, but when you add up the increments it’s the death of a thousand cuts, because no one ever considers the aggregated opportunity cost of course.
This remorseless slide of our public and private institutions into a hysteria of risk aversion seems to me to be be due to an inherent societal psychosis that nations sharing the english common law tradition are prone to. At best we end up with pointless safety theatre, at worst we end up bankrupting our culture.
Separation of privilege and the avoidance of unpleasant surprises
Another post in an occasional series on how Saltzer and Schroeder’s eight principles of security and safety engineering seem to overlap in a number of areas, and what we might get from looking at safety with from a security perspective. In this post I’ll look at the concept of separation of privilege.