Week 18: Resilience, Part Seven (Second Day, Mid-Day)

We were back in the garden.

I had been jostled awake as my fellow conference attendees exited the auditorium for our morning break.  After catching my bearings (and a quick check for drool) I joined them in the garden.

One of the nice things about this conference was the international flavor of the participants.  The speakers and practitioners were drawn mostly from the EU: Lund University in Sweden, Delft University in the Netherlands, and Paris Science and Lettres in France; with additional cohorts from Japan, the States, Brazil, and Russia.  As I navigated to the main house for coffee and a morning snack the conversations I overheard reflected this diversity: Dutch, German, Japanese, Portuguese, a stray strand of English, and probably others I did not recognize. This was much different than the aviation conferences I had attended during the previous ten years: English is the standard language of flight, and dominated lectures and conversations at these venues.  It was invigorating and a bit lonely at the same time.

After some coffee mixed with orange juice (they had run out of cream by the time I arrived) and a slice of veg and egg frittata, it was back to the auditorium.  And we were in for a treat: a presentation by Liberty Mutual’s Chief of Human Factors Research on the strengths and perils of sociotechnical systems.

For those not familiar, sociotechnical systems are those that combine people, technology, and the rules and procedures needed to operate effectively.  These systems tend to be large, such as hospitals, transportation and power generation systems, and nuclear power plants.  One common feature of these large entities is stratified leadership: corporate management, middle management, supervisors, and, at the bottom of the heap, the sharp end workers.  He explained that due to the complexity of these systems, no one person can understand them in full; and, depending on where you were compartmentalized by expertise, location in the hierarchy, and focus of attention, your mental model and goals could be vastly different than others operating within the same system.  Because each person or team in the structure has an incomplete model, decisions made in one area (which naturally ripple throughout a system) led to not only to intended consequences, but, in his experience as an insurance investigator, a vastly greater array of unintended consequences. (The eventual and permanent closure of Mill Stone (CT) Reactor 1 due to deferred maintenance was raised as an example.) He recommended that organizations should be viewed as control systems, and we should be careful which processes and goals are stressed as operational process and management commitment to safety are only two of the goals that need to be balanced.

I drifted through most of the day, catching lectures in railway control room operations, measuring excess capacity within systems, and resilience in healthcare, before drifting off again during another session I had been looking forward to, a panel discussion on resilience in practice by representatives from aviation, maritime and other domains.  I again woke, disappointed (and slightly defeated, did I really come all this way just to nap?), during the break.  Fortunately, two of the most dynamic presentations of the event were yet to come.

More soon!

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