3.11 SUMMARY
In the cases studied in this and the preceding chapter, a common thread was the reliance on erroneous views of one or more critical stakeholders. In the Royal Canberra Hospital case, we saw how there was an almost religious reliance on the expertise of the shot-firer. This expertise was flawed; the consequences were tragic. In the Black Hawk case, in Chapter 2, there was heavy reliance on the inexperienced Flight Lead pilot. This proved similarly tragic.
The case studied in this chapter contain a number of disturbing similarities to the Black Hawk helicopter crash studied in Chapter 2. The critical common thread is failure to appreciate, or understand, the inherent detail and dynamic complexity and underlying systemic structures. In turn, this became a major contributor to the failure to learn (from experience) and failure to manage the most influential risk factors, that is, those having the greatest consequence.
This raises an important challenge; to find effective ways to help stakeholders and decision-makers, alike, to become familiar with the cues associated with messy or wicked problems in order to catch them before they develop, or to minimise their consequences. This involves recognising their characteristic nature. Only then can effort be directed toward investigating underlying systemic structures and where effort might be directed to greatest effect.
In this chapter, the theme of failure to understand inherent complexity, failure to learn and, hence, failure to manage most important risks, is strengthened. Evidence presented here is that managers and decision-makers repeatedly failed to appreciate the significance of the complexity they faced. Further to Chapter 2, the suggestion is that they had unacceptably low rates of recognising or responding to highly relevant cues. This occurred despite recognition being a powerful human cognitive capacity. This suggests that the context did not enable recognition to occur, noting that recognition is highly context dependent. It is also obvious that other influences such as politics stifled or precluded the taking of necessary remedial action.
The deduction from the cases studied in Chapter 3, building on earlier chapters, is that problem-conceptualisation efforts should be directed at creating the context within which recognition is enabled. It is argued in subsequent chapters that how the context is created is not so important. The important issue is that the context is created. In subsequent chapters, how to create that context is investigated, as are barriers to achieving it.
From the empirical case studies, it is clear that managers and decision-makers can spend a good deal of their time being unaware of exactly what is developing around them. So, they become ineffective in meeting their responsibilities, or duties of care, to rectify routinely what, otherwise, might develop into insidious, systemic problems. The focus must remain directed at finding effective ways of enhancing situation awareness among managers and decision-makers. Situation awareness means more than developing ecological efficiency in use of heuristics; it means developing experience and understanding of behaviour of systems and systems-of-systems.
This chapter studied one particular case in considerable detail. It was found that underlying every systemic problem is a set of causal interrelationships, or ‘structures’, which create the environment for undesirable, or catastrophic, outcomes. These structures can exist and remain uncorrected for periods of years. But a reasonable person, with reasonable situation awareness should be able to identify systemic problems. If that person is in a position of responsibility, it is reasonable to expect they would make corrections that should routinely obviate the opportunity for undesirable or catastrophic outcomes to develop. As obvious as it seems after-the-fact, this describes risk management. These cases have significant theoretical and practical implications for the development of risk management or risk-mitigation strategies. Findings from this and the preceding chapter are incorporated in the principles of method described in Chapters 4 and 5.
Perhaps the biggest challenges for managers in finding out about problem situations within their domains of action, lies in firstly winning the information they need. The subsequent steps of bringing the problem situation into focus, thereby enabling recognition of the developing patterns we have seen in this and the preceding chapter will become much easier.