How often is there really just a single cause when things go wrong? In the wake of an incident rarely is it as simple as putting the pieces back together again until fault is found.
We need think beyond a simplistic cause and effect model – beyond the view that the cause has either a physical (mechanical failure) or cognitive (human error) route. Otherwise we risk people on the front-line being perpetually blamed for the symptoms of more profound problems in an organisation.
A better way to approach an incident is to investigate it in the context of a wider system. Look at how one part of a complex system affects others, even if at first they seem unrelated.
Two Parts of a system performing sub-optimally, local drift to meet their needs, not recognising the wider implications
Yes, an individual’s influence on the system is important but other aspects like personalities in their team, the task at hand, the working environment and, in some circumstances, even the influence of the regulatory framework in which an organisation functions.
At JOMC our tried and tested approach is to look for root causes within an organisation holistically from every angle – to discover problems before accidents ever even happen. From culture assessments to one-to-one interviews and group workshops, all are underpinned by our conversational approach and supported by our Engage learning platform.
However you assess culture, keep an open-mind and expect to trace problems which have their origins in multiple areas within complex systems.