Internal investigations can be shallow in richness, relationships, and also time. Without the flow of events, ‘shallow time’ obliges managers to categorise and judge. When it comes to mishaps, curiosity needs animation: a story to explore, and the opportunity to explore it.
Stopping the clock at a ‘salient’ moment, leaves blurred the moments before and after. It makes it easy to apply a label and to add the mishap to a database. This is okay, so far as it goes—trends are useful—but a label can fool us into thinking that we know more than we do. I recall a colleague saying that once labelled as an ‘unstable approach’ a mishap would tend to live there, pinned like a butterfly to a board. The story leading to the aircraft’s approach and the story of its eventual landing were left as hazy background. An ‘unstable approach’ is eye-catching, but it is just one glimmer from a multifaceted mishap. Someone else’s eye might be caught by other facets, but only if the description makes them visible.
Stopping the clock makes it easier for managers to reach for ‘did not’ or ‘failed to’ phrases. They seem factual and efficient—neatly giving both cause and cure. However, ‘did not’ and ‘failed to’ rely on other facts, usually facts that are not given. More than this, the subtle segue from describing what happened to asserting what did not, has radical effects. It slyly provokes judgements about the people who ‘did not’ or ‘failed to’. As we know (e.g. from Daniel Kahneman and, somewhat earlier, David Hume) moral judgement easily leads reasoning, and bias. Sometimes ‘did not’ and ‘failed to’ are sound conclusions, but after sifting the facts, not instead of.
These two effects of stopping the clock are like a contracting bubble. If you talk through a mishap with those involved minutes after it has happened, you are in the bubble together. Politeness and empathy rule the situation inside the bubble. But once remote in time, it is easy to find oneself on the outside looking in at ‘them’ who are no longer ‘us’. ‘Objective’ and ‘sympathetic’ are not opposites. Usually there is some delay, but it need not force the manager to be remote. As a trainee, I was advised to ‘stay in present time’ when looking into mishaps. If there are enough facts, we can always join our colleagues in the bubble to see how the firm does its work.
Shallowness can also reflect how time is invested: managers need to allow enough time to complete an efficient process. Some mishaps reflect accepted risks; looking into them means checking that management’s model of the risk is valid. That can be quick: verify the facts, add them to the database, keep an eye on the statistics. The danger is that a fast process may leave little room for a manager to reflect on the validity question. Helpful templates and form-filling interfaces emphasise throughput. Indeed, firms sometimes find they have sped up the creation of records that are of little use. As noted by others, such tools make it easy to account for mishaps in ways that may “increase the likelihood of eventual surprise” (e.g. Weick and Sutcliffe, 2001; Hopkins, 2007). Although fast is not the same as efficient, neither is slow the same as thorough. The central issue is to be clear about the goals of looking into a mishap and the process that will reach them. Managers seem often to take those matters for granted.
This piece developed ideas set out in an earlier article. The next article will look at relationships as goals, and the role of giving and receiving explanations after mishaps.