Tuesday, March 22, 2011

Ignoring near misses can lead to catastrophe

There are many different types of mistakes, and many different types of failures. Most are discussed or demonstrated somewhere on this site. But it's instructive to think of a particular class of mistake, one which authors Catherine H. Tinsley, Robin L. Dillon, and Peter M. Madsen discuss in the April 2011 Harvard Business Review.

They call it the "near miss." It is the kind of mistake or set of mistakes that occur but don't lead to a total catastrophe (the near miss's close relative). Tinsley et al argue that managers overlook near misses and thereby fail to correct the mistakes that lead, on occasion, to terrible, preventable catastrophes. The Deepwater Horizon spill is merely one of the latest of these examples.

The typical reaction of a manager to a near miss is (and I paraphrase), "Whew! That was close. Let's move on." That last statement is endemic of almost every company I've worked with - the desire to press ahead even (or especially) if the result wasn't perfect. But in ignoring the lessons of the near miss, they set the table for a subsequent, more terrible, occurrence.

Because, as the authors point out, the difference between the near miss and the catastrophe is one of circumstance and luck, not good planning or execution. A flawed process or sloppy execution repeated under less favorable conditions will eventually blow up.

Here's an important paragraph:

For the past seven years, we have studied near misses in dozens of companies across industries from telecommunications to automobiles, at NASA, and in lab simulations. Our research reveals a pattern: Multiple near misses preceded (and foreshadowed) every disaster and business crisis we studied, and most of the misses were ignored or misread. Our work also shows that cognitive biases conspire to blind managers to the near misses. Two in particular cloud our judgment. The first is “normalization of deviance,” the tendency over time to accept anomalies—particularly risky ones—as normal. Think of the growing comfort a worker might feel with using a ladder with a broken rung; the more times he climbs the dangerous ladder without incident, the safer he feels it is. For an organization, such normalization can be catastrophic. Columbia University sociologist Diane Vaughan coined the phrase in her book The Challenger Launch Decision to describe the organizational behaviors that allowed a glaring mechanical anomaly on the space shuttle to gradually be viewed as a normal flight risk—dooming its crew. The second cognitive error is the so-called outcome bias. When people observe successful outcomes, they tend to focus on the results more than on the (often unseen) complex processes that led to them.

This work reminds me of the research of Amy Edmondson, who studied the work of nurses and found that psychologically-safe working environments enabled sharing mistakes, which then allowed them to be correct, while unsafe environments covered up mistakes, with the result we can all well imagine.

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