The other day I was observing a medical first aid class, and the instructor was discussing the signs and symptoms of heart attacks. He showed a video from the deadliest catch where one of the people was clearly in distress and asked us to identify how we would know that he had a heart attack. Take a look at the video and see if you can tell.
Figure it out? It’s pretty easy. It’s the music.
Think about it. The easiest way to tell that this was a dangerous situation is the ominous music playing in the background telling you that, indeed, he’s not joking around.
My favorite definition of safety and resilience is that they are the capacity to be successful in varying conditions. Others have similar definitions, such as the capacity to fail safely. There is also a lot of discussion these days about something called adaptive capacity. All of these definitions and concepts share the common idea that capacity is a thing, and it’s a thing that we should pay attention to.
But what’s capacity?
Capacity is fundamentally about the ability or potential to do something. However, I differentiate between ability and capacity. When people use the word ability, they tend to mean more what an individual can do. Capacity involves individual ability but is also more than that. Capacity relates to a systemic ability or potential to do something.
For example, the music in the clip above that alerted us to the fact that the situation was serious is an external factor that works with our individual abilities to help us understand more clearly what is happening. The music tapped into the way we process situations to focus our attention. In a sense, the music increased our capacity to get to the right answer. The capacity was not any one thing though. It was the music interacting with how we evaluate music interacting with how we were evaluating the cues we saw.
In the same way, when we talk about building capacity to do something, we are meaning creating conditions when features of the environment interact with the features of the individuals involved to create the outcomes we are looking for. This is what differentiates capacity from other approaches to dealing with people. Whereas other approaches often seek to limit the negative aspects of people or perhaps even to eliminate people from the system altogether, approaches based on capacity seek to work with the innate potential of people. This does not mean that we see people as perfect. Instead, we recognize that what we call “error” is merely a product of human-environment mismatch. If we create more capacity within the situation, not only do we eliminate ‘errors’, but we create more success.
To build capacity, you first need to start by asking what it is you are trying to do. In the case of the clip above, the producers wanted the viewers to have the capacity to identify the situation as serious. So they created multiple cues pointing in that direction and minimized cues that would contradict that assessment. But in your role, capacity will likely be quite different. Below is a list of things to consider when determining what capacity is necessary to complete a task. Please do not consider this list exhaustive. It is only for illustration.
Tools. This one is straightforward. But if we are looking to build the potential for resilient performance, we should not only consider what tools are needed for the planned work but for the work that does not go exactly as planned (i.e., basically always)?
Competence. Every task involves some skill and knowledge. What is necessary for this task? For example, if you know the signs of a heart attack, you are less likely to need the music to tell you that the situation is serious because you’d recognize it in how the person was behaving. Sometimes the competence you need is not found in one person. Perhaps you need more than one or even something else (e.g., computational ability competence from a computer)
Time. All tasks require time. But no task exists in a vacuum. Other tasks must also be done, all competing for time. How can we provide the necessary planned and unplanned time to do them all? And what happens when we can’t do them all? How are we going to manage the trade-offs? Do people know how to prioritize amongst varying goals?
Space. All tasks require space to do. Diagnosing a heart attack does not take much space. Using a crane requires much more space. How much do you need?
System State Information. This is where things can get very complicated. By this I mean knowledge of the state of the system. What we are looking for is information about what the situation is. In the case of the clip above, the music gave us an added clue that this situation was not a funny one but rather a serious one. Some systems are designed to help deal with issues of time or competence but have the unintended consequence of reducing our knowledge about what’s going on. Automation is a big culprit in this area, where the system will act in ways that make it hard for operators to know what’s happening. Additionally, we have this problem whenever we have processes that define “safety” by the absence of accidents. They may influence people to think that the system must be safe if they go long periods without an accident, which may or may not be true.
Cognitive Processing. Humans process things in specific ways, and not always how we think they should (which is ironic), so how we provide information changes what people think about the situation and how they act. How information is conveyed to people is critical, whether it is visual or verbally. Read a Don Norman book if you want a primer on what this is about.
Cognitive Load. There’s a reason why people turn down the music they are listening to when they are looking for an address. Our minds can only process so much at any given time. Telling people to pay more attention doesn’t really work. We need to create a system that makes it easy to pay attention to the most critical things in the moment. And remember, there are always a multitude of things that could be drawing our attentional resources at any given moment.
