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. 

Kickoff blog 1

Here's a challenge.

I think anyone connected with safety or mishap investigations needs to rethink why we do investigations, rather than blindly accepting the folk wisdom about investigation purposes. I suggest that purposes like "to prevent recurrence!" or "find the cause or  probable cause or  root causes" or affix blame or find out what happened and why or find lessons learned or settle claims miss the ultimate purpose, and misdirect investigation practices.

I'd offer this simple candidate: TO CHANGE BEHAVIORS. The reason for investigating an occurrence is to find, understand and report the behaviors that produced an unwanted occurrence, and their context,  in a way that others engaged in similar behaviors can learn about them and apply that information to their future activities. 

I would argue that this purpose would change how investigators do investigations and what they produce, by focusing their inquiries on what people, objects or energies did during mishaps, and why they did that. I would argue further that this would improve future investigation efficiency, efficacy and value. I would also argue that this would produce better predictive understanding of mishap phenomena if it were applied to present system safety analysis practices.

Anyone want to defend the status quo?