Investigations and The Simplicity Attraction
In the face of so much noise, competing values, diversity and confusion stands the myth of Occam’s Razor, a wish that when faced with multiple factors, humans will always opt for the shortest simplest route. The 14th Century philosopher/theologian William of Occam stated ‘plurality should not be assumed without necessity’. The principle since then has become known as Occam’s Razor’.
Standing in opposition to Occam’s Razor is the challenge of Wicked Problems. Wicked Problems (https://hbr.org/2008/05/strategy-as-a-wicked-problem ) are beyond complex, beyond paradox and are intractable problems that cannot be solved. Indeed, the more one tries to solve a Wicked Problem (http://www.enablingchange.com.au/wickedproblems.pdf ) the worse it gets indeed, the problem amplifies. Wicked problems can only be ‘tackled’ they cannot be ‘tamed’.
Risk is such a problem, fallibility is such a problem. The more one tries to control risk, the more one diminishes learning. The more one endeavours to take away fallibility the more fallible one becomes. Taleb discusses this in his book Antifragility (http://en.kgt.bme.hu/files//BMEGT30M400/Taleb_Antifragile__2012.pdf ). Amalberti also discusses the impossibility of ultra-safety (https://pubmed.ncbi.nlm.nih.gov/15867408/)
No-one likes to be overwhelmed by uncertainty which is why we develop rituals (https://safetyrisk.net/practice-repetition-habit-routine-ritual-and-decision-making-in-risk/ ) to give the ‘feeling’ of certainty, when there is none. There’s nothing like parading the meme of KISS (Keep it Simple Stupid) to a safety industry that demonizes complexity. It’s simple: here’s the rule, obey the rule, police the offender. Sadly, for the simpleton, tackling risk is not simple.
The trouble is that when we construct investigations, safety training and inductions on this simplistic stuff we create an expectation that shapes how risk is envisioned (https://www.humandymensions.com/product/envisioning-risk-seeing-vision-and-meaning-in-risk/ ) and, through confirmation bias, end up with dangerous forms of safety naivety. Any claim that risk and safety can be made simple is dangerous. Any claim that leadership in risk is simple is dangerous and delusional. Such courses are currently being advertised with peak risk and safety associations.
Human persons are not behaviourist objects. You don’t develop understanding of personhood by consulting an engineer. Similarly, when things go wrong you won’t find much help in a mechanistic formula as an investigation methodology. You may wish for life and being to not be a Wicked Problem but that doesn’t make reality disappear. Indeed, when one holds to the KISS principle what happens is the construction of false hypotheses to prove assumptions that are not real. Memes and rituals may be attractive but they are not helpful. The reason why the courts often come up in investigations with insufficient evidence for a declared cause is because there is no root cause (https://vimeo.com/167228715 ). Such language of ‘root cause’ is just as dangerous as KISS. There is no great virtue in false consciousness (https://safetyrisk.net/false-consciousness-and-perception-in-risk-and-safety/).
One of the worst things one can do in investigation is to bring to the table nonsense memes like ‘safety is a choice you make’, ‘all accidents are preventable’, KISS or root cause.
Looking for neat and tidy outcomes and cause in any safety activity is not just nonsense but creates dangerous construction of explanations that are simply not true. If persons are involved and fallible systems be assured, expecting messiness is your best ally. Similarly, your investigations methodology should be the same.
One of the things we do in the SEEK Program is explore the many critical elements excluded from the most popular investigations programs (https://safetyrisk.net/the-seek-investigations-donut/ ). This includes methods like iCam that have somehow been normalized into some kind of industry standard. The reason why programs such as these are so attractive is again a wish for certainty, authority and control. This is the quest for the investigations sausage, and it tastes like it.