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Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents

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Chapter 20
Distancing Through
Differencing: An Obstacle to
Organizational Learning
Following Accidents
Richard I. Cook
David D. Woods
The future seems implausible; the past seems incredible.1
Introduction
A critical component of a high resilience in organizations is continuous
learning from events, ‘near miss’ incidents, and accidents (Weick et al.,
1999; Ringstad & Szameitat, 2000). As illustrated by the many cases
referenced in this book, incidents and failures provide information
about the resilience or brittleness of the system in the face of various
disruptions. This chapter explores some of the barriers that can limit
learning even by generally very high quality organizations.
Despite terrible consequences, accidents, as fundamentally
surprising events, offer an opportunity for learning and change as there
is a profound sense among many that the usual concepts and policies
are insufficient to cope with what has happened (Woods et al., 1994).
The immediate aftermath of a serious failure produces an atmosphere
of inquiry and frees up resources normally dedicated to production
which are refocused on the accident and its consequences. The lines
that divide participants, management, regulators, and victims from each
other are momentarily thin. As one National Transportation Safety
Cook & Woods: Distancing Through Differencing 309
Board observer put it, “when the vividness of the tragedy is fresh in
everyone’s mind, and the broken wreckage is still smoldering ... people
... have only one pressing goal, and that is to determine precisely what
happened and see that it does not happen again.” (NTSB, Accident
Investigation Symposium, 1983, page 8). This period of cooperation
and focus makes it possible to ask questions that are not usually asked,
gather data not usually gathered, and probe issues not usually open to
inquiry.
Not all stakeholders are in the same position relative to the
surprising event. Some are closer; others more distant in knowledge,
point of view, and in experiencing the consequences. Distance from the
work context where an accident occurs appears to alter what is learned
from incidents and accidents. Those people who are at the epicenter of
high consequence accidents are usually devastated and entirely caught
up in the consequences and reactions to failure (Dekker, 2003b).
Conversely, people who are far distant from the epicenter are too
divorced from the complex context of technical work and accept
skeletal descriptions of the events that reach them (the first stories in
Cook et al., 1998) As a result, those distant from the technical work
area tend to fall back on oversimplified sterile responses.
But near the epicenter are people who have both a detailed
understanding of the context of work yet are sufficiently distant from
the consequences. Because their technical work corresponds closely to
conditions of work at the epicenter, the event has direct relevance.
Because they are some distance from the epicenter, their attention is
not captured by the need to react to the event itself and they have an
opportunity to extract deeper information (they can begin to explore
the second stories of Cook et al., 1998), i.e., to learn about how safety is
created.
Barriers to Learning
Learning in the aftermath of incidents and accidents is extraordinarily
difficult because of the complexity of modern systems. Layers of
technical complexity hide the significance of subtle human performance
factors. Awareness of hazard and the consequences of overt failure lead
to the deployment of (usually successful) strategies and defenses against
failure. These efforts create a setting where overt failures only occur
310 Resilience Engineering
when multiple small faults combine. The combination of multiple
contributors and hindsight bias makes it easy for reviewers after the fact
to identify an individual, group or organization as a culprit and stop.
These characteristics of complex systems tend to hide the real
characteristics of systems that lead to failures.
When an organization experiences an incident, there are real,
tangible and sometimes tragic consequences associated with the event
which create barriers to learning:
The negative consequences are emotional and distressing for all
concerned,
failure generates pressure from different stakeholders to resolve the
situation,
a clear understandable cause and fix helps stakeholders move on
from a tragedy, especially when they continue to use or participate
in that system,
managing financial responsibility for ameliorating the consequences
and losses from the failure,
desire for retribution from some stakeholders and processes of
defense against punitive actions,
confronting dissonance and changing concepts and ways of acting
is painful and costly in non-economic senses.
In this chapter we present a case study of learning from incidents.
Analysis of the case reveals 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 no lessons
for their own operation and practices or only narrow well bounded
responses. We call this pattern-distancing through differencing.
