In today’s post I am pondering the question – as a regulator, should you be going towards or away from a target? Are the two things the same? I will use Erik Hollnagel’s ideas here. Hollnagel is a Professor Emeritus at Linköping University who has a lot of work in Safety Management. Hollnagel challenges the main theme of safety management as getting to zero accidents. He notes:
The goal of safety management is obviously to improve safety. But for this to be attainable it must be expressed in operational terms, i.e., there must be a set of criteria that can be used to determine when the goal has been reached… the purpose of an SMS is to bring about a significant reduction – or even the absence – of risk, which means that the goal is to avoid or get away from something. An increase in safety will therefore correspond to a decrease in the measured output, i.e., there will be fewer events to count. From a control point of view that presents a problem, since the absence of measurements means that the process becomes uncontrollable.
He identifies this as a problem from a cybernetics standpoint. Cybernetics is the art of steersmanship. The controller identifies a target and the regulator works on getting to the target. There is a feedback loop so that when the difference between the actual condition and the target is higher than a preset value, the regulator tries to bring the difference down. Take the example of a steersman of a boat – the steersman propels the boat to the required destination by steering the boat. If there is a strong wind, the steersman adjusts accordingly so that the boat is always moving towards the destination. The steersman is continuously measuring the difference from the expected path and adjusting accordingly.
Hollnagel continues with this idea:
Quantifying safety by measuring what goes wrong will inevitably lead to a paradoxical situation. The paradox is that the safer something (an activity or a system) is, the less there will be measure. In the end, when the system is perfectly safe – assuming that this is either meaningful or possible – there will be nothing to measure. In control theory, this situation is known as the ‘fundamental regulator paradox’. In plain terms, the fundamental regulator paradox means that if something happens rarely or never, then it is impossible to know how well it works. We may, for instance, in a literal or metaphorical sense, be on the right track but also precariously close to the limits. Yet there is no indication of how close, it is impossible to improve performance.
The idea of the fundamental regulator paradox was put forward by Gerald Weinberg. He described it as:
The task of a regulator is to eliminate variation, but this variation is the ultimate source of information about the quality of its work. Therefore, the better job a regulator does, the less information it gets about how to improve.
Weinberg noted that as the regulator gets better at what it is doing, the more difficult it is for them to improve. If we go back to the case of the steersman, perfect regulation is when the steersman is able to make adjustment at a superhuman speed so that the boat travels in a straight line from start to end. Weinberg is pointing out this is not possible. When 100% percent regulation is achieved, we are also cutting off any contact with the external world. This is also the source of information that the regulator needs to do its job.
Coming back to the original question of “away from” or “towards”, Hollnagel states:
From a control perspective it would make more sense to use a definition of safety such that the output increases when safety improves. In other words, the goal should not be to avoid or get away from something, but rather to achieve or get closer to something.
While pragmatically it seems very reasonable that the number of accidents should be reduced as far as possible, the regulator paradox shows that such a goal is counterproductive in the sense that it makes it increasingly difficult to manage safety… The essence of regulation is that a regulator makes an intervention in order to steer or direct the process in a certain direction. But if there is no response to the intervention, if there is no feedback from the process, then we have no way of knowing whether the intervention had the intended effect.
Hollnagel advises that we should see safety in terms of resilience and not as absence of something (accidents, missed days etc.) but rather as the presence of something.
Based on the discussion we can see that “moving towards” is a better approach for a regulator than “moving away” from something. From a management standpoint, we should deter from enforcing policies that are too strict in the hopes of perfect regulation. They would lack the variety needed to tackle the external variety thrown at us. We should allow room for some noise in the processes. As the variety of the situation increases, we should stop setting targets and instead, provide a direction to move towards. Putting a hard target is again an attempt at perfect regulation that can stress the various elements within the organization.
I will finish with some wise words from Weinberg:
The fundamental regulator paradox carries an ominous message for any system that gets too comfortable with its surroundings. It suggests, for instance, that a society that wants to survive for a long time had better consider giving up some of the maximum comfort it can achieve to return for some chance of failure or discomfort.
Please maintain social distance and wear masks. Please take vaccination, if able. Stay safe and Always keep on learning…
In case you missed it, my last post was The Cybernetics of the Two Wittgensteins:
- The Trappers’ Return, 1851. George Caleb Bingham
- Safety management – looking back or looking forward – Erik Hollnagel, 2008
- On the design of stable systems – Gerald Weinberg, 1979