The Paradox of “Lifesaving Rules”
Guest Post by Danny Fay
As part of my assignment in Unit 5 of the Diploma in Social Psychology of Risk, I am evaluating the paradox of “Lifesaving Rules” against the five principles of collective mindfulness as developed by Professor Karl Weick.
Collective mindfulness is an acceptance of equivocality; understanding that all possible outcomes cannot be known and that the environment is continually changing. This creates a mindset of active wariness and attentiveness through continual questioning and revision of previously held assumptions, plans, and expectations.
Weick’s philosophy of organising shows how mining industries inadvertently inhibit their capacity to understand and manage risk through tightly coupled systems (rules), based on what is known and not what is imagined or unforeseen. Whereas loosely coupled systems can provide the conditions of adaptability, flexibility and stability.
The ability to manage the unexpected is mindful management; no matter what you do, there is always a trade-off or by-product. Understanding that all possible outcomes cannot be known and that the environment is continually changing creates a mindset of entertaining doubt and attentiveness through continual inquiry.
Mine sites develop precautionary norms that are set out as “Lifesaving Rules”. These culturally accepted principles about the industry and its risks are established as non-negotiable with regards to choosing to follow the rules; breaches often result in a disciplinary outcome. This suggests a belief that organising by creating “Lifesaving Rules” amounts to certainty and order.
As I am learning through Social Psychology of High Reliability Organising there is ambiguity around this certainty creating a paradox. The trade-off for micromanaging through rigid rules and procedures, in order to manage risk, only increases susceptibility to failure and decreases capacity to understand and manage risk.
There is also a discourse in the language of ‘Lifesaving Rules’. This is the hero-myth in traditional leadership and management theory and the delusion of safety, where there is a belief that you can control what is feared. However; in the words of Rob Long, you cannot predict it, cannot control it, and definitely cannot measure it.
Using the 5 principles of Collective Mindfulness developed by Carl Weick I will critique “Lifesaving Rules” and demonstrate how they cannot reduce equivocality or manage risk.
Weick has identified 3 common principals that make up the category of anticipation. Anticipation involves identifying and halting weak signals of failure before they are able to become damaging events.
The First principal Preoccupation with failure is an attitude that allows small failures to be identified and managed before they become larger, damaging failures. These failures are not seen as isolated events, rather as a sign that something may be wrong with the entire system and could result in widespread consequences.
“Lifesaving Rules” discourage reporting near misses, as the outcome is often blame and punishment which restricts learning opportunities. The rules are only focused on catastrophic or fatal risks and preclude small failures.
The capacity to anticipate unexpected problems involves identifying and halting weak signals of failure before they are able to become damaging events. This is not the prevention of the unexpected, but the ability to act immediately in the initial stages of an unexpected occurrence when there is only a hint that something might be wrong.
Creating a culture able to learn from itself, allows small failures to be noticed, as they are a learning opportunity that allows people to make more informed decisions in the future.
The Second principal Reluctance to simplify is to see the world as complex, unstable, unknowable and unpredictable. It takes a complex system to make sense of a complex environment. Organisations that are reluctant to simplify take nothing for granted, question their assumptions, and introduce complexity and create differing worldviews during decision-making events allowing for a richer and more varied picture of the situation, the potential outcomes and consequences.
Following the rules does not consider ongoing mindfulness of the workforce, as they direct workers to follow simple rules for them to be safe.
As sharing of information is by nature social, having conversations before the work starts where scepticism and differing worldviews are encouraged allows for a richer and more varied picture of the situation and potential outcomes.
The Third principal Sensitive to Operations is being attentive to where the work gets done. Face-to face communication between management and operators allows for the rich and timely exchange of key information and also builds the trust that is required to develop a comprehensive ‘big picture’ of the operation.
Lifesaving Rules” do not promote situational awareness as they inhibit people from speaking up and questioning, as well as structurally making it harder to lead with a big fence around them. As an artefact, “Lifesaving Rules” symbolise a lack of sensitivity to operations by being authoritative to follow the rules and not question. Focusing on authoritarian approaches to safety are tools for power and control, which devalues dialogue, trust and respect.
To build trust managers should practice “Humble Inquiry’ to understand the nuances of operations, and help neutralise threats to sensitivity.
Weick has identified 2 common principals that make up the category of containment. Containment focuses on how a damaging event is handled after it has occurred and improvising workarounds to keep functioning.
The Fourth principal Resilience is about bouncing back from unexpected change, absorbing and learning from the changes and moving forward.
The rigidly of “Lifesaving Rules” confines the trajectory and reduces flexibility of the people dealing with an unexpected event. You cannot manage the unexpected through prediction alone and you cannot be resilient in a tightly coupled system based on rules.
Improvisation plays a large role in maintaining an organisations capacity for resilience. When people have an expanded repertoire of highly developed skills and experiences, they are able to recombine them into novel combinations to apply to unexpected events.
The Fifth principal Deference to Expertise is a social rather than individual concept. Experience and hierarchical rank in an organisation does not necessarily equal expertise. In an organisation that defers to expertise, the hierarchy is loosened, allowing employees in the best position to tackle the problem and make the required decision.
Through studying Carl Weick’s book on Managing the Unexpected and seeing (understanding) that expertise is relational, creating “Lifesaving Rules” based on decisions already made, are not relational. They have no respect to diversity or experience of the workforce conducting the work or dealing with a damaging event. This precludes using local expertise to improvise workarounds by deferring to authorities rather than experts.
