My team have been discussing the nature of
“resilient” behavior, the basic idea being that people develop strategies for
anticipating and avoiding possible errors, and creating conditions that enable
them to recover seamlessly from disturbances. One of the examples that is used
repeatedly is leaving one’s umbrella by the door as a reminder to take it when
going out in case of rain. Of course, getting wet doesn’t seriously compromise
safety for most people, but let’s let that pass: its unpleasant. This presupposes that people
are able to recognize vulnerabilities and identify appropriate strategies to
address them. Two recent incidents have made me rethink some of the
presuppositions.
On Tuesday, I met up with a friend. She had
left her wallet at work. It had been such a hot day that she had taken it out
of her back pocket and put it somewhere safe (which was, of course, well
hidden). She recognized that she was likely to forget it, and thought of ways
to remind herself: leaving a note with her car keys, for instance. But she didn’t act on this intention. So she
had done the learning and reflection, but it still didn’t work for her because
she didn’t follow through with action.
My partner occasionally forgets to lock the
retractable roof on our car. I have never made this mistake, but wasn’t sure
why until I compared his behavior with mine. It turns out he is more relaxed
than I am, and waits while the roof closes before taking the next step, which
is often to close the windows, take the keys out of the lock and get out of the
car. I, in contrast, am impatient. I can’t wait to lock the roof as it closes,
so as the roof is coming over, my arm is going up ready to lock it. So I never
forget (famous last words!): the action is automatised. The important point in
relation to resilience is that I didn’t develop this behavior in order to keep
the car safe or secure: I developed it because I assumed that the roof needed to be secured and I wanted it to happen as quickly as possible. So it is not intentional, in terms of safety, and yet
it has the effect of making the system safer.
So what keeps the system safe(r) is not
necessarily what people learn or reflect on, but what they act on. This is, of
course, only one aspect of the problem; when major disturbances happen, it’s
almost certainly more important to consider people’s competencies and knowledge
(and how they acquired them). To (approximately) quote a London Underground
controller: “We’re paid for what we know, not what we do”. Ultimately, it's what people do that matters in terms of safety; sometimes that can be clearly traced to what they know and sometime it can't.