Drift Into Failure, page 14
Our understanding of the psychological sources of failure is subject to reductive Newtonian recursion as well. In cases where the component failure of "human error" remains incomprehensible, we take "human error" apart too. Methods that subdivide human error up into further component categories, such as perceptual failure, attention failure, memory failure or inaction are now in use in air traffic control and similar linear, reductionist understandings of human error dominate the field of human factors. The classically mechanistic idea of psychology that forms the theoretical bedrock for such reductionist thinking of course predates human factors. Analytic reduction sponsors an atomistic view of complex psychological phenomena: understanding them comes from revealing the functioning or breakdown of their constituent components.
Even sociological or cultural phenomena are often explained using a reductionist approach. Much safety culture work, for example, breaks "culture" down into what individual employees experience or believe (mostly through attitude surveys about, for example, work pressure, management behaviors in relation to safety, risk perceptions), as well as the presence or absence of particular components of, for example, a safety management system, safety investments, worker qualifications or other safety arrangements. It measures those, adds them up and gets a number for a safety culture. Together, these components are assumed to constitute a "culture," yet it is never made clear how the parts become the whole. Such approaches meet with skepticism from those who see culture as something much more complex and incompressible:
Culture cannot be managed; it emerges. Leaders don't create cultures; members of the culture do. Culture is an expression of people's deepest needs, a means of endowing their experiences with meaning. Even if culture in this sense could be managed, it shouldn't be (...) it is naive and perhaps unethical to speak of managing culture.4
This is not to say that measuring these things is not meaningful. It may well identify interesting areas for safety intervention. But to say that it measures "culture" is making a particular set of Newtonian assumptions about the relationship between part and whole, between individual and society. This relationship is called into question by anthropologists like Hutchins, who argue that the regularities that are seen as characteristic for a culture (the whole) cannot be easily found inside the members (the parts):
A given group of individuals may enact different distributed cognitive processes depending on institutional arrangements. Observed patterns of behavior emerge from the interactions of the internal processes with structures and processes that are present in the environment for action. This means that the regularities that are often identified as being characteristic of a culture may not be entirely "inside" the individual members of the society in question and may not generalize across activity settings. From the contextual point of view, the term culture can be read as a shorthand label for an emergent uneven distribution of a variety of material, social, and behavioral patterns that result from a universal human process.5
The atomistic view of culture or community or society sees the relationship between parts and whole as unproblematic. The parts simply add up to make the whole. If parts are imperfect or even missing (for example, if particular components of a safety management system are incomplete, or access to the boss with safety concerns is impossible), then this will add up to a culture in a straightforward way, to a measurable safety culture (or lack thereof). This logic (of a simple, additive relationship between parts and the whole) is so pervasive that Margaret Thatcher even denied die existence of community or society altogether in an interview in 1987: "... there is no such tiling as society. There are individual men and women, and there are families." From that extreme point of view, there are only atoms, parts, components. And somehow, they make up a whole. But for that point of view, the whole isn't the point. It's the parts and the easily added numbers they represent.
It is interesting to note that such a position is quite consistent with Western, and often Protestant societies. Through the Enlightenment, and the intellectual tradition since the Scientific Revolution, it has seemed self-evident to evaluate ourselves as individuals, bordered by the limits of our minds and bodies, and that we get assessed in terms of our own personal achievements. From the renaissance onwards, the individual became a central focus, fueled in part by Descartes' psychology that created self-contained individuals. The rugged individualism developed on the back of mass European immigration into North America in the late nineteenth and early 20th centuries accelerated the image of independent, free heroes accomplishing greatness against all odds, and anti-heroes responsible for disproportionate evildoing. The notion that it takes teamwork, or an entire organization, or an entire industry (think of Alaska 261) to break a system is just too eccentric relative to this cultural prejudice.
The philosophy of Newtonian science is one of simplicity: the complexity of the world is only apparent and to deal with it we need to analyse phenomena into their basic components. The way in which legal reasoning in the wake of accidents separates out one or a few actions (or inactions) on the part of individual people follows such reductive logic. For example, the Swedish Supreme Court ruled that if one nurse had more carefully double-checked a particular medication order before preparing it (mistakenly at 10 times the intended dose) a three month old baby would not have died. Such condensed, highly focused accounts that converge on one (in)action by one person (the "eureka part") give componential models of failure a societal legitimacy that keeps reproducing and instantiating Newtonian physics.
Causes for Effects Can be Found
In the: Newtonian vision of the world, all that happens has a definitive cause and a definitive effect. In fact, there is a symmetry between cause and effect (they are equal but opposite). The determination of the "cause" or "causes" is, of course, seen as the most important function of accident investigation today, and assumes that physical effects (a crashed airliner, a dead patient) can be traced back to physical causes (or a chain of causes-effects). The notion that effects cannot occur without causes makes it into legal reasoning in the wake of accidents too. For example, "to raise a question of negligence, harm must be caused by the negligent action."6 It is assumed that a causal relationship (that negligent action caused harm) is indeed demonstrable, provable beyond reasonable doubt.