By reducing the reliance on rigid and static systems and creating a flexible decision structure, lets decision-making migrate to the people who have the most expertise to deal with the problems.
In conclusion, looking through the lens of this research, it is my view that “Lifesaving Rules” cannot manage the unexpected, as it is overly simplistic to believe people will stop doing something life threatening because there is a rule in place. Each new story of a catastrophic or fatal incident on a mine site confirms this view. When organisations fail to practice collective mindfulness, they are unable to understand and manage risk and will be prone to catastrophic unexpected events.
Is it better for a man to have chosen evil than to have good imposed upon him? – Anthony Burgess (A Clockwork Orange)
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I have a question about the concept of “weak signals”. What is the difference between “weak signals” and the bottom line of the Heinrich pyramid? The quest for Zero started with an effort to identify weak signals, and lead to a culture of absolutes. The theory became “catch all the small incidents to prevent the large ones”. One of the problems with this view is the focus on the “trivial many” vs. the “critical few”. How then do you focus on weak signals, yet avoid the trap of spending all your energy on the “trivial many”? (This would also relate to the concept of “drift to failure”. How do you differentiate between drifting to failure and day to day “normal” issues that only needs minimal attention?
This relates to the difference between operational risk or material risk and general risk. Most safety crusaders become embroiled in pettifogging and hard hat safety, which is exacerbated by accident theory and the black box psychology of behaviour based safety.
Meanwhile, weak signals pertaining to process safety and operational or material risks are ignored at the expense of implementing disciplinary action for not maintaining three points of contact on a stairwell or walking through the office without the lid on a cup of coffee, viz Deepwater Horizon.
Hi Bernard, That is a sweeping statement that sounds good at first … but is it really valid? For example it implies that you think that its better for someone to choose rape or murder (evil) rather than to have ordinary decency imposed on them. What trajectory does such a statement lead to?
James, the assumptions of the statement suppose that the value of freedom/choice overrides all. I find it somewhat similar to the provocation by Luther to ‘sin all the more so that grace will abound’. I think the context of Clockwork Orange is important. Within a dystopian world like Handmaids Tale what is often articulated as ‘good’ is at the expense of humanising people. I think T.S Elliot does it well, but any of the authors that prophecy about dystopias do this. Subversion becomes the only rebellion when the state has become authorised terrorism (eg. Nazis). This was also the message of Orwell (who I know Bernard follows). When Power corrupts absolutely, it is often the artists and poets that speak truth to such power.
Somewhere along the line we need to understand some fundamentals of ethics. eg. Can we coerce another in safety for their own ‘good’ and remain moral? When can bullying another in the name of ‘saving lives’ be justified? It has now come to this in safety that injury is associated with a choice to be unsafe. That’s the outcome of the silly mantra ‘safety is a choice you make’. I think Safety doesn’t do very well in understanding the politics of power and the power of politics. and so if ‘all accidents are preventable’ and the goal is ‘zero’, how much more can I justify cruelty to others in the name of ‘good’. All forms of eugenics follow such a discourse.
I think in the context of A Clockwork Orange where humans have been made machines the statement make sense. I can think of countless acts of imperialism in history where terror was administered in the name of ‘good’. Indeed, most acts of colonization of indigenous peoples was undertaken in the name of a religious ‘good’ of ‘saving lives’ while the merchants raped and plundered the ‘goods’ of the country.
Where does this leave us? I think Safety has a long way to go before it understands its own ethic or develops some sense of its own politik. That’s certainly not going to happen under the current regime of regulation as naturally ‘good’ and a closed curriculum that deifies dumb down.
A good overview Danny. Many bring in policies and language without really considering the discourse and associated trade offs. Then, a few years down the track wonder why they have a brutalising culture that cycles back into the very things they want to manage. Usually there is some catastrophe and they do it all over again after sackings etc. Then some bright spark comes up with a new policy or another form of zero and the lemmings follow.
Interesting Wynand, the idea of ‘weak signals’ is not the language of Heinrich and associates but seems a way of devotees of brutalism justifying the assumptions of the pyramid. Similarly, the idea of ‘drifting to failure’ assumes some sense of having ‘made it’ to somewhere. I just get astounded at the language of this sector and how it drives a discourse focused on systems, objects, hazards, policing and regulation and so rarely talks about fallible humans and how we should ‘tackle’ risk.
Dear James,
It was not a statement it was a question posed by the late Anthony Burgess FRSL and literary critic for The Spectator, The Guardian and The Observer and author of A Clockwork Orange, a book that is well worth reading, along with Brave New World, Animal Farm, 1984, Catcher in the Rye, anything by Ernest Hemingway. I would also recommend reading The Two Cultures by CP Snow, the former president of The Royal Society.
Thanks Rob, I like your idea of contrasting safety as “having made it” to “being a journey” (implied in the comment). I think I get a bit of better understanding the concepts, although it remains difficult to articulate to someone else. I understand that you are saying there should be a constant focus towards “drifting towards safer” without the implication of some that this should relate to “always be in the moment” and “constant awareness”. (If I may “drift” off topic a bit – advocates of “always be aware” are never able to complete the sentence with “of…”. This means the outcome is always “you should have been aware of xyz, without taking into account all the things you were aware of at the point in case.)
Wynand, I don’t like the language of ‘drift’ as it conjures up some unconscious sense of loss against some conscious sense of gain, much prefer the language of ’emergence’ and ‘enactment’.