Social System Influence. It is critical to note that none of the above happens in a vacuum. Humans are social creatures, and everything we do exists within a network of social systems exert influence on what we see and do. What something is, what behaviors are or are not appropriate, what we can and cannot say, and who has the power to make these determinations are socially determined. We ignore them at our peril.
It is also worth noting, as David Wood notes, the capacities needed for normal operations are likely quite different from, and likely compete with, the capacities required to operate in situations of high stress or pressure. But identifying that, first of all, capacities are what we actually manage (not risk per se), and identifying the specific capacities required to deal with both known and unknown situations to do work provide us with better ways to manage safety and operations. It takes a lot of work and thought, and you are never really done because situations are constantly changing. However, in doing this, we actually get at the essence of what safety and operational resilience are really about.
Excellent!!!
Thank you Ron for your excellent observations. Does your company have process in place to evaluate capacities/potentials? I have recently spoken to FAA audiences about resilience engineering and resilient potentials but have not been able to find examples of how companies have operationalized these concepts.
Thanks Richard. You’re right, there’s not a lot of examples out there that we can draw on unfortunately. The process I use is typically quite informal, using job observations and interviews. I don’t have a way to measure capacity as of yet. Although I would assume that one could utilize the resilience assessment grid to help with this. I have not tried it myself yet though.
Wonderful post!
Great points Ron, the issue for me though is that fundamentally the building of capacity requires a systemic approach to management and yet even now what has been termed the prevailing style is still founded on principles of division, reduction and optimisation of components viewed in isolation. Even taking safety as a separate part of work to be overseen by specialists is indication of how ingrained this approach is. It is no unrelated coincidence that the struggle to implement tools copied from Japan to attempt to match their success that have been going on since Lean was coined as a term and have been ongoing since the mid-80s is mirrored in the attempts to improve Health and Safety. You cannot have the level of sharing of knowledge necessary in an organisation that divides in order to rule and equates the inability to accurately predict the outcome of an intended action with personal responsibility for that failure, that trumpets teamwork and then isolates the performance of the individual from the environment they work within and that believes threat of punishment or offer of reward is the way to engage cooperation from humans who are still characterised as hands to be rented by the hour with their brains left at the door. (What else does having a Human Resources department indicate with each person defined by their Full Time Equivalent (FTE)?) What is most worrying is not that other ways are unknown or untried and tested but that they have been available since about 1950 and were acknowledged as being in use in the US, UK and even NZ BEFORE the Japanese were made aware of the potential benefits of working as a system and engaging in cooperation.
Ron – your post is starting to scratch the surface of what I believe is a great need here with the US workforce. With the mass exit of our boomer workforce over the next 10 yrs, we have the least amount of “capacity” left to spot the need for our next gen workforce to learn and develop their hands-on skillset (competency) to safely and reliably carry out whatever task they’re assigned as an individual or team.
How do we “assess” that Sid is having a heart attack? Well, as you stated, having trained individuals who know what signs to watch for (international sign of a person having a heart attack is to grab their chest and try to get away from others). Point is, we need trained and qualified occupational assessors who can measure the knowledge, skills, and ability of individuals/teams against recognized standards vs just a personal opinion on whether I think a person have the knowledge and capacity to perform. BTW: we need to hold our next gen. accountable to those standards.
To Richards question in the comments, yes there is a way to measure this and the US is the last industrialized nation to left not really doing that to a large extent. Space, Aviation, Nuclear, Medical all require competency assessment for those in critical roles, yet for everyone else we continue to “just train” then and expect they’ll figure it out once they get in the job.
I would suggest the only reason that has worked in the US is due to our large capacity of workers in the workplace, but now that is changing quickly. We’ve already started to see the rise in incidents where OSHA records. More and more events are due to a younger workforce with limited experiences, and very few older/wiser workers standing beside them to say: “do this, this, this, and don’t touch that (here’s why) and never left me see you by that!!!
Thanks Ron for touching on this subject. We need to have more discussions on how to prepare our next generation workforce to be successful. Getting them to stay with a single company longer term is for another post. If interested, look up Dr. Gustavo on that topic.
Thanks for the comment Daryl. I am concerned though with the idea of applying the standards of the past to the work environment of the future. Could there be a downside to this approach?