The Newtonian view of the world that holds all this up is materialistic: all phenomena, whether physical, psychological or social, can be reduced to matter, that is, to the movement of physical components inside three-dimensional Euclidean space. The only property that distinguishes particles is where they are in that space. Change, evolution, and indeed accidents, can be reduced to the geometrical arrangement (or misalignment) of fundamentally equivalent pieces of matter, whose interactive movements are governed exhaustively by linear laws of motion, of cause and effect. A visible effect (for example, a baby dead of lidocaine poisoning) cannot occur without a cause (a nurse blending too much of the drug). The Newtonian assumption of proportionality between cause and effect can in fact make us believe that really bad effects (the dead baby) have really bad causes (a hugely negligent action by an incompetent nurse). The worse the outcome, the more "negligent" its preceding actions are thought to have been. In road traffic, talking on a cell phone is not considered illegal by many, until it leads to a (fatal) accident. It is the effect that makes the cause bad.
The Newtonian model has been so pervasive and coincident with "scientific" thinking, that if analytic reduction to determinate cause-effect relationships (and their material basis) cannot be achieved, then either the method or the phenomenon isn't considered worthy of the label "science." This problem of scientific self-confidence has plagued the social sciences since their inception, inspiring not only Durkheim to view the social order in terms of an essentialist naïve Newtonian physics, but also for example to have Freud aim "to furnish a psychology that shall be a natural science: that is, to represent psychical processes as quantitatively determinate states of specifiable material particles, thus making those processes perspicuous and free from contradiction."7 Behaviorists like Watson reduced psychological functioning to mechanistic cause-effect relationships in a similar attempt to protect social science from accusations of being unscientific.8
The Foreseeability of Harm
According to Newton's image of the universe, the future of any part of it can be predicted with absolute certainty if its state at any time was known in all details. With enough knowledge of the initial conditions of the particles and the laws that govern their motion, all subsequent events can be foreseen. In other words, if somebody can be shown to have known (or should have known) the initial positions and velocities of the components constituting a system, as well as the forces acting on those components (which in turn are determined by the positions of these and other particles), then this person could, in principle, have predicted the further evolution of the system with complete certainty and accuracy. A system that combines the physiology of a three-month old baby with the chemical particles diethylamino-dimethylphenylacetamide that constitute lidocaine will follow such lawful evolution, where a therapeutic dose is less than 6 mg lidocaine per gram serum, and a dose almost 10 times that much will kill the baby.
If such knowledge is in principle attainable, then the harm that may occur if particles are lined up wrongly is foreseeable, too. Where people have a duty of care (like nurses and other healthcare workers do) to apply such knowledge in the prediction of the effects of their interventions, it is consistent with the Newtonian model to ask how they failed to foresee the effects. Did they not know the laws governing their part of the universe (that is, were they incompetent, unknowledgeable)? Were they not conscientious Or assiduous in plotting out the possible effects of their actions? Indeed, legal rationality in the determination of negligence follows this feature of the Newtonian model almost to die letter: "Where there is a duty to exercise care, reasonable care must be taken to avoid acts or omissions which can reasonably be foreseen to be likely to cause harm. If, as a result of a failure to act in this reasonably skillful way, harm is caused, the person whose action caused the harm, is negligent."9
In other words, people can be construed as negligent if the person did not avoid actions that could be foreseen to lead to effects — effects that would have been predictable and thereby avoidable if the person had sunk more effort into understanding the starting conditions and the laws governing the subsequent motions of the elements in that Newtonian sub-universe. Most road traffic legislation is founded on this Newtonian commitment to foreseeability too. For example, a road traffic law in a typical Western country might read how a motorist should adjust speed so as to be able stop the vehicle before any hinder that might be foreseeable, and remain aware of the circumstances that could influence such selection of speed.10 Both the foreseeability of all possible hinders and the awareness of circumstances (initial conditions) as critical for determining speed are steeped in Newtonian epistemology. Both are also heavily subject to outcome bias: if an accident suggests that a hinder or particular circumstance was not foreseen, then speed was surely too high. The system's user, as a consequence, is always wrong. And any search for the cause of failure will therefore always turn up a broken part.
