Overcoming blind drift By designing to contain risk management can create an 'illusion of control' and an institutional blindness to the possibility of extreme events by ignoring weak signals, practical drift and the normalisation of risk.

Achieving safety via organisational ambidexterity The ability to achieve both efficiency, control, and incremental improvement as well as develop the flexibility, autonomy, and experimentation needed to deal with unexpected events. •  Structural (e.g. different departments, groups) •  Temporal (e.g. normal operations, high tempo and

emergency) •  Contextual (e.g. leaders and employees who can manage

the tensions/paradoxes)

Managing the unexpected

Complexity limits our ability to explain, predict and control…. resulting in uncertainty and stress.

Changing after extreme events Events that require "legitimate" recommendations to codify learning and institutionalise practices may constrain creative and flexible responses to an emerging future crisis event. Managing change in aftermath of an extreme event can be a wicked problem due to the multiplicity of stakeholders, the socially constructed nature of 'extreme' events, ambiguity relating to the cause, lack of precedents, the opportunity cost and unintended consequences of interventions, the difficulty of learning by trial and error and the inability to define an achievable endpoint – how safe is safe enough? Significant also are the media in shaping public perception and often transforming 'incidents' into 'real crises' worthy of a front-page story. Changes need to be embedded into the culture of the organisation.

Addressing latent flaws Active errors occur at the sharp end of the process. Latent errors occur at the blunt end (e.g. equipment design flaws or organisational flaws, such as staffing decisions) creating ‘holes’ in the ‘defensive layers” in the process :

Overcoming latent flaws and improving organisational capabilities in risk governance

Professor David Denyer

David Denyer, Professor of Organisational Change Email: david.denyer@cranfield.ac.uk

A strategic and integrating perspective on risk management

Increases understanding of the role of management practices and organisation culture in both the causation of extreme events and in enabling or constraining the implementation of lessons learned to prevent recurrence.

Centre  for  Customised  Executive  Development

Cross disciplinary approach

The research builds bridges between researchers in different f ields of study through the inter-disciplinary, collaborative and cross-sector approach.

Whole event

sequence

Through the application of a range o f methods, the research offers a detailed empirical and analytical account of extreme events from event ini t iat ion to implementation of lessons learned. Few previous studies address the whole event sequence

Preventing the failure of TECHNOLOGY AND

MANAGEMENT in complex systems

Dynamic Cause and effect are subtle, and where the effects over time of interventions are not obvious…. Senge Interactive Unfamiliar, unplanned, or unexpected sequences of events in the system particularly at the level of the working environment… Tightly coupled The parts are highly interdependent, that is, linked to many parts in a time-dependent manner - change in one part rapidly affects the status of other parts and influences the system’s ability to recover… “We should expect normal accidents’ (Perrow)

“Accidents do not occur because people

gamble and lose, they occur because people do not believe that the accident that is about to

occur is at all possible” Perrow

Informed decision making: avoiding biases, judgement traps, and bounded awareness Common biases that contribute to extreme events: •  ‘Overconfidence’ (tendency of decision-makers to

overestimate their abilities to consistently make effective decisions)

•  ‘Confirmation’ (tendency to seek out or put more weight on information that supports an initial opinion)

•  ‘Anchoring’ (being closely ‘wed’ to an initial thought and reluctant to adjust sufficiently away from it)

•  ‘Availability’ (tendency to consider information that is easily retrievable from memory as ‘more likely, more relevant, or more important’ for making the judgement)

•  ‘Hindsight’ (seeing events that have already occurred as being more predictable than they were before they took place)

•  Judgement traps that contribute to extreme events •  Rush to solve’ (a tendency to strive toward quick compromise

and early consensus, often to avoid conflict); •  ‘Groupthink’ (suppression of divergent views and/or

acceptance of dominant team members’ views expressed early on)

•  ‘Solving the wrong problem’ (often by not carefully/precisely defining the problem)

•  ‘Bounded awareness’ also contributes to extreme events •  ‘Inattentional blindness’ (failing to notice an unexpected

stimulus that is in one's field of vision when other attention-demanding tasks are being performed)

•  ‘Change blindness’ (failing to see changes in one’s environment)

Creating HROs High reliability organisations (HROs) are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement.