Pathological Organisations Do Not Learn
Dangerous accidents lie in the system, not in the components. (Perrow, 1984)
Learning from experience is a critical element in system safety. In this blog post, I will revisit the impact of safety culture on what response can be expected from an organisation when a major accident happens. More specifically, I will explain the main reasons why a pathological organisation is not supportive of public inquiry and, as a result, unable to learn from a tragic safety loss.
Background
According to Westrum (2004), patterns in information flow reflect the safety climate of an organisation. He identifies three typical patterns, inluding pathological, bureaucratic, and generative cultures. The first one describes a power oriented organisation that is preoccupied with personal glory and political power plays. The second one focuses on titles, rules, and departmental turf wars. The third one concentrates on the common mission objective, and not individual goals. These patterns create recognisable safety climates that shape the organisation’s response to the problems and opportunities it encounters.
In pathological organisations leaders only tolerate information sharing when it serves their personal interests or political goals. In response, there is very low cooperation between organisational units. Low- and middle-level managers do not speak up and, if they do, there is a tendency to shoot the messenger. Promotion is only available to those who are loyal, have a can-do attitude, and do not generate problems. Hazard and risk assessments become box-ticking excercises, or not done at all.
Typical response to a major accident
Whenever there is a failure, there is an immediate need to find a scapegoat. In an aviation context, this usually means that the organisation nominates either the pilot, the mechanic, or a technical (design) fault as the likely cause of the accident, whatever that means. Case studies and anecdotal evidence suggest that this nominated construct heavily influences investigation outcomes. Top managers suddenly become victims of their unit-level delegates and their “incompetent” subordinates who are “unable” or “unwilling” to cope.
A pathological safety climate usually elicits the following response to a major accident investigation: suppression, isolation, or a public relations (PR) excercise. Suppression comes as a natural response, including the withholding of information, classifying reports as a secret, selectively sharing critical evidence, etc. Isolation (or encapsulation) targets key messengers, making sure that their message is not heard by others. If all else fails, the organisation orchestrates a PR exercise to properly explain the context by obfuscating and delaying tactics, hoping to mitigate the impact on its senior leaders.
Impact on system safety
As mentioned in the first paragraph, learning from experience is critical to maintaining or improving system safety. Unfortunately, the inability to learn from accidents is a baked-in feature of a pathological safety culture. Based on past examples, the problem is so pervasive that even public safety inquiries - that should uncover the systemic causes of major accidents - can be derailed by the powerful negative response routines embedded in the organisation.
In summary, without shining a searchlight to the darkest corners of an organisation, even a public inquiry is powerless in identifying the required systemic changes. And without those changes, it is not only system safety that suffers. The real burden is carried by the families who are left behind.
References
Perrow, C. (1984). Normal accidents. Basic Books.
Westrum, R. (2004). A typology of organisational cultures. Quality and Safety in Health Care, 13. https://doi.org/10.1136/qshc.2003.009522