Examining how this particular organization struggled to recognize
and overcome distancing through differencing also provides useful
insights on how to support the organizational learning process.
Cook & Woods: Distancing Through Differencing 311
An Incident
A chemical fire occurred during maintenance on a piece of process
machinery in the clean room of a large, high technology product
manufacturing plant. The fire was detected and automatically
extinguished by safety systems that shut off flow of reactants to the
machine.
The reactant involved in the fire was only one of many hazards
associated with this expensive machine and the machine was only one
of many arranged side by side in a long bay. Operation and
maintenance of the machine also involved exposure or potential
exposure to thermal, chemical, electrical, radio frequency, and
mechanical hazards. Work in this environment was highly
proceduralized.2 Both the risks of accident and the high value of the
machine and its operation had generated elaborate formal procedures
for maintenance and required two workers (buddy system) for most
procedures on the machine.
The manufacturer had an extensive safety program that required
immediate and high level responses to an incident such as this, even
though no personal injury occurred and damage was limited to the
machine involved. High level management directed immediate
investigations, including detailed debriefings of participants, reviews of
corporate history for similar events, and a ‘root cause’ analysis.
Company policy required completion of this activity within a few days
and formal, written notification of the event and related findings to all
other manufacturing plants in the company. The cost of the incident
may have been more than a million dollars (and plant’s score card
suffered significantly).
Two things prompted the company to engage outside consultants
for a broader review of the accident and its consequences. First, search
for prior similar events in the company files discovered a very similar
accident at a manufacturing plant in another country earlier in the year.
Second, one of the authors (RIC) recently had been in the plant to
study the use of a different machine where operator ‘error’ seemed
prevalent but only with economic consequences. He had identified a
systemic trap in this other case and provided some education about
how complex systems fail a few weeks earlier. During that visit, he
pointed out how other systemic factors could contribute to future
312 Resilience Engineering
incidents that threatened worker safety in addition to economic losses
and suggested the need for broader investigations of future events.
Following the incident the authors returned, visited the accident
scene, and debriefed the participants in the event and those involved in
its investigation. They studied operations involving the machine in
which the fire occurred. They also examined the organizational
response to this accident and to the prior fire.
Organizational Learning in this Case
The obstacles to learning from failure are nearly as complex and subtle
as the circumstances that surround a failure itself. Because accidents
always involve multiple contributors, the decision to focus on one or
another of the set, and therefore what will be learned, is largely socially
determined.
In the incident just described, the formal process of evaluating and
responding to the event proceeded along a narrow path. The
investigation concentrated on the machine itself, the procedures for
maintenance, and the operators who performed the maintenance tasks.
For example, they identified the fact the chemical reactant lines were
clearly labeled outside the machine but not inside it where the
maintenance took place. These local deficiencies were corrected quickly.
In a sense, the accident was a ‘normal’ occurrence in the company; the
event was regretted, undesirable, and costly but essentially the sort of
thing for which the company’s incident procedures had been designed
and response teams created. The main findings of this formal, internal
investigation were limited to these rather concrete, immediate, local
items.
A broader review, conducted in part by outsiders, was based on
using the specific incident as a wedge to explore the nature of technical
work in context and how workers coped with the significant hazards
inherent in the manufacturing process. This analysis yielded a different
set of findings regarding both narrow human engineering deficiencies
and organizational issues. In addition to the relatively obvious human
engineering deficiencies in the machine design discovered by the formal
investigation, the event pointed to deeper issues that were relevant to
other parts of the process and other potential events.
Cook & Woods: Distancing Through Differencing 313
There were significant limitations in procedures and policies with
respect to operations and maintenance of the machine. For example,
although there were extensive procedural specifications contained in
maintenance ‘checklists’, the workers had been called on to perform
multiple procedures at the same time and had to develop their own task
sequencing to manage the combination. Similarly, although the primary
purpose of the buddy system was to increase safety by having one
worker observe another to detect incipient failures, it was impossible to
have an effective buddy system during critical parts of the procedures
and parts of this maintenance activity. Some parts of the procedures
were so complex that one person had to read the sequence from a
computer screen while the other performed the steps. Other steps
required the two individuals to stand on opposite sides of the machine
to connect or remove equipment, making direct observation
impossible.
