276 – Synchronicity, systems, facts and accidents…

1300 words (14 minutes reading time) by Lancing Farrell

I have been doing some diverse reading recently, some of it inspired by world events. Serendipitously, it has led me to an insight that I thought I would share.

Why we’re Polarized

The first book is Ezra Klein’s international bestseller ‘Why we’re Polarized’. He says the book is an examination of the American political system and that it is unlike most books on American politics, which he says tend to focus on the individuals.

“Let me be clear from the beginning: This is not a book about people. This is a book about systems.”

Ezra Klein, ‘Why we’re Polarized’

Klein is an American and says two decades of reporting on American politics has shown that it has predictable cycles and patterns that repeat. He sets out to explain the failure of the political system, which he says occurs despite it being ‘full of rational actors making rational decisions given the incentives they face’. He describes it as a collection of functional parts that combine into a dysfunctional whole.

I was reminded of a story the CEO of a regional council once told me about their town planning service and the Council’s frustration with it taking too long to issue permits. He had looked back over data from a 20-year period in which five CEOs had addressed this problem, only to find that only one of them had made any difference at all to the time taken. In the case of that CEO, they were a Town Planner and they assessed applications themselves and directly managed the planning team, which reduced the time to issue permits. When they left, the time taken went back to where it started.

I asked the CEO what the learning from this data was, and they said that it was that the problem was systemic. A powerful and motivated person could work around the system conditions and improve outcomes, but everyone else would be trapped into producing just what the system is capable of producing. It seems to have a lot in common with American politics.

Factfulness

Someone I worked with described the way that the world connects around you as ‘synchronicity’, which started happening to me when I picked up the book ‘Factfulness’, another bestseller. It is a beautiful book written by Hans Rosling, a Professor of Global Health, with assistance from his son and daughter-in-law.

In it Rosling says we each have ten ‘instinct-shaped’ holes in our ‘attention filter’ and that these holes shape the information we receive and how we process it, leading to many people having an ‘overdramatic’ worldview. I won’t say more because it is a book everyone should read. He discusses each of the ten instincts that create these holes and prevent us holding a ‘fact-based’ worldview and puts forward factfulness as the solution.

“Factfulness: The stress-reducing habit of only carrying opinions for which you have strong supporting facts.”

Hans Rosling, ‘Factfulness’

One of the ten instincts that Rosling thinks we need to understand and control is the tendency to try and find ‘a clear, simple reason for why something bad has happened’. He calls it the Blame Instinct. He says it is natural for us to think that a bad individual with bad intentions is responsible when things go wrong. He believes that people need to believe individuals have power and agency because otherwise the world feels unpredictable and frightening. Whatever the reason, this way of thinking exaggerates the importance of the actions of individuals and overlooks systemic factors.

Rosling says that when we blame someone it prevents us developing a true, fact-based understanding of the problem. It undermines our ability to solve the problem and prevent it happening again. He says that if you really want to change the world, you need to understand it and stop blaming people. This struck a chord with me and resonated with Ezra Klein’s thinking about the American political system. When something goes wrong it is easy to just blame someone, remove them from office, and pretend the problem has been solved. Then the pattern repeats.

Another important ‘instinct-shaped’ hole Rosling describes is the Single Perspective Instinct. He says we are attracted to attention-grabbing simple ideas and the belief that all problems have a single cause and a single solution. It is a version of the OECD thinking described in an earlier post. What could be simpler than blaming a person for something.

Human contributions to accidents

At about this point the synchronicity continued when I started reading about the work of Sidney Dekker in understanding the cause of workplace accidents. Ezra Klein says Dekker’s book ‘Drift into Failure: From Hunting Broken Components to Understanding Complex Systems’ is useful in understanding a political system. I am still waiting for this book to arrive but I found a fascinating article Dekker wrote in 2002 titled ‘Reconstructing human contributions to accidents: the new view on error and performance’. In this article, Dekker discusses the consequences for organisational safety of people behaving in ways that are consistent with Rosling’s Blame Instinct.

Dekker effectively says that blaming is the ‘old view’, which sees human error as a cause of failure. In this view, work systems are inherently safe and the threat to safety comes from the actions of people. It is the people that make work unsafe, and safety is improved by proceduralising and automating work, and in the selection, training and disciplining of people. We have all worked in this type of system. In contrast, the ‘new view’ sees human error ‘not as a cause, but as a symptom of failure’. If human error is the cause of failure, the critical question is what caused the human error?

This ‘new view’ says that human error is a signal and a sign of trouble deeper in the system. People are typically asked to work in systems with multiple goals, which often compete (e.g. get the job done on time, do it to the satisfaction of the customer, and do it safely). In this environment people have to create safety. It is a critical change in thinking that is well underway in workplace safety. In Victoria, we understand that the person having the accident is not responsible because they do their work in a system that the leaders have control over. Our law says leaders have ‘effective control’ and are responsible for the design of work.

“What is striking about many accidents in complex systems is that people were doing exactly the sorts of things they would usually be doing—the things that usually lead to success and safety. Mishaps are more typically the result of everyday influences on everyday decision making than they are isolated cases of erratic individuals behaving unrepresentatively.”

Sidney Dekker, ‘Reconstructing human contributions to accidents: the new view on error and performance’

It interests me that we understand that human error is not an explanation for failure in workplace accidents, and that instead we must understand the error-producing system conditions. We know that effective responses to workplace accidents don’t start and finish with the individual who had the accident and that we need to examine the system of work. Unfortunately, we don’t have the same understanding of failure in political systems, or for the other outputs of workplace systems.

My question is: Why we don’t have the same approach to all failures? Perhaps this is the really big paradigm change that local government needs.

Paradigm shift

In local government, the tendency to change CEOs the way America changes Presidents hasn’t worked. When CEO’s bring in new teams of Directors or General Managers it hasn’t worked either. Both types of changes appear to address fundamental problems with a bunch of new faces but after a while, and definitely as soon as the CEO leaves, the old problems re-emerge. It is like the town planning approvals problem I discussed earlier.

Many years ago, I heard the new CEO of a major Australian bank talking about savings measures implemented before he arrived to bring the organisation back on budget and describing them as being like ‘pushing footballs under water’ – as soon as you stop holding them under, they come to the surface. The ‘savings’ he was told had been made turned out to be simply cost cutting that was unsustainable without change to the system that was causing the budget over expenditures.

What is your organisation holding under water in the absence of a systemic approach?

‘Why we’re Polarized’ by Ezra Klein, 2021

‘Factfulness’ by Hans Rosling, Ola Rosling and Anna Rosling Ronnlund, 2018

‘Reconstructing human contributions to accidents: the new view on error and performance’ by Sidney Dekker, Journal of Safety Research 33 (2002) 371-385

One thought on “276 – Synchronicity, systems, facts and accidents…

  1. Pingback: 277 – Mediocrity at work. | Local Government Utopia

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