How Fragility Can Increase Risk in Organisational Systems

The concept of fragility can help OHS professionals in making more informed decisions about potential risks in systems and organisations, according to an expert in the area.

Fragile systems are more prone to complete failure, rather than just a minor breakdown, said Dave Whitefield, director of Semiosphere, a consulting firm that helps organisations tackle risk and uncertainty through culture, people and leadership.

“Within the safety and risk field, we are talking about core systems and processes that will look fine, and then fail, because we’ve been making them more fragile over time,” he said. “This will be systems around reporting, measurement, competence, permitting, risk management, emergency response, etc – all the big ones.

“So, when fragility is added into systems over time, they look fine, until they don’t, and then it’s chaos.”

While it is important to point out that fragility in itself is not necessarily bad, Whitefield said the point of talking about fragility is to shine a light on it: “to move it from being unseen and unspoken about, to being considered in decision-making,” said Whitefield.

“I think it’s vital that leaders understand when they are adding fragility, so they are making more of an informed, or a risk intelligent, decision.

“Fragility is added over time, and so risk (in this case risk of complete failure) accumulates in the systems over time.”

Whitefield spoke about the work of Nassim Taleb, who often best known for introducing the term “black swan” into the risk management world.

Taleb’s book Antifragile: things that gain from disorder focusses more on the unexpected, and often hidden, trade-offs and by-products associated with the implementation of many orthodox or traditional business practices, particularly in the systems space.

“In the end, fragility gives a framework to better understand how implementing strategies to reduce risk in one area of an organisation, may increase risk in another by introducing fragility, or in essence, making the systems and organisation more prone to failure as additional stressors are applied,” said Whitefield.

“This is often non-intuitive, and that’s why I typically frame it as a paradox; thus the title of my talk – fragility and the risk paradox.”

Some traditional safety strategies and initiatives actually end up increasing risk, and Whitefield said the concept of naive-intervention, which is essentially about intervening without fully understanding problem or context, can be found in the example of safety investigations.

“I often ask people in a safety role why they investigate incidents. The answer is usually about preventing further incidents,” said Whitefield.

“What this indicates is that corrective actions are an automatic and inevitable outcome of investigation activities. In this scenario, every incident has a cause, because every investigation has to have corrective actions.”

The problem, however, is that sometimes it is not known what happened and Whitefield said sometimes the real causes may not be available.

“Also, sometimes the causes are known, but the event isn’t serious enough to warrant corrective actions (this one really challenges some very traditional safety people),” he said.

“Where every incident has to be responded to with corrective actions, you’ll inevitably end up searching for smaller and smaller things, as well as blaming people (because they are always at the end of the line).”

Whitefield said this leads to intervening for the sake of intervening, even if the organisation doesn’t really understand what happened, and this, in turn, adds fragility because the investigation process becomes less meaningful and effective.

“The organisation learns less, and as the system becomes less useful because people value it less, and then it might then not work when it needs to,” he said.
Another example can be found in short- versus long-term thinking, and Whitefield said constant short-term thinking adds fragility because of the constant corrections and changes made to an organisation.

“We see this in the way organisations might overreact to short-term changes in incident data by demanding changes and improvements, when it might just be a data anomaly (or the data just isn’t reliable in the first place),” he said.

“It’s destabilising and changes behaviour because people overreact to everything.

“Again, I’m not saying not to react, do this, but to understand that when they do they may be making the organisation more fragile.”

Whitefield explained that people may report less, there is less long-term learning, or great ideas may not be realised because they are not given the time to come to fruition.

There are a number of strategies that can be used to remove fragility (or at least minimise the fragility that’s added into systems).

“Going back to my earlier example, one strategy is to separate investigations (of any sort) from corrective actions,” said Whitefield.

“What this looks like in practice is to anchor investigations to learning, and then, once you have learnt what you think happened, you can then choose a corrective action (if needed).

“It’s about giving space to sometimes say ‘We don’t know what happened, or maybe even ‘We know what happened, but we actually believe that what we were doing was reasonably practicable.’”

Skin in the game is another hallmark of reducing fragility, and Whitefield said this is simply making sure that anybody who will be affected by a decision, has a chance to give genuine input to the decision.

“Ironically, this is meant to be baked into our legislation and systems already in safety, but in practice, most safety decisions are made to frontline staff, not with them,” he said.

“Often leaders make decisions that either only affect others.”

Importantly, Whitefield said this isn’t about everyone signing onto a permit or risk assessment: “rather, this is about having to comply with the outcomes of decisions (policies and procedures) that you didn’t get a say in formulating.”

“So, it’s more about the permit or risk assessment process itself.”

Whitefield explained that it is easy for leaders to say that formal risk assessments must be completed for every task when they won’t actually be doing them – because it only applies to the field or factory.

“Again, I’m not saying you can do this every single time, but to understand that the more often skin in the game is missing, the more fragility will be added,” he said.

There are a number of important implications in this for OHS professionals, and Whitefield said it is important to come to terms with the concept of fragility.

“You have to decide whether you think this is a load of crap or a valid concept that helps explain unexpected trade-offs within organisations,” he said.

“I think it’s important to do some reading about fragility and to ‘try it on’ and see what you think.”

Whitefield said this might be uncomfortable because of the way it can clash with some traditional practices such as investigations or having centralised control processes.

“It’s entirely possible that your direct actions have been adding fragility so you really have to come to terms with that first and consider how you move forward,” he said.
“I mean, do you really agree with the idea that some events might not need corrective actions? Could less measurement and fewer KPIs actually be safer?

“Can you see deviations away from the predicted or planned path as expected and potential learning opportunity? If not, you might as well save your time and not bother learning more about this,” said Whitefield, who explained it’s not really worth learning about topics that directly confront your worldview until you’re ready to have it challenged.
“If you get that far, then it’s time to start having some more conversations within your organisations,” he said.

“I think it’s important to be able to talk about the concept in a pretty concise and meaningful

“I try to be careful and not demonise fragility (because it is often necessary to add it, and sometimes there is no choice), and instead I try to present this is simply a trade-off of typical organisations behaviour.

“It’s not that fragility is bad, it’s that often we are not aware of it being added or subtracted. In end I believe leaders should have an understanding of this so they can make informed risk decisions,” said Whitefield.

Article originally published by the Australian Institute of Health and Safety.