Surprisingly, the formal process of investigating accidents in the
company actually made deeper understanding of accidents and their
sources more difficult. The requirement for immediate investigation
and reporting contributed to pressure to reach closure quickly and led
to a quick superficial study of the incident and its sources. The intense
concern for ‘safety’ had led the company to formally lodge
responsibility for safety in a specific group of employees rather than the
production and maintenance workers themselves. Treating safety as an
abstract goal generated the need for these people as a separate entity
within the company. These ‘safety people’ had highly idealized views of
the actual work environment, views uninformed by day to day contact
with the realities of clean room work conditions. These views allowed
them to conceptualize the accident as flowing from the workers rather
than the work situation. They were captivated in their investigation by
physical characteristics of the workplace, especially those characteristics
that suggested immediate, concrete interventions that could be applied
to ‘fix’ the problems that they thought led to the accident.
In contrast, the operators regarded the incident investigation and
proposed countermeasures as derived from views that were largely
divorced from the realities of the workplace. They saw the ‘safety
people’ and their work as being irrelevant. They delighted in pointing
out, for example, how few of them had any practical experience with
working in the clean room. Privately, the workers said that production
pressures were of paramount importance in the company. This view
314 Resilience Engineering
was communicated clearly to the workforce by multiple levels of
management. Only after accidents, they noted, was safety regarded as a
primary goal; during normal operations, safety was always a background
issue, in contrast to the primary need to maintain high rates of
production.3
During the incident investigation, it was discovered that a very
similar incident had occurred at another manufacturing plant in another
country earlier in the year – a precursor event or rehearsal from the
point of view of this manufacturing facility. Within the company, every
incident, including the previous overseas fire, was communicated within
the company to safety people and then on to other relevant parties.
However, the formal report writing and dissemination about this
previous incident had been slow and incomplete, relative to when the
second event occurred. Part of the recommendations following from
the second incident addressed faster production and circulation of
reports (in effect, increasing the pressure to reach closure when
investigating incidents).
Interestingly, the relevant people at the plant knew all about the
previous incident as soon as it had occurred through more informal
communication channels. 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.
Notice how speeding up formal notification does nothing to
enhance what is learned and does nothing to prevent or mitigate
discounting the relevance of the previous incident. The formal review
and reports of these incidents focused on their unique features. This
made it all the easier for audiences to emphasize what was different and
thereby limit the opportunity to learn before they experienced their
own incident.
Cook & Woods: Distancing Through Differencing 315
It is important to stress that this was a company taking safety
seriously. Within the industry it had an excellent safety record and
invested heavily in safety. Its management was highly motivated and its
relationships with workers were good, especially because of its strong
economic performance that led to high wages and good working
conditions. It recognized the need to make a corporate commitment to
safety and to respond quickly to safety related events. Strong pressures
to act quickly to ‘make it safe’ provided incentives to respond
immediately to each individual accident. But these demands in turn
directed most of attention after an accident towards specific
countermeasures designed to prevent recurrence of that specific
accident. This, in turn, led to the view that accidents were essentially
isolated, local phenomena, without wider relevance or significance.
The management of the company was confronted with the fact that
the handling of the overseas accident had not been effective in
preventing the local one, despite their similarities. They were
confronted by the effect of social processes working to isolate accidents
and making them seem irrelevant to local operations. The prior fire
overseas was noticed but regarded as irrelevant until after the local fire,
when it suddenly became critically important information. 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.4 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. After all, their reasoning went, the fire
occurred because the workers to whom it happened were less careful
than we are. Despite their beliefs, there was no evidence whatsoever
that there were significant differences between workers on different
316 Resilience Engineering
shifts or in different countries (in fact, there was evidence that one of
the workers involved was among the better skilled at this plant).
