Systemic drift and rail accidents

Can the drift metaphor risk simplifying complex organisational phenomena, and result in generic cookie-cutter explanations and remedies?

A fascinating paper to be summarised discussed this in the context of rail infrastructure and rail accidents.

The author suggested a starting point is to expand on the drift metaphor.

He found four general theoretical categories of drift:

1) drift as gradual adaptation of behaviour based on local optimisation,

2) epistemological drift,

3) drift as an implication of complexity, and

4) drift and power.

He identified elements of different drift across rail accidents. For one, generational differences in technology generations (like centralised control operating with manual control), meant complex operating modes, multiple conflicting rule sets, and poor knowledge were in effect.

It was also found that railway work “often revert to more basic operating modes during infrastructure breakdown and planned maintenance and modifications of safety systems” (p117).

These basic operating modes during abnormal modes may lead to “operational complexity, loss of technical barriers, and increased dependence on human performance” (p117).

The tasks of drivers and traffic controllers was said to be particularly demanding, and this occurred at a time when “no technical barriers were in place to help the system recover from erroneous actions” (p117).

In concluding, the author states his paper was prompted by:

“a concern that the ‘‘drift’’ metaphor might account too easily for a broad range of accidents, leading to somewhat stereotyped calls for generic safety management remedies such as change analyses, tools for manoeuvring the safety space, or measures to promote rule compliance” (p125).

It was a fascinating read, but probably the most difficult yet for me to summarise.