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Learning to Deal with Drift

Posted by Ron Gantt on Thursday April 6th, 2017

In January 28th, 1986, the NASA Shuttle Challenger launched from Cape Canaveral, Florida, only to break apart 73 seconds later in a catastrophic chain of events that began with the failure of o-rings in a joint on the shuttle’s right solid rocket booster. All seven crew-members were killed in the disaster. Subsequent investigations by Diane Vaughan, William Starbuck, Frances Milliken, and others identified that although the technical cause of the accident was o-ring failure, and although official reports blamed management failures, the Challenger disaster was far more complex. The loss of the shuttle and lives of the astronauts could not be chalked up to any one failure, but rather to the interaction of organizational culture, individual risk perception, sensemaking, and decision-making under uncertainty.

Investigations into other significant failures have shown similar patterns of what the safety science community has come to call ‘organizational drift’, or ‘drift into failure’ when the drift results in a significant failure. Rather than viewing failures as the result of failed system components or erratic, unreliable people, organization drift sees failures as the result of incremental, locally rational adaptations. Drift is a function of normal people organizing and adapting to meet the challenges of complexity, such as goal conflicts and resource constraints.

This makes drift particularly challenging to identify, much less manage and avoid. First, because drift is inherently tied to locally rational adaptations, the drift makes sense to those in the moment. Indeed, to not engage in the actions that we call drift would seem inefficient and foolish. Organizational drift is inherently tied to how people adapt to achieve success within the organization. It should be noted that these adaptations achieve their goal most of the time, i.e., they are successful. It follows from this, secondly, that drift may not be something that the organization would wish to avoid at all, or else the source of much of the success the organization has may be eliminated in the bargain.

Instead, perhaps organizational drift should be seen as an inevitable feature of organizational life. Rather than being something that should be eliminated, perhaps organizations should seek to harness drift and create the conditions for drifting into success. This requires changing focus away from old models of management and safety that seek to merely constrain workers, towards a system built upon learning and improvement.

 

Recommended References

Starbuck and Milliken_Challenger

Dekker and Pruchnicki_Drifting into failure

Texas City Investigation Report

Management Strategies for Complex Adaptive Systems available at http://onlinelibrary.wiley.com/doi/10.1111/j.1937-8327.2007.tb00438.x/abstract

Risk Management in a Dynamic Society: A modelling problem available at http://www.sciencedirect.com/science/article/pii/S0925753597000520

More is Different available at http://science.sciencemag.org/content/177/4047/393

 

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Ron Gantt is Vice President and Principal Consultant with SCM Safety, a safety management consulting and training firm located in San Ramon, California. He has over 15 years experience in safety management in industries such as construction, utilities, and petrochemical. Ron is a Doctoral student in safety engineering at the University of Alabama at Birmingham studying organizational drift. He obtained a Master's Degree in safety engineering, as well as undergraduate degrees in psychology and occupational safety and health. Ron is adjunct instructor at Embry-Riddle Aeronautical University and a co-editor at SafetyDifferently.com

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