I’m currently involved in a large and ongoing cultural change within my organisation, and I was ruminating on why the %$#@ is change so difficult even when everyone agrees the need for it is self evident?
As someone with an interest in safety I started to think about why do safety critical organisations also fail to change in response to events that, with the benefit of hindsight, should have triggered immediate and robust response?
If the data and the logical conclusions that we can draw from them are not driving our decisions then what is? It seems that there might be something going on here other than detached and passionless logic when people get together and act in a group.
The status quo has a thousand fathers, change has none
When in doubt on issues political and managerial I find that the original political scientist usually has something worthwhile to say, and this case was no exception:
“And one should bear in mind that there is nothing more difficult to execute, nor more dubious of success, nor more dangerous to administer than to introduce a new order to things; for he who introduces it has all those who profit from the old order as his enemies; and he has only lukewarm allies in all those who might profit from the new. This lukewarmness partly stems from fear of their adversaries, who have the law (management) on their side, and partly from the skepticism of men, who do not truly believe in new things unless they have personal experience in them.”
The Prince 1513
Of course an obvious consequence of such unwillingness is the tendency of organisations (especially large ones) to fall into a reinforcing sense of complacency where belief is substituted for knowledge. In turn these belief structures reinforce the bias to inaction that Machiavelli points to.
And as Machiavelli points out when people’s jobs, careers or reputations are involved this inertia/complacency loop can become a deep rooted and intractable problem, at least until the day after the catastrophy.
For me this is a critical point. Time and time again accident investigations have identified precursor ‘near miss’ events that, were they recognised and acted upon, could have prevented the final accident. The problem it seems is not a lack of data but a lack of understanding.
Of course to be effective a safety management system must be able to both perceive impending threats and then respond to them. Without such perception there can be no response. We must logically conclude therefore that:
The failure of safety management systems are usually not in being un-informed or ignorant but rather in failing to comprehend and act to change.
Complacency shaping factors
So adding to Machiavelli’s point about the organisationa bias against change, I’d also add some organisational factors that have traditionally compounded the complacency side of this vicious loop:
- a reliance on past success,
- the arrogance of expertise or incumbency,
- a slide from a ‘can do’ to a ‘can always’ attitude,
- a belief in the infallibility of technology, of process, of tradition,
- falling into the inductive proof trap (as both Hume and Popper have pointed out we can never prove a theory only disprove it), and
- that old favourite group-think.
Management responses to change inertia and cmplacency
What we can do in management is be mindful of this tendency and put in place mechanisms to reduce the bias for inaction. Such countermeasures might include an organisational focus upon:
- organisational structures to enhance accountability and responsibility,
- improving the quality of data upon which discussion is based,
- inculcating and maintaining the safety culture itself, and
- fostering a sense of ‘creeping unease’ to address the risk from “unknown, unknown’s”.
Finally to address Machiavelli’s original point about self interest, all the above need to be coupled with a clear acknowledegment (and demonstration of willingness) by upper management that it may be necessary to transform quickly and radically.
As James Reason has pointed out regarding his ‘swiss cheese’ model of human error the management or ‘organisational layer’ is also the most distantly linked to a direct unsafe events and therefore the highest hanging fruit as far as safety management goes. Developing such a set of countermeasures as the core of any safety management system within an organisation may go some way towards establishing objective criteria for the organisation layer of a safety culture.