Some organizations sustain near-error-free operation through preoccupation with failure, deference to expertise, and reluctance to simplify.
Weick and Sutcliffe's study of aircraft carriers, air traffic control and nuclear plants. The counterintuitive finding is that these organisations treat the absence of incidents as a warning sign rather than as success.
In practice
- A control room that treats a quiet month as a warning sign rather than a success finds the drift before the incident.
- A team that defers a technical decision to whoever knows the system, regardless of grade, catches problems a hierarchy would have escalated past.
- Subject
- Risk & Reliability
- Essay
- How accidents actually happen