Paper: Distancing Through Differencing
As I slowly re-index old forum posts here, I decided to grab some old notes I had on Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents by Richard Cook and David Woods.
High-consequence incidents represent severe challenges to learning: emotional and distressing consequences, high pressure from stakeholders to solve things, financial impacts, simplified clearer causes providing more comforting answers, retribution, dissonance from having to change how you do things. This paper however focuses on a pattern they noticed where people go through a discounting or distancing process where they focus on differences real and imagined between the place, people, organization and circumstances where an incident happens and their own context.
By focusing on the differences, they see no lessons for their own operation and practices or only narrow well bounded responses. We call this pattern-distancing through differencing.
They first look at a chemical fire that happened during maintenance in the clean room of a large high-technology manufacturing plant causing more than a million dollars worth of damage. The manufacturer had a lot of processes in place, and one of the authors (Richard Cook) had been involved with them for a past study, and had given them training on systems failure recently, so they called them back to help do the investigation. They have identified a lot of systemic factors around the process, the plant, the tools, the policies, etc.
They noticed that the local process demanding immediate investigations had a lot of side-effects:
- high pressure to return quick results resulting in superficial investigations
- "safety" was owned by a set of expert workers rather than production workers themselves
- safety people had an idealized view of the company, which meant they often put blame on the production workers
- safety people by large favored rapid fixes and concrete interventions that could be applied right away
- production workers and operators saw the safety recommendations as irrelavant and divorced from reality
- production workers said production pressures were far more important to the company than anything; safety only became important in the aftermath of an incident
During the incident investigation, it was found out that a similar one had happened in the same company earlier that year, but in another country. The report had been disseminated by the safety people incompletely, but all the relevant people at the factory had been aware of the previous incident already. However:
They had reviewed the incident, noted many features that were different from their plant (non-US location, slightly different model of the same machine, different safety systems to contain fires). The safety people consciously classified the incident as irrelevant to the local setting, and they did not initiate any broader review of hazards in the local plant. Overall they decided the incident “couldn’t happen here.”
This is an instance of a discounting or distancing process whereby reviewers focus on differences, real and imagined, between the place, people, organization and circumstances where an incident happens and their own context. By focusing on the differences, they see few or no lessons for their own operation and practices.
The authors point out that sharing more information and making sure people are aware does nothing to change results in this case. The reports focused on the unique nature of things that had happened, and in doing so, they had made the differences more obvious, which in turn meant they limited the potential for others to learn.
The authors hammer on that this is a good company that took security seriously and put their money where their mouth is. But in putting incentives to act fast and decisively to prevent further incidents, the attention of everyone involved was oriented towards countermeasures of specific incidents, which meant people also framed incidents as "isolated, local phenomena, without wider relevance or significance."
The prior fire was noticed but considered irrelvant until the local fire let people draw connections:
It was not that the overseas fire was not communicated. Indeed it was observed by management and known even to the local operators. But these local workers regarded the overseas fire not as evidence of a type of hazard that existed in the local workplace but rather as evidence that workers at the other plant were not as skilled, as motivated and as careful as they were, after all, they were not Americans (the other plant was in a first world country). The consequence of this view was that no broader implications of the fire overseas were extracted locally after that event.
Interestingly (and ominously) this distancing through differencing that occurred in response to the external, overseas fire, was repeated internally after the local fire. Workers in the same plant, working in the same area in which the fire occurred but on a different shift, attributed the fire to lower skills of the workers on the other shift. [...] They regarded the workers to whom the accident happened as inattentive and unskilled. Not surprisingly, this meant that they saw the fire as largely irrelevant to their own work.
By considering that incidents happen to others because they're worse workers and considering the incidents as proof of them being worse in the first place, workers enter a sort of circular reasoning where they don't necessarily learn much of incidents happening around them, even if there are no actual proof of any different competency levels across work groups.
Interestingly, that type of fire used to be a lot more common, but safety improvement had made them rare enough that few workers even had experience with them anymore, and those who had often had been promoted out of the clean floors; the younger workers had no great concept of the hazards.
By comparison, the extensive reports generated by external eyes (the paper's authors) without the pressure to do quick fixes yielded different results by using the specific incidents to focus on wider system effects: labelling being confusing on a machine prompted revisiting labelling across departments, or extending safety procedures from transport to machine maintenance.
This kind of reasoning from the specific to the more general is a pronounced departure from the usual approach of narrowly looking for ways to prevent a very specific event in a specific place from occurring or reoccurring.
[...]
By almost all standards, managers, safety officers, and workers took a narrow view of the precursor event. By narrowing in on local, concrete, surface characteristics of the precursor event, the organization limited what could be learned.
The authors therefore warn against going so specific that people are going to be distancing through differencing, and to instead use the proper opportunity of incidents to generalize findings to make sure they are applicable to more systemic improvements, rather than incident-specific corrections that end up inherently limiting their applicability.
I found it specifically interesting that having the very specific takeaways meant that workers just felt like other workers were less competent or that their own circumstances wouldn't let things happen, and that this "it couldn't happen here" pattern is something you can also preempt by the type of recommendations and observations you make.