Safety as Avoidance
The language of ‘error’ is unhelpful when it comes to understanding human judgment and decision making. One can assemble pyramids of ‘unsafe acts’ and ‘unsafe conditions’, fault trees of ‘active and latent failures’, maps of ‘violations’, ‘slips’ and ‘missed barriers’, sets of hazard conditions and, classify ‘omissions’, ‘organisational factors’ and ‘system failures’ and still not have a clue about the fundamentals of motivation or how social arrangements affect decision making. Most of the noise assembled about ‘human error’ is driven by systemic and mechanistic efforts in trying to understand the social psychology of decision making from a flawed assumption: that humans are behaviorist cogs in a system. It’s like trying to understand fruit with a geological tool.
When I look at the legacy of human error discourse in the safety sector all I see is the continual perpetuation of a Calvinist projection of original sin. One only has to look at the popular Bradley Curve to realize that its assumption is that humans are born into ‘unsafety’. The Bradley Curve labels this condition ‘natural instincts’ and humans must be saved from themselves. The Bradley Curve is one of the most absurd models in safety. It is a religious projection of unsafety as a ‘natural state’ without interventions of others. Here is a model (https://vimeo.com/124273239) that then justifies the interference in the freedom of others, in the name of saving people from themselves.
In safety we assume that an error made by someone in an organization is a consequence of miscalculation, incompetence, bad luck, bad choice, stupidity or impotence in the face of some challenge. It carries with it the aura of failure and original sinfulness. No wonder that safety is so seduced by the language of immortality and infallibility – zero. This comes from it’s religious like avoidance of embracing error. Error must be suppressed and repudiated.
Error avoidance and error denial is the ‘way of being’ now for safety. Reinforced by an anthropology which rewards only the right answers and good grades. When there is any error (miscalculation) or falling short of expectations, one must be crucified. This is the experience of most safety people I know in tier 1 organisations. Any error must incur a Spanish inquisition. The language and symbol of zero amplifies the power of error and there must either be a sacrificial lamb or a purge of cleanliness. When safety has lost control, there must be blame.
Unfortunately, error avoidance directly contradicts the idea that human development advances by taking risks. Error avoidance is also fallibility suppression. So, everyone walks around delicately trying to not step into the black hole of error yet we believe that Science and discovery are all about a willingness to embrace error. If humans held to the security of the status quo, there would be no evolution or advancement. There is no innovation or learning without risk.
Acknowledging the likelihood of error before it occurs makes it easier to abandon the kind of rhetoric, symbols and language that anticipates no error. The belief in no error (omniscience, omnipotence, immortality) then requires a new language to hide error, rather than learning from it. Once the language has changed it is then easy to set meaningless goals.
Embracing error means one must acknowledge the life of uncertainty. This doesn’t mean that one wishes others to be harmed. Binary thinking is immature thinking that denies complexity and only sees the world in black and white. Embracing error is supported by the logic of learning, avoidance is the illogic trajectory of anti-learning. The binary mindset only hears the avoidance of responsibility and accountability. The argument goes, that if people are not threatened with punishment and sever consequences, they will not be motivated to avoid error. Here we are back to the assumption of original sin. The language of error doesn’t assume anyone does good but in its binary cocoon can only think of avoiding error.
I remember being staggered in 1976 watching the Olympics and Nadia Comaneci receive a perfect score in gymnastics, 10. Strange that in all of the advancements in gymnastics since then (by score) no one has since been perfect. In one sense it is good that Don Bradman fell short of the perfect 100. What happens to someone when you tell them they are perfect, when one reaches the pinnacle of no error? What happens the next day to the one declared to be inerrant? What happens when anyone deviates from a desired goal? What happens when you or I fall short of any desired performance? What is the best human thing to do when someone falls short of expectations?
To be error embracing doesn’t mean encouraging gratuitous error (the binary seduction). Error embracing is a mindset of non-avoidance but not fatalism. Weick called it a disposition of ‘preoccupation with failure’, Hudson calls it ‘chronic unease’, I call this ‘entertaining doubt’. The language of perfection only primes blindness in perception, thereby increasing risk.
The anticipation of no error (zero) creates a delusionary disposition that expects no surprises and punishes learning. A mindset of error avoidance creates a preoccupation with barriers, holes in cheese and fear of surprise. Denial means when the surprise comes, one will be more fragile and less resilient in the mismanagement of it.
If you want to read more, the best book I know on the topic is by Bauer and Harteis (2012) ‘Human fallibility, The Ambiguity of Errors for Work and Learning’. Springer. Germany.
Dr Rob Long
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