Contributing to this situation was, paradoxically, safety. Over a
span of many years, the incidence of accidental fires with this particular
chemical and in general had been reduced. But as a side effect of
success, personnel’s sensitivity to the hazard the chemical presented in
the workplace was reduced as well. Interviews with experienced ‘old
hands’ in the industry indicated that such fires were once relatively
common. New technical and procedural defenses against these events
had reduced their frequency to the point that many operators had no
personal experience with a fire. These ‘old hands’ were almost entirely
people now in management positions, far from the clean room floor
itself. Those working with the hazardous materials were so young that
they had no personal knowledge of these hazards, while those who did
have experience were no longer involved in the day to day operations
of the clean room.
In contrast with the formal investigation, the more extensive look
into the accident that the outside researchers’ visit provoked produced
different findings. Discussion of the event prompted new observations
from within the plant. Two examples may be given. One manager
observed that the organization had extensive and refined policies for
the handling of the flammable chemical delivery systems (tanks, pipes,
valves) that stopped at the entrance to the machine. Different people,
policies, and procedures applied to the delivery system. He made an
argument for carrying these rules and policies through to the machine
itself. This would have required more extensive (and expensive)
preparation for maintenance on the machine than was currently the
case, but would have eliminated the hazardous chemical from within
the machine prior to beginning maintenance. Another engineer
suggested that the absence of appropriate labeling on the machine
involved with the accident should prompt a larger review of the labeling
in all places where this chemical was used or transported.
These two instances are examples of using a specific accident to
discover characteristics of the overall system. 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.
The chemical fire case reveals the pressures to discount or distance
ourselves from incidents and accidents. In this organization, effective
Cook & Woods: Distancing Through Differencing 317
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.
Extending or Enhancing the Learning Opportunity
An important question for resilience management is a better
understanding of how the window of opportunity for learning can be
extended or enhanced following incidents. The above case illustrates
one general principle which could be put into action by organizations –
do not discard other events because they appear on the surface to be
dissimilar. At some level of analysis, all events are unique; while at other
levels of analysis, they reveal common patterns.
Promoting means for organizations to look for and consider
similarities between their own operation and the organization where an
incident occurred could reduce the potential for distancing through
differencing. This will require shifting analysis of the case from surface
characteristics to deeper patterns and more abstract dimensions (Cook
et al., 1998). Each kind of contributor to an event then can guide the
search for similarities.
When this process of learning moved past the obstacle of
distancing through differencing in this case, the organizational response
changed. The organization derived and shared with us a new lesson –
safety is a value of an organization, not a commodity to be counted or a
priority set among many other goals.
1 Originally in Woods & Cook (2002). The phrase was constructed from comments by
Trevor Kletz Process Plants: A Handbook for Inherently Safer Design, 1998, Taylor &
Francis London, p. 67 – “Once we have changed to an inherently safer material, the
original often seems incredible.” and a remark by N. R. Hanson (1958) - Observations
made before the perceptual pattern is appreciated are epistemically distinct from the
observations (and their descriptions) made after that pattern has cast them into intelligible
constellations-although the observations and descriptions, those before and those after,
might be congruent.
2 The site had repeatedly undergone ISO 9000 certification and review.
3 The workers themselves internalized this view. There were significant incentives to
provided directly to workers to obtain high production and they generally sought high
levels of output to earn more money.
4 Workers and managers of other parts of the manufacturing process also saw little
relevance or potential to learn from the event.
... This is significant because of the challenges of ascribing stable states and conditions within complex systems, [98][99][100] and the propensity of organizations to dismiss literal interpretations of accident findings as inapplicable, citing disparities between their context and the findings. 101,102 This tempered stance also accommodates the shallowness found within most of the included investigation reports describing auditing failures, sometimes necessitating interpretation by the study's authors. ...
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... Distancing through differencing. In this process, organizational members look at other incidents or failures in other organizations or subunits as not relevant to them and their situation ( Cook and Woods, 2006 ). They discard other events because they appear to be dissimilar or distant. ...
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