David Slater September 23, 2021
The Industrial Revolution – from peasant to problem
For much of the 19th and 20th centuries, the industrial revolution shaped the way people looked at safety. Machines were the marvel of the age, and a major challenge was how to convert a predominantly rural, peasant population, to operate them without breaking them, or themselves; although for much of this time the emphasis was on the former, rather than the latter.
The “safety pioneers” (Heinrich et al) were thus developing ways to prevent the inevitable accidents and mistakes that impaired the efficiencies of these installations. Their approach was essentially to try and make the machinery and its operators more reliable and efficient. This culminated in the classic “Quality” initiatives, where efforts were focussed on eliminating any defects (human or mechanical) impairing the theoretical capacity of the processes. This philosophy still survives today in the LEAN, six sigma black belt analyses, much beloved of the manufacturing industries.
The Organisation as Machine
But after the Second World War, the development of nuclear power, the guaranteed reliability (safety) of which, was critical to its acceptability by communities, meant that a more formal demonstration of its integrity was needed. Thus, Boolean Logic fault and event trees were developed to identify potential defects and failure mechanisms; and then quantified to claim negligible probability of failures due to reliability of components, controls and safety measures.
Similar probabilistic “safety” analyses (PSA’s or PRA’s or QRA’s) were employed to demonstrate the same sort of “safety” levels from everything from space shuttles to offshore drilling.
But first, the 3 Mile Island and then the Challenger incidents, called into question the claims and reassurances based on the computer printouts. In the Challenger incident, potential defects were identified, such as the low temperature fallibility of the O rings, which were not only reported but raised as real possibilities not probabilities. Nevertheless, the system was operated with tragic consequences.
But in NASA, the management had to cope with more than just delivering guaranteed reliability. The realities of political and economic pressures combined to force efficiency thoroughness trade-offs and cost and risk benefit compromises. This brought home the realisation that organisations were not machines and humans were not components and the conventional, current approaches that treated them as such, were no longer adequate, if they ever really were.
In the 21st century, we now realise that they are systems; but more than that, they are complex sociotechnical systems. Thus, they need more understanding about how they behave as a whole, in totality, as systems; not just the detailed behaviour and reliability of individual components. In fact, an organisation is more akin to an organism than a machine.
The Organisation as Organism
So, what can we learn from a life form, that is evidently complex and an assembly of interacting systems, not just components, such as organs or cells? How do organisms, not just survive, but thrive?
The first imperative is survival, and all living things have a detailed set of instructions on how to survive and reproduce. These instructions are encoded as genes, which form readable (by other chemicals) sections of a unique molecule known as DNA. They essentially program the organism to build and operate a viable complex system and are passed on to enable more copies of the organism to be made to ensure survival of that particular type of organism.
It is essential then, for the survival of the organism and its species, that these DNA blueprints are faithfully copied and transmitted for future generations. But in the real world, natural variability in environments and conditions can lead to corrupted DNA code, which if not picked up can be fatal.
In organisational terms, the equivalent would be the corporate repository of IP, Business plans, and management systems, encoded as procedures and policies. This essentially corporate DNA is inevitably setting out how ideally things should be done (Work as Imagined). Unfortunately, as well in organisations, not everything can be written in the book and not everything gets done by the book, (i.e. Work as actually Done).
Also in organisms, not all operations are carried out exactly as predetermined, programmed by the DNA. Such variability can cause defects, failures and threaten survival. Thus, organisms have developed mechanisms to constantly check the accuracy of the DNA strands, that can systematically look for and repair defects.
Organisations have also often developed (like organisms) their equivalent of gene editing and correcting mechanisms.1 In the corporate world, there are functions, (The Deming Juran Quality – ISO 9000 process is an example) which perform the same task. One part of this is focussed on Health and Safety, and its goal is to eliminate faults and hence failures and enforce the (necessarily incomplete?) “Correct” procedures – the equivalent of the original DNA.
Translated into the corporate world this is comparable to the earlier approaches to managing safety or quality. Eliminate the faults, failures and defects and stick rigidly to the corporate standards by monitoring, enforcement, training and retraining by the book. These days it is often referred to as SAFETY I
From survival to success
In organisms, occasionally, stochastically, some variability in conditions can lead to changes in the code which can offer the organism more than just continued survival, but an actual advantage over other competing organisms, or increased survival chances in a changing environment. These superior genes then get incorporated into new DNA and established as the new blueprint for a more successful organism.
The logical consequences of this are then apparent as the continuous Darwinian evolution of better and better “adapted” organisms.
On this model, the SAFETY I mechanism above, can ensure “survival”, but not “success”. The Darwinian development of extra competitiveness or competence – where success equals continuous improvement, gets continually discouraged and “trained out” of the system.
One could say that purely SAFETY I organisations can thus only toe the corporate DNA line and be seen solely to monitor for deviations and respond with corrections.
