"The Failure of Foresight"

Last month, I reviewed one of the classic books in safety science, The Logic of Failure by Dietrich Dörner.  Dörner suggested that "Failure does not strike like a bolt from the blue; it develops gradually according to its own logic."  He went on to say, "Catastrophes seem to hit suddenly, but in reality the way has been prepared for them.  Unperceived forces gradually eat away at the supports necessary for favorable development until the system is finally unable to resist any longer and collapses."  

Dörner was referring to the concept of "incubation periods" which was first introduced by Barry Turner in his classic book, Man-Made Disasters.  The book was first published in 1978 with the working sub-title "The Failure of Foresight."  Turner later published a second edition with Nick Pidgeon in 1997 (actually, Turner died before completing the second edition and Pidgeon completed the revision for him).  Unfortunately, both editions are incredibly difficult to find - I think I found a copy available on Amazon for around $250.  Rather than paying that much for an old book, I once again headed to my local public library and was able to read a copy of the first edition.  For those of you who aren't so lucky, Turner published a summary of his findings and recommendations in an article published the Administrative Science Quarterly ("The Organizational and Interorganizational Development of Disasters").

Turner conducted a qualitative review of 84 British accident inquiry reports spanning a 10-year period.  While the accidents all occurred more than 50 years ago, Turner's findings still have relevance for us today.  One of his most important findings was that accidents in large-scale technological systems are almost never chance events.  Instead, there are almost always preconditions to any major system failure, some of which may be present for years prior to the actual event.  Turner calls this period the "incubation period."  He writes, "in most cases of undesirable or catastrophic events, some forewarning is available potentially, and some avoiding action is possible notionally."  He goes on to describe that "a failure of foresight may therefore be regarded as the collapse of precautions that hitherto been regarded culturally as adequate."  Turner then describes a sequence of events associated with this "failure of foresight" which involves the "incubation period", the triggering event itself (which leads to the catastrophe, or what he calls "man-made disasters" to distinguish them from "natural disasters"), and the rescue or salvage period that occurs after the catastrophe.

Stage I: Notionally normal starting point: All organizations operate within some cultural framework with certain unwritten norms or beliefs, as well as written or codified rules and regulations.  Certainly part of this relates to the concept of "safety culture".  Pidgeon suggests that a "good" safety culture is characterized by at least four components:

1. Senior management commitment to safety (see my recent post, "Be the best at getting better")

2. Shared care and concern for hazards (for more, see "Preoccupation with Failure")

3. Realistic and flexible norms and rules about hazards (see "Commitment to Resilience")

4. Continual reflection upon practice through monitoring, analysis, and feedback systems (see "Sensitivity to Operations"

Importantly, as Turner himself recognized, "managers cannot simply 'install' a culture."  While it is absolutely essential that leaders are committed to safety, safety culture cannot be instituted by decree.  Rather, a culture of safety is established over time through organizational learning using a combination of top-down and bottom-up approaches (for more, see my post "Can you mandate culture change?").

Stage II: Incubation period: It is important to recognize (and this may be Turner's most important point) that "man-made disasters" take place because of some inaccuracy or inadequacy in the accepted organizational norms and beliefs (and, in some cases, in the codified rules and regulations).  Turner defines the "incubation period" as the period of time (which may take place over several years) in which "an unnoticed set of events which are at odds with the accepted beliefs about hazards and the norms for their avoidance" accumulate.  Here, Turner accepts that the world is complex, and organizations often have to address complicated and complex problems (so-called "wicked" problems).  Leaders within these organizations almost never have "perfect information" (see my post, "Buridan's Ass"), so their decisions are frequently made based on a set of beliefs and assumptions which are flawed.  Rather than making a perfect decision, they make decisions that are "good enough"("satisficing" or "bounded rationality").  This only compounds the risk of a triggering event leading to catastrophe during this "incubation period."  Notably, Turner's concept of "incubation" calls to mind the Sidney Dekker's "drift to failure" and Scott Snook's "practical drift".  

Stage III: Precipitating event: Given the failure of foresight necessary to correct or mitigate some of the cultural norms, beliefs, rules, and regulations described above, a precipitating or "trigger" event occurs and sets off a chain of events that results in the man-made disaster.

Stage IV: Onset: Here in this stage, the immediate consequences of the precipitating event become apparent.  Importantly, these consequences were neither anticipated nor even believed to be within the realm of possibility.  Remember, the organization was operating with a faulty framework.

Stage V: Rescue and Salvage: Once the accident becomes readily apparent, the organization finally recognizes and redefines the situation in such a way that rescue from the event (hopefully) becomes possible.

Stage VI: Full Cultural Readjustment: Only after the immediate effects have subsided and the important rescue and salvage operations have occurred is it possible to take a more in-depth re-assessment of the incident (what the U.S. military calls an "After Action Review").  Just as important, during this stage the organization reviews the beliefs, norms, and rules/regulations that contributed to the accident.  Here is where transformation of the culture must occur, so that similar events do not happen again in the future.  Pertinent to this stage, Turner described a concept in his book that I found absolutely brilliant.  He cautions against the organizational tendency to address the problem(s) that caused the disaster "as it was later revealed and not as it presented itself to those involved beforehand."  He goes on to suggest that "the recommendations treat the well-structured problem defined and revealed by the disaster, rather than with preexisting, ill-structured problems."

In other words, we should be careful to avoid hindsight bias or overutilize the retrospective lens.  Remember, leaders during the crisis were forced to make decisions based upon the information that was readily apparent, which is typically far from complete and imperfect at best.  During the "After Action Review", important information may become readily apparent that was hidden during the crisis itself.  Leaders may have chosen an entirely different path if they had all the information that is usually available after the fact.  As Turner states, "Not every failure which is obvious now, would be obvious before the disaster."

Turner makes one last key point here.  It's helpful to review and study the man-made disasters of the past, and the accident inquiry reports that Turner reviewed for his book provide a treasure trove of information that organizations can and should learn.  However, he also suggests that "It may be fruitful to look at the circumstances of 'near-miss' disasters as a source of comparative data."  Learning from these weaker signals - that "Reluctance to Simplify" - is just as important.  Again, man-made disasters "do not spring into life on the day of the visible failure; they have a social and cultural context and a history."  For example, the events at Three Mile Island (covered at length in another safety classic, Charles Perrow's Normal Accidents) were foreshadowed by several similar near-miss events at other nuclear power plants in the years before.

There's a lot more that I want to discuss from this classic safety text, which I will do in the next few posts.  We will first take a look at the three accidents that Turner reviews in depth before discussing some of his key concepts introduced above in greater detail.