And do we have any evidence to suggest that the younger generations are responsible for any increase in injury rates? I wonder if looking at previous generational changes would be instructive to help us answer this question.
Ron –
Sorry for any confusion on my use of “standards” terminology. We need to create/develop occupational competency standards that are current to today’s work environments. This is what space, aviation, nuclear, medical have done to a large degree. They are controlled documents, just like a work procedure, and would have to be updated and maintained. Those competency standards would list the knowledge and performance criteria necessary to execute the assessment of an individual by a qualified workplace assessor.
On your second and third questions, yes and yes.We’re starting to see reports on injury rate increases with younger workers. My point remains that this is mainly not their fault. A majority of companies still only use a variety of training for new hires, relying heavily on their more experienced workers in place to help prevent/control incidents from happening. But, with fewer and fewer sr., competent workers in place as our new hires show up, they don’t know what they don’t know yet and without someone who is competent there to direct, we see the increase in events. So, with the ongoing loss of our competent workforce due to retirements, I would suggest we need to look at competency mg’mt as a central tool to help us develop and maintain the safety and technical competency of our next gen workforce here in the US, the same way our counterparts have done in the UK, Europe, Australia, etc…for those working on the frontline of operations. And don’t forget the critical role of their first level leader and their competency to lead them. Who’s developing and measuring that???
How fascinating to discuss capacity without any reference to learning, education and socialitie.
I assume it is just as fascinating as discussing capacity without any reference to food, water, or oxygen.
Sorry Ron, it just reads like an engineering understanding of capacity.
Fair enough. It wouldn’t be the first time you misunderstood something I wrote. 😉
Ron, my understanding of capacity is much more about intuition and this is backed up by a huge wealth of research. It’s not a matter of misunderstanding but rather differing worldview. Please don’t take this as personal but I don’t understand capacity for being and doing in such a way.
My perspective is based on a sociological and cognitive psychological view Rob and is also backed by research. Hence my comment about misunderstanding.
Yes, I understand but was just responding to the quantitative metaphors and language in the discourse (power/culture) and the absence of what I understand as critical aspects for a notion of capacity . eg. Intuition rather than ‘tools’, embodiment rather than ‘cognitive load’, socialitie rather than ‘social systems’ etc. Much better to chat offline if you want to chat again.
That’s all well and good but those terms are social science terms, not engineering terms. And my original comment to you was noting that the things you mentioned are mostly considered and present in the piece. There’s a reason they were not included and that reason is not that they are not important. Happy to discuss more if you’re curious.
yes, will email. Also fascinating that wood’s paper uses metaphors such as ‘mystery’ and ‘grace’ in an engineering struggle to understand wicked problems.
630,000 Americans die each year from heart disease. Maybe if we recognized the symptoms we could save a few. Those of you that needed the music to realize it was serious, should take a CPR class. Capacity also has to take weight into account. We don’t weigh the consequence appropriately and thus miss opportunities to act on insights. For example an American is more likely to die from over eating than a terrorist. Yet we spend 170 billion a year on anti terrorism. Being unable to recognize the symptoms that can kill hundreds of thousands per year is not capacity only…it’s availability bias. We act on the last thing we saw on the news.
We have to identify and weigh risk appropriately. More people die each year from suicide than from soldiers and crime.
The heart attack victim is exhibiting the most common male symptom of a heart attack. Denial.
And evidently so are we, if we think the music makes it serious.
Thanks for sharing.
Ron, a really interesting post. Some nice examples of resilience and creating the capacity to fail safe. This is an subject that needs much greater focus upon, particularly given that systems are increasingly hyper-connected and slack is being reduced. It’s often argued that the OHS profession has focused heavily on preventing error, rather than allowing for it through capacity. Articles like this provide examples of how to take a different perspective.
Illuminating! Thanks Ron
Nicely done Ron. It is easy for our mental models to view individual, social (teaming) and organisational capacities in isolation of each other when, in reality, it is their interplay that confounds outcomes. An individual or a team might have highly developed capacities but if those capacities are not enabled by the conditions, as manifested, within the organisational environment then they are at risk of not being fully realised and, therefore, rendering the system brittle to the inevitable variability “attacking” the good intentions of organisations. For me, that is at the heart of all ‘new safety’ concepts. We just need more empirical research to test and validate those concepts in operational contexts within and in collaboration with industry to establish those concepts.