Time-Reversibility
The trajectory of a Newtonian system is not only determined towards the future, but also towards the past. Given its present state, we can in principle reverse the evolution to reconstruct any earlier state that it has gone through. The Newtonian universe, in other words, is time-reversible. Because the movement of, and the resulting interactions between, its constituent components are governed by deterministic laws of cause and effect, it does not matter what direction in time such movements and interactions are plotted. Such assumptions, for example, give accident and forensic investigators the confidence that an event sequence can be reconstructed by starting with the outcome and then tracing its causal chain back into time. The notion of reconstruction reaffirms and instantiates. Newtonian physics: our knowledge about past events is nothing original or creative or new, but merely the result of uncovering a pre-existing order. The only thing between us and a good reconstruction are the limits on the accuracy of our representation of what happened. We then assume that this accuracy can be improved by "better" methods of investigation, for example.
Completeness of Knowledge
The traditional Western belief in science is that its facts have an independent existence outside of people's minds: they are naturally occurring phenomena "out there," in the world. The more facts a scientist or analyst or investigator collects, the more it leads, inevitably, to more, or better, science: a better representation of "what happened." The belief is that people create representations or models of the "real" out there, models or representations that mimic or map this reality. Knowledge is basically that representation. When these copies, or facsimiles, do not match "reality," it is due to limitations of perception, rationality, or cognitive resources, or, particularly for investigators or researchers, due to limitations to methods of observation. More, or more refined methods and more data collection, can compensate for such limitations.
Newton argued that the laws of the world are discoverable and ultimately completely knowable. God created the natural order (though kept the rulebook hidden from man; instead God gave man intelligence to go figure it out for himself) and it was the task of science to discover this hidden order underneath the apparent disorder. The Newtonian view is based on the reflection-correspondence view of knowledge; our knowledge is an (imperfect) mirror of the particular arrangements of matter outside of us.11 The task of investigations, or science, is to make the mapping (or correspondence) between the external, material objects and the internal, cognitive representation (for example, language, or some mental model) as accurate as possible. The starting point is observation, where information about external phenomena is collected and registered (for example, the gathering of "facts" in an accident investigation), and then gradually completing the internal picture that is taking shape. In the limit, this can lead to a perfect, objective representation of the world outside.12 The world is already there, pre-formed and pre-existing. All we need to do is uncover and then describe the order that the world already possesses, that it was given by its creator.
The Newtonian position can be recognized in what society generally sees as high science today. The leader of the International Human Genome Sequencing Consortium and currently director of the U.S. National Institutes of Health recently wrote a book entitled The Language of God.13 For him, the sequencing of the human genome (our genetic information, stored on 23 chromosomes and occupied by more than three billion DNA base pairs) was ultimately a discovery of God's language: God's code in which the essence of humanity had been written. The language, the order, had been there for thousands of millennia already. But at the closing of the second millennium CE, science had finally arrived at a method to lay it bare. It is a position that inspires awe and respect: people can marvel in the amazing creation.
But the human genome project revealed that the supposedly pre-existing order of the building blocks of life (DNA) severely underdetermines how the complex system looks, or works, or fails. Only about 1 percent of the 3 billion base pairs actually code for human features that we know about. Humans have fewer than double the number genes of very basic organisms such as fruit flies and roundworms, and have more than 99 percent genes in common with chimpanzees. Genetically, we are even closer to Neanderthals. This is typical for complex, as opposed to Newtonian, systems. Complexity implies an ultimately intractable relationship between the parts and the whole.
What is more, the language that the Human Genome Sequencing Consortium uncovered was actually hardly orderly, and hardly entirely pre-existing. Human cells make extensive use of alternative splicing by which a single gene can code for multiple proteins, which already explodes any straightforward relationship between parts and whole. There also seem to be nonrandom patterns of gene density along chromosomes which are not well understood, and regions of coding and non-coding DNA. Then there is gene-switching: the ability to turn genes on or off through the organism's interaction with its changing environment.
The human genome, in other words, can at best be described as a set of hardware, which in turn can run all kinds of versions of software and thousands of different and partially overlapping and even contradictory programs at the same time. Complex systems are open systems, and so is the human genome. It is this openness to the environment and the system's ability to recognize, adapt, change, and respond that renders any project to describe the pre-existing order quite hopeless. When you think you've described the system once, you'll find that it will have morphed away from your description before you're even done. And even any temporary or tentative description of the arrangement of parts spectacularly underdetermines what can be observed at the system level.
Founding sociologist Emile Durkheim took the same Newtonian position for social science in the nineteenth century. Underneath a seemingly disordered, chaotic appearance of the social world, he argued, there is a social order governed by discoverable laws (obligations and constraints) and categories of human organization (institutions). As with the theological reading of the human genome project a century-and-a-half later, Durkheim wanted to pursue the essential properties of social systems: those features that are enduring, unchanging, and that can be discovered and described independent on who does the discovering or describing, from what angle or perspective, and at what point in time. Such "essentialism" is typical for Newtonian science: the idea that behind our initial befuddlement and confusion of the world as it meets us, lies an unchanging, preexisting order of hard facts that we can lay bare in due time.