To achieve the second step, inheritance mechanisms within organisations need not only to correct mistakes in transmitting the authentic procedures, but also to incorporate and update them with those discovered adaptations or variabilities that improve the procedures (SAFETY II).2 Recent studies of evolutionary biology have indicated that the environment, can impact the inheritance mechanisms and that DNA is not the only inherited source of information. There is genetic transfer of information and non-genetic (epigenetic transfer), where the environment can modulate information transferred, as another route for transfer of adaptations/variants.3 Where WAI can be visualised as DNA, one may envisage WAD as modulated DNA and other transferred material.2 Such differing inheritance mechanisms may explain temporal aspects of evolving resilience potentials, those that are rapid and those more gradual. 2 Thus, a further mechanism that is available to an organisation is to formally seek out and incorporate improvements to be encoded in DNA or transferred rapidly be other material. Building on these learned behaviours, further advantage can be obtained by not only consciously adapting to stay abreast of challenges, but by anticipating and avoiding predicted difficulties and taking advantage of realised opportunities.
So, the evolving, Darwinian-like (SAFETY II) organisation, adapting to enable superior responses and hence, performance, can also learn from what goes right, or better still, can compensate for individual “failures” and has the resilience to anticipate (modify the DNA or transmit by other means) to deal with these emergent (competitive, novel) survival challenges.
The observed performance of organisations.
Public versus Private sector Organisations
Public sector bodies are archetypal SAFETY I organisations.
They are designed to survive by successfully executing the prescribed (Statutory DNA) procedures to the letter without deviation. One could say therefore they are not competitive and hence variability is a bad thing. This includes the NHS and Public sector Healthcare organisations. They can only ever be as good as the master plan DNA. (Value for money – work to a minimum spec – not a penny more?)
Private sector organisations, however, are rarely guaranteed survival by statute, or subsidy and hence inevitably survival is very competitive. Of these organisations, those with no, or limited capacity to change their procedures (the corporate DNA), will inevitably succumb to “black swan” events – “not imagined in their philosophies”.
On the other hand, they are free to strive for more than survival, and to realise the need to evolve and adapt to changing circumstances; to capitalise on their freedom to strive for continuous improvement
This view of organisational behaviour can be seen clearly in the responses of different organisational models in recent events.
In recent years public sector bodies: police, fire and health in the UK have come under intense scrutiny following headline events and tragedies where (arguably) their programmed response (trained by the DNA) was lacking or manifestly incorrect, and they were unable to reflexively adapt their response to the evolving situations.
Whereas Big Pharma and academic institutes (competitive environment bodies) have been seen to rapidly adapt and evolve; for example, during the Covid-19 pandemic by using novel thinking to produce several vaccines reducing the morbidity/mortality on a global scale (enigma thinking).
Devolved and delegated organisations
Much more interesting, is that despite the challenges with the “management” layers of the NHS, the emergency response and intensive care unit teams in the COVID-19 pandemic, Manchester Arena and London Bridge incidents, each having the same sort of training, were able to adapt and cope successfully
This seems to have been a spontaneous response (and a SAFETY II adaptation), appearing to respond to deeper than the “normal” SAFETY I encoded public sector management procedures. The challenge we face is to start to discuss, analyse and understand if and how such adaptations can be inherited to enhance resilience in public sector organisations.
Why just Safety?
The other insight from looking at an organisation as an organism, is that the organism has a single mechanism which allows learning and anticipation in all aspects of its existence. The “code-words” and instructions can be grouped into separate chapters, or chromosomes, but the basic processes are the same for each chapter.
So, another insight could be that in most organisations, there are separate but similar procedures and functions that concentrate on improving performance in different areas, such as Productivity, Quality, Safety and Reliability. But, as they are all examples of the inheritance process, there is inevitably some duplication, competition and friction if each of these is considered a silo.
Applying a common approach across all these areas, (as complementary, cooperating, chromosomes) then would seem to offer real benefits. Hollnagel has recently proposed such an approach – Synesis, 4 which could again follow naturally from considering the implications of a genetic paradigm.
Conclusions
Far from being new revolutionary thinking about Safety, the concentration on learning from experience and applying the insights gained to improve what goes right as well as correcting what goes wrong, is embedded in our DNA. Now we have got over our 19th century preoccupation with marvellous machines, we can embrace the full potential of systems thinking. To appreciate the need for utilising the advantages of integrating the human, physical and cyber components into not just safer, more efficient and resilient systems, but with a capacity to evolve and continually improve.
Ralph MacKinnon and David Slater
References
1. Pukk K, Aron DC. The DNA damage response and patient safety: engaging our molecular biology-oriented colleagues. International journal for quality in health care. 2005;17(4):363-367.
2. MacKinnon R. From in-situ simulation to beyond. PhD thesis submitted for publication, Karolinska Institutet, Stockholm; 2021.
3. Müller GB. Why an extended evolutionary synthesis is necessary. Interface focus. 2017;7(5):20170015-20170015. doi:10.1098/rsfs.2017.0015
4. Hollnagel, E. (2020). Synesis: The unification of productivity, quality, safety and reliability. Abingdon, Oxon, UK: Routledge.