When Things Go Wrong Let’s Do More of the Same


imageI always find it fascinating when there is an increase in safety statistics or incidents that the call is always about greater vigilance, more checklists, more policing and more effort. What an amazing industry that still doesn’t know why things go wrong.

Rather than question the fundamental flaws in safety ideology or safety orthodoxy or apply a bit of imagination, the assumption is that what has been normalized is effective, its just a glitch. This is despite the fact that something went wrong. It often comes back to blame the individual or blame the system. Ah that’s it, we need to spend more money on a systems review and develop better systems. This is to follow the last three reviews that had the same finding. Clever!

Unfortunately, orthodox safety inquiry assumptions are never questioned, we select the same old mindset to undertake the same old investigation, under the same assumptions, under the same ideological thinking so that nothing in safety orthodoxy will be questioned.

The best way to keep the safety status quo is to get a regulator (or ex-regulator) to undertake an investigation to find out what they already know. This is done using the same STEM tools that have been used over the past 20 years. In this way we can get the same outcome that was achieved last time and run a ‘safety blitz’ across the industry under the assumption that wrong programming or failure in systems is the problem. STEM thinking comes all neatly packaged with no questioning of flawed anthropology, flawed thinking about personhood, no knowledge of human unconsciousness, no understanding of social influence or the nature of human embodied decision making. In this way the enquiry can always come out with the problem being the worker typically in the style of the Danny Cheney tragedy (https://safetyrisk.net/theres-a-hole-in-your-investigation/ ).

Usually the outcome from an orthodox safety investigation is that someone was either ‘not careful’ or ‘complacent’ or perhaps that ‘human error’ was a cause. In the case of Danny Cheney apparently he wanted to suicide that day!

In this way the inquiry thinks it has found something when all of this is an attribution and means nothing. This is all assisted by the behaviourist-cognitvist assumptions of James Reason who established that decisions are made by ‘violations’ and ‘omissions’ (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/ ).

One thing Safety does know is that there couldn’t be a fundamental flaw in the assumptions of safety thinking or systems. There couldn’t be a flaw in the assumptions of the behaviourist-cognitivist investigation. There couldn’t be any problem with STEM assumptions of personhood or understanding of human decision-making. All of these must remain unquestioned. It couldn’t be that there are other worldviews that could offer astounding insight into the way things go wrong. There is no other worldview (https://safetyrisk.net/can-there-be-other-valid-worldviews-than-safety/) there are only ‘known knowns’ and never ‘unknown unknowns’.

This is how Safety makes sure that things stay the same.

Dr Rob Long

Dr Rob Long

Expert in Social Psychology, Principal & Trainer at Human Dymensions
Dr Rob Long
PhD., MEd., MOH., BEd., BTh., Dip T., Dip Min., Cert IV TAA, MRMIA Rob is the founder of Human Dymensions and has extensive experience, qualifications and expertise across a range of sectors including government, education, corporate, industry and community sectors over 30 years. Rob has worked at all levels of the education and training sector including serving on various post graduate executive, post graduate supervision, post graduate course design and implementation programs.

10 Replies to “When Things Go Wrong Let’s Do More of the Same”

  1. Technological progress has merely provided us with more efficient means for going backwards – Aldous Huxley

    Only a fool would dismiss the literary influence of authors and poets such as Huxley, Orwell, Wordsworth, Auden, Montaigne, Swift, Wells, Melville, Maupassant and many others.

  2. Thanks Rob, you are always questioning my many underlying beliefs.

    The “fix the system” is directly from Deming who suggests 85% of faults lie with systems, processes, structures and practices in an organisation and only 15% is down to operator skill and it is the responsibility of management to fix this.

    Just a minor point, a great quote but Einstein never said those words: https://www.history.com/news/here-are-6-things-albert-einstein-never-said

    1. Hi Craig, I find it interesting how the industry remains stuck in antiquated ideas put forward by Heinrich, Deming, Reason etc. The moment someone in safety gets something into the mix like the matrix or whatever, it gets sacralised. Of course, the rationalism of Deming assumes a range of unquestioned assumptions in knowledge, particularly STEM assumptions. Even the word ‘system’ is loaded and not questioned. BTW, I didn’t attribute the saying in the text, Dave threw that in. It is one of the interesting things in our modern society to validate an aphorism by attaching it to a famous person. Most of the aphorisms on Linkedin and other social media are like this and typically few question that too. It’s how propaganda gets so much airtime these days.

      1. When Deming presented in NZ back in 1984 many (well hundreds) of NZ’s top CEOs were present. The messages from the visit were pronounced (well certainly in the manufacturing industries I was involved with back then). I believe that legacy still continues somewhat – see NZ companies like Air NZ or Xero.
        Maybe the assumptions weren’t questioned (and still aren’t) but his messages of having a commitment to continuous improvement, building quality in (don’t inspect quality in), drive our fear, ditch slogans etc are such powerful messages, these principles can drive companies to new levels of performance.
        I don’t readily see these principles in the safety industry. Am I blind?
        Is Zero Harm the new mantra (principle) that usurps everything else?

        1. Craig, despite the fact that Deming may have said some good things his overall philosophy was tied to technique (efficiency – Ellul) and the assumptions of STEM. We see this everywhere in safety where good things pop up but regardless of rhetoric there is no movement in ideology so there is rarely any movement over time just momentary window dressing. Have a look at any incident investigation methodology and nothing is moving except money into bank accounts, but no shift in ideology.

          You are right, none of these principles espoused by Deming are in the safety space, when the rule is compliance and zero there can be no critical thinking or vision. Sure there are plenty of vision statements but again rhetoric, no questioning of STEM assumptions, mechanistic or behaviourist assumptions, full steam ahead and shift the deck chairs.

          1. The latest responses to the spate of fatalities throughout the Queensland mining sector include more training and industrial manslaughter legislation.

            The training will inevitably be rote learning or indoctrination delivered by a certified zero harm zombie.

            Industrial manslaughter will be most interesting when caveats such as a year and a day arise with deaths from industrial diseases such as black lung and silicosis.

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