Paper: Failure to adapt or adaptations that fail
Here's another one by Sidney Dekker: Failure to adapt or adaptations that fail: contrasting models on procedure and safety, which looks at the duality between organizations perceiving safety as “not deviating from the procedures” and contrasting it with situations where “procedures were inadequate and someone should have adapted”.
I’ve highlighted like 1/3 of the paper on my copy, but if I had to give a TL:DR; it would be that:
- Rote rule following may harm safety because people don’t get good at knowing when to adapt procedures; mandating procedures to be followed as a rule further encourages that gap to widen. People may get blamed for their inflexibility if this goes wrong.
- Adapting procedures may also act as its own source of risks, particularly when circumstances or outcomes are uncertain. People may be blamed for their non-adherence in this case.
- These two factors create a double-bind for all practitioners, where a gap may continuously grow between work-as-prescribed and work-as-done.
- monitoring the gap to understand why it exists (and not just to enforce compliance) to adjust procedures, and helping developing skill in your people to figure out when and how to adapt are seen as productive ways to maintain or improve safety.
- This can prevent what I had heard termed as normalization of deviance, but in this paper it has a tone saying that this is also possibly a failure of the organization to provide better/adjusted procedures, which then creates the deviance as an adaptive mechanism to succeed. It is not a failure or people becoming lazy (at least not at first), it’s people responding to pressures by bypassing maladapted processes.
- A key solution to letting your people develop skill in adapting is to create a "continuing expectation of future surprise", with examples such as "controlled shedding" which lets people know which tasks are at a higher priority during crises or busy times.
Discouraging people’s attempts at adaptation can increase the number of failures to adapt in situations where adaptation was necessary. Allowing procedural leeway without investing in people’s skills at adapting, on the other hand, can increase the number of failed attempts at adaptation. In order to make progress on safety through procedures, organizations need to monitor the gap between procedure and practice and understand the reasons behind it.
The whole paper is worth reading.