This book* was suggested by a regular blog visitor. Below we provide a summary of the book followed by our assessment of how it comports with our understanding of decision making, system dynamics and safety culture.
Hollnagel describes a general principle, the efficiency-thoroughness trade-off (ETTO), that he believes almost all decision makers use. ETTO means that people and organizations routinely make choices between being efficient and being thorough. For example, if demand for production is high, thoroughness (time and other resources spent on planning and implementing an activity) is reduced until production goals are met. Alternatively, if demand for safety is high, efficiency (resources spent on production) is reduced until safety goals are met. (pp. 15, 28) Greater thoroughness is associated with increased safety.
ETTO is used for many reasons, including resource limitations, the need to maintain resource reserves, and social and organizational pressure. (p. 17) In practice, people use shortcuts, heuristics and rationalizations to make their decision-making more efficient. At the individual level, there are many ETTO rules, e.g., “It will be checked later by someone else,” “It has been checked earlier by someone else,” and “It looks like a Y, so it probably is a Y.” At the organizational level, ETTO rules include negative reporting (where the absence of reporting implies that everything is OK), cost reduction imperatives (which increase efficiency at the cost of thoroughness), and double-binds (where the explicit policy is “safety first” but the implicit policy is “production takes precedence when goal conflicts arise”). The use of any of these rules can lead to a compromise of safety. (pp. 35-36, 38-39) As decision makers ETTO, individual and organizational performance varies. Most of the time, things work out all right but sometimes failures occur.
How do failures occur?
Failures can happen when people, going about their work activities in a normal manner, create a series of ETTOs that ultimately result in unacceptable performance. These situations are more likely to occur the more complex and closely coupled the work system is. The best example (greatly simplified in the following) is an accident victim who arrived at an ER just before shift change on a Friday night. Doctor A examined her, ordered a head scan and X-rays and communicated with the surgery, ICU and radiology residents and her relief, Doctor B; Doctor B transferred the patient to the ICU, with care to be provided by the ICU and surgery residents; these residents and other doctors and staff provided care over the weekend. The major error was that everyone thought somebody else would read the patient's X-rays and make the correct diagnosis or, in the case of radiology doctors, did not carefully review the X-rays. On Monday, the rad tech who had taken the X-rays on Friday (and noticed an injury) asked the orthopedics resident about the patient; this resident had not heard of the case. Subsequent examination revealed that the patient had, along with her other injuries, a dislocated hip. (pp. 110-113) The book is populated with many other examples.
Relation to other theorists
Hollnagel refers to sociologist Charles Perrow, who believes some errors or accidents are unavoidable in complex, closely-coupled socio-technical organizations.** While Perrow used the term “interactiveness” (familiar vs unfamiliar) to grade complexity, Hollnagel updates it with “tractability” (knowable vs unknowable) to reflect his belief that in contemporary complex socio-technical systems, some of the relationships among internal variables and between variables and outputs are not simply “not yet specified” but “not specifiable.”
Both Hollnagel and Sydney Dekker identify with a type of organizational analysis called Resilience Engineering, which believes complex organizations must be designed to safely adapt to environmental pressure and recover from inevitable performance excursions outside the zone of tolerance. Both authors reject the linear, deconstructionist approach of fault-finding after incidents or accidents, the search for human error or the broken part.
Hollnagel is a psychologist so he starts with the individual and then extends the ETTO principle to consider group or organizational behavior, finally extending it to the complex socio-technical system. He notes that such a system interacts with, attempts to control, and adapts to its environment, ETTOing all the while. System evolution is a strength but also makes the system more intractable, i.e., less knowable, and more likely to experience unpredictable performance variations. He builds on Perrow in this area but neither is a systems guy and, quite frankly, I'm not convinced either understands how complex systems actually work.
I feel ambivalence toward Hollnagel's thesis. Has he provided a new insight into decision making as practiced by real people, or has he merely updated terminology from earlier work (most notably, Herbert Simon's “satisficing”) that revealed that the “rational man” of classical economic theory really doesn't exist? At best, Hollnagel has given a name to a practice we've all seen and used and that is of some value in itself.
It's clear ETTO (or something else) can lead to failures in a professional bureaucracy, such as a hospital. ETTO is probably less obvious in a nuclear operating organization where “work to the procedure” is the rule and if a work procedure is wrong, then there's an administrative procedure to correct the work procedure. Work coordination and hand-offs between departments exhibit at least nominal thoroughness. But there is still plenty of room for decision-making short cuts, e.g., biases based on individual experience, group think and, yes, culture. Does a strong nuclear safety culture allow or tolerate ETTO? Of course. Otherwise, work, especially managerial or professional work, would not get done. But a strong safety culture paints brighter, tighter lines around performance expectations so decision makers are more likely to be aware when their expedient approaches may be using up safety margin.
Finally, Hollnagel's writing occasionally uses strained logic to “prove” specific points, the book needs a better copy editor, and my deepest suspicion is he is really a peripatetic academic trying to build a career on a relatively shallow intellectual construct.
* E. Hollnagel, The ETTO Principle: Efficiency-Thoroughness Trade-Off (Burlington, VT: Ashgate, 2009).
** C. Perrow, Normal Accidents: Living with High-Risk Technologies (New York: Basic Books, 1984).