
On January 16, 2003, NASA personnel reviewed footage from
the liftoff of the space shuttle Columbia where they noticed a large piece of
foam falling off the external tank and hitting the left wing of the shuttle.
This piece of foam was one of the largest pieces of foam to strike the shuttle
during launch, but foam coming off during launch was a relatively normal
occurrence, and had since undergone a risk assessment process and been
determined to not be a safety issue. So what harm could a bigger piece of the same foam do?
Obviously, in both cases a little more was just enough to
cause disaster in both cases, resulting in a total loss of the crews and the
shuttles. Both cases have had very public investigations, sometimes with
conflicting factors identified (some say amoral managers, some say
organizational causes, some safety normalization of deviance). One common theme
though is the inability to see how sometimes doing the “same” thing can lead to
different results.
The title for this post comes from the title of a 1972 article where the author makes the case that the systems are often completely different
than the sum of their parts. This makes the typical approaches of science,
i.e., reductionism, invalid. You can’t explain the behavior of the whole by
taking it apart like a clock and figuring out how each piece works
individually. When you put the pieces of a complex system together you get
behavior that is only understandable and explainable by understanding how the
pieces work in concert. You can understand how one part works, but when you add
another piece you have changed things. More is different.
Another way to explain this is to understand the concept of
phase transitions.
Phase transitions are essentially how matter changes states, such as from solid
to liquid to gas to plasma and back again. So let’s take the example of a piece
of ice kept at a temperature of -1˚ C (30˚ F). It is a solid material. Now add
one degree. Now the temperature is -0˚ C (32˚ F). Not much has changed. We
still have ice. Lets add one more degree. After all, we added one before and
nothing changed, so adding one more shouldn’t have any significant effect,
right? Now we’re at 1˚ C (34˚ F), and what do we have? Water. We’ve
significantly changed what we’re looking at simply by adding more of the same.
We added more and we got something different.
Obviously this is a bit of a simplistic example, but it
illustrates the power of adding more. Sometimes this is called drift or normalization of deviance. These processes should be very troubling to us as safety professionals. If more
is different, we must contend with the fact that perhaps the seeds of the next
disaster in our organization will not be found on even the most robust hazard
and risk assessment (in the cases above, NASA conducted rigorous risk
assessments for both shuttle launches and identified the risks as acceptable in
both cases). Even management of change processes often won’t catch this because
often adding more is simply adding more of the same, so there is no perceivable
change.
The causes of the next disaster could be found in the normal,
boring, messy details of everyday work. It could be in us applying the same
methods we’ve always applied to get jobs done, using the same old tools,
working with the same people. The same things that have been successful in the
past could cause failure this time. Safety professionals often don’t have the
tools necessary to identify these things, because we often are only focused on
finding negatives – such as deviations, hazards, risks, etc. But applying more
of the same can’t be seen by only focusing on negatives… with one
exception. Unfortunately, the only tool
in the traditional safety person’s arsenal that might identify this problem is
the accident investigation (and even that is a bit of a stretch if we’re
honest). But do we really only want to wait to find the next major event in our
organization until after it happens?
We obviously need a better way forward if we really want to
make progress in preventing the serious injuries and fatalities that have
become so difficult to reduce for so long. Interestingly, the one tool in the
traditional safety professional’s toolbox that can help us identify the
tinderbox that may be hiding beneath the surface of adding more of the same
(i.e. normal work), investigation, hints at a potential way forward – learning. Some things to consider for
your organization:
- How is safety defined in your organization? If it’s defined as the absence of accidents, you may have some work to do. Every job you complete without an accident means that it was a safe job, regardless of how it was done. This limits your opportunity to learn because there’s nothing to learn if everything worked out. Instead start asking questions about what it takes to do that job safely tomorrow and the next day.
- When do we learn? If safety is not just the absence of accidents, this opens up all sorts of opportunities to learn that weren’t there before. This means that jobs can be done successfully (by some definition) but still be “unsafe”. Essentially this means that every job is a learning opportunity, regardless of the outcome. Do you have structures in place that allow you and the leadership to learn about how work is actually performed? Or do you just assume that everything happens according to plan? Spoiler Alert – Nothing happens according to plan. So start finding ways to learn from everyday work.
- How are people who bring up conflicting views treated? It is remarkably difficult for insiders to identify a problem of adding more of the same. For this reason when you have people in your organization who bring up conflicting views (we have them in every organization), those people must not be treated like the proverbial “boy who cried wolf”. Yes, these people can be frustrating, but if you chastise people for bringing up conflicting viewpoints you can’t be surprised when you stop getting conflicting viewpoints brought to your attention. This will kill your ability to identify the risk of more of the same.
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