Wednesday, July 29, 2009

Self Preservation (MIT #4)

The MIT paper [pg 7] introduces the concept of feedback loops, an essential ingredient of systems dynamics, and critical to understanding the dynamics of safety management.  The MIT authors suggest that there is a “weak balancing loop” associated with individuals responding to a perceived personal threat associated with increased incident rates.  While the authors acknowledge it is a weak feedback, I would add that, at best, it represents an idealized effect and is hard to differentiate from other feedbacks that individuals receive such as management reaction to incidents and pressures associated with cost and plant performance.  The MIT paper [pg 8] goes on to address management actions and states, “When faced with an incident rate that is too high, the natural and most immediately effective response for managers is to focus the blame on individual compliance with rules.”  Note the conditional phrase, “most immediately effective” as it is an example of single loop learning as described in one of my prior posts (MIT #3).  Certainly the fact that procedure adherence is an issue that recurs at many nuclear plants suggests that the “blame game” has limited and short term effectiveness.

My sense is that the self preservation effect is one that exists deeply embedded within the larger safety climate of the organization.  In that climate how strictly is rule adherence observed?  Are procedures and processes of sufficient quality to enhance observance?  If procedures and processes are ambiguous or even incorrect, and left uncorrected, is there a tacit approval of alternate methods?  The reality is self preservation can act in several directions – it may impel compliance, if that is truly the organizational ethic, or it could rationalize non-compliance if that is an organizational expectation.  Life is difficult.

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