SafetyInsights.org

What-you-look-for-is-what-you-find.

In other words, if you go into something expecting to find error, non-compliance, management or design issues, you will likely find them (see Friday’s post, linked in comments).

As Scott Snook put it regarding the accidental shootdown of two friendly US Blackhawk helicopters in 1994, “the more expected an event, the more easily it is seen or heard”.

Further, as Weick argues “seeing is not necessarily believing; sometimes, we must believe before we can see”.

US F15 pilots expected to see enemy helicopters, not friendly helicopters, that allowed them to interpret ambiguities and uncertainties in the environment to what they expected to see.

Similarly, safety investigations are also influenced and constrained by the mental models and expectations of investigators. Dekker in his 2014 paper highlights an example from aviation. Here, investigation conclusions are contrasted between the aviation authority versus the involved airline.

In this example, it’s argued that while two investigations of the same incident “produced radically different conclusions … it is not merely their conclusions that differ” (p3).

Rather, “Both stories narrate the same broad events, with the same players in it, but still they tell two entirely different stories which presage their respective (and different) conclusions. Political agendas in accident investigation are pursued by omitting, marginalising and selectively highlighting” (p.3).

He argues that, in part, while investigations may be seen as objective exercises of facts, findings and causes, they’re also heavily a form of political sensemaking: different stakeholders, with different competing objectives, contradictions and narratives.

If you’d like a more comprehensive example: check out the multiple investigation/inquiry reports around Macondo – internal vs external, and different stakeholder groups.

Source: Dekker. (2014). Theoretical Issues in Ergonomics Science, 2014

1. Study link: http://dx.doi.org/10.1080/1463922X.2014.955554
2. Link to the LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_what-you-look-for-is-what-you-find-in-activity-7055697903922675712-g8Uc?utm_source=share&utm_medium=member_desktop
3. What-you-look-for-is-what-you-find: https://www.linkedin.com/posts/benhutchinson2_an-update-and-repost-of-one-of-my-favourite-activity-7054926563921784832-KWDK?utm_source=share&utm_medium=member_desktop