In a recent conversation with Todd Conklin on his Pre-Accident Investigation Podcast we discussed how stability may not be so good for an organization. This may seem odd to safety practitioners because it may seem counterintuitive to think that stability is bad for safety. Let’s dig a bit deeper and start with a common lexicon for the discussion:
Stability: “the quality or state of something that is not easily changed or likely to change; the quality or state of something that is not easily moved”
In fact, a third definition may give us more insights into why stability may not be all that helpful for safety; “the property of a body that causes it when disturbed from a condition of equilibrium or steady motion to develop forces or moments that restore the original condition”
So, if we look at the definitions of safety, particularly the third and most descriptive one, it would appear that if we seek stability in safety and within our organizations we are really after something that will cause disturbances to result in a return to the original condition. But what if the original condition was wrong to start out with? What if something that caused the disturbance in the first place was because of something that needed to change?
As safety practitioners it may seem like a generally accepted practice to sort of seek stability with such things as low injury rates. And if we can get to zero we become heroes (not intended as an example of a good safety slogan). How about the follow areas of stability; do these sound desirable?
Zero Rule Violations
These may sound great and from a lagging indicator perspective it may seem like success. Unfortunately, zero occurrences in certain areas may lead to zero learning about key organizational properties and conditions. Stability and zero in the areas of rule violations and reporting, error occurrences and reporting, and near-misses and near-miss reporting could mean that the organization has stopped learning, stopped adapting and evolving, and halted forward progress.
Here are a few mechanical examples to illustrate the challenges with stability:
When you first get into a car to drive to work or anywhere else, what happens if you simply seek stability? Would the car even move? You have to move from stability to instability momentarily to get the vehicle moving forward, right? Additionally, when you get up to a steady speed, are you really stable or are you using performance variability to make micro-adjustments as you drive?
Aircraft wings are often designed to be inherently stable, depending on the mission. However, some, like this Harrier jet pictured below, are designed to be less stable. If you look at the wings you will notice something called negative dihedral (the wings slope downward), which makes the jet more maneuverable.
This isn't a discourse on physics, though, but these are some illustrative examples, and this isn’t to say we want organizations to be like tactical jets, which require a great deal of control to keep the instability from getting out of control. However, from a conceptual standpoint, don’t organizations need maneuverability to make progress over time? Don’t they need to maneuver the competitive landscape of the marketplace in order to determine product/market fit, what their customers and clients need and desire, and how to meet those market demands? After all, we must remember that the founders of organizations most likely did not create their businesses with the mission statement “To remain safe.” They founded their organizations to deliver some type of value to a market of clients and customers. That being said, some of the most successful organizations will understand how to balance safety and productivity and make decisions in favor of safety over production in instances when major injury or fatality risks are at stake. In fact, safety may be referred to as a “a dynamic non-event.” 1
I think what we really need in organizations is a balance of transient stability and an emphasis on adaptation. In fact some, like Nassim Taleb in his book Antifragile: Things that Gain from Disorder, might argue that when some organizations (the anti-fragile kind) are exposed to volatility they adapt and actually become stronger. 2 If we choose not to adapt and we choose to overemphasize stability here is what we may get:
Zero Rule Violations-What happens if employees are given the wrong tools for the job? They may violate rules and adapt the tool for the purpose to get work done and perhaps hide the fact that they are doing it. They may also introduce hazards in the process as they simultaneously create success. However, they may also be actively creating safety in the process, but you may never know this if you simply seek stability. If authoritarian approaches to compliance are used (where workers are punished for non-compliance) then perhaps workers will comply with rules and will use the same inadequate or deficient tools, perhaps resulting in inefficiencies and maybe even injuries.
Zero Error Tolerance-What if you discourage errors with a zero error tolerance policy? How will you learn? Sure we can learn from success, but in many cases we learn success by making small errors along the way as we adapt. Rather than discouraging all errors, organizations should seek to manage errors, and detect and correct them early before they escalate. I do not believe that zero error is possible in any organization and I would be concerned of under-reporting and hence under-learning from error events. Sometimes errors can lead to adapted and improved procedures.
Zero Near-Misses-Of course we never want anyone to get hurt and we don’t want equipment damaged, but in many cases crews and teams can do all things correctly (from their perspective and given their planning tools and the operational context at the time they planned and executed their work) and near-misses may still occur. Near-misses should be looked at as a benefit to be harnessed by the organization. On the negative side, maybe some equipment was damaged, but on the positive side, something happened to prevent injury to a person. Learn from these events. Try to learn what caused the hazard to occur. How were the conditions unfolding that enabled workers to escape harm? How could this happen again and what could possibly be done to attempt to prevent this type of event from occurring in the same system or a different system within the organization? These may not be perfect questions and they may not have perfect answers, but if you seek a zero near-miss culture you may be more likely to not receive these types of reports and this could inhibit learning.
Shouldn't safety and operations practitioners be striving to adapt and improve systems and organizations? In the process you may be able to help the most important part of your system (the workers) improve their performance. In order to do these things a system approach must be used and all people affected should be talking. We can’t have out of control adaptability, where workers simply make their own procedures every time a job must get done, because quality, efficiency, and safety could be degraded. However, we can encourage an adaptability mindset and climate, and encourage reporting and dialogue around adaptability and in the process help our organizations improve safety and operations performance. In the process this mindest, strategy, and dialogue may help organizations as a whole adapt and remain competitive in the marketplace. This may be viewed as an example of safety as a mission-enabler!
Regarding crew and organizational adaptability, I am currently in the process of finalizing my draft version of V-Speed’s Crew Resource Management (CRM) Implementation Guide, which includes CRM operational principles and a section that specifically discusses adaptability. If you want to learn more about this CRM Implementation Guide you may find more details (including pre-order information) here.
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1. Hollnagel, Erik. "The Issues." Safety-I and Safety-II: The Past and Future of Safety Management. Burlington: Ashgate, 2014. 5. Print.
2. Taleb, Nassim Nicholas. Antifragile: Things That Gain from Disorder. New York: Random House, 2012. Print.