Monday, March 3, 2008

Drifting toward failure

This expression is being recognized with growing frequency in major investigations like the Challenger loss. It reflects ideas about the responsibility of managers to direct their operations in a "safe" way, coming our of the human factors community.  A recent book called 10 Questions about Human Error, by Sidney Dekker, discusses it at length.

This  ideas behind the expression create some interesting challenges for mishap investigators. To name a few, what data should an investigator seek to illustrate this "drift" in a specific investigation? How does an investigator identify and acquire data that has to be coupled to the outcome of a mishap to show this "drift" in the context of when the mishap occurred? How should an investigator present the data to demonstrate its influence on the outcome in an objective, logical, persuasive and verifiable way? What risks are inherent in the investigating and reporting of this "drift" and who can be at risk of harm if the investigator does not do it properly? How can the quality of the reported drift be assessed or ensured? Are the answers primarily dependent on the investigator's experience or the methodology selected, or something else? 

As one ponders this expression and the ideas behind it, it becomes evident that they have application to many  kinds of activities other than mishaps.