Accident debriefing bingo
Postmortems and distancing through differencing
Overview
Have you ever participated in an event investigation or post-incident postmortem and heard participants say
That wouldn’t have happened to us…
This is a form of denial, and is common after accidents. Next time you’re in that situation, try playing a game of Accident debriefing bingo. See how long it takes to check a complete row or column of postulated “reasons” why your organization or system wouldn’t be affected by this kind of problem.
Learning after an accident is subject to multiple barriers, one of
which is denial. It is based on a “distancing through differencing”
phenomenon [Cook and Woods
2006], in which people attempt to identify reasons for which
the event would never occur on their site.In psychology, social distance describes the
amount of separation between different groups in society; it’s a measure
of “us”/“them” differences.
This is a natural psychological tendency: accepting that
an accident could happen to us is quite frightening, and (for safety
specialists) calls into question our professional competencies.
Illustration
The Blayais nuclear power plant in France, located on an estuary near Bordeaux, was affected by a severe flooding event in 1999. Tide and winds from a storm led to water levels higher than the protective dikes around the facility, and disabled the plant’s offsite power supply as well as a number of safety systems.
Multiple lessons were learned from this event, leading to changes to a number of other nuclear power plants in France (reassessment of the validity of flood models and of the strength of protective dikes, organization of emergency response). However, these measures were not adopted by all countries operating nuclear power plants.
Denial is contrary to the preoccupation with failure encouraged by HRO researchers.
References
Cook, Richard I., and David D. Woods. 2006. Distancing through differencing: An obstacle to organizational learning following accidents. In Resilience Engineering: Concepts and Precepts, edited by Erik Hollnagel, David D. Woods, and Nancy Leveson. Ashgate, ISBN: 978-0754646419.
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