What if everybody did everything right?

In the wake of an incident, we want to answer the questions “What happened?” and, afterwards, “What should we do differently going forward?” Invariably, this leads to people trying to answer the question “what went wrong?”, or, even more specifically, the two questions:

• What did we do wrong here?
• What didn’t we do that we should have?

There’s an implicit assumption behind these questions that because there was a bad outcome, that there must have been a bad action (or an absence of a good action) that led to that outcome. It’s such a natural conclusion to reach that I’ve only ever seen it questioned by people who have been exposed to concepts from resilience engineering.

In some sense, this belief in bad outcomes from bad actions is like Aristole’s claim that heavier objects fall faster than lighter ones. Intuitively, it seems obvious, but our intuitions lead us astray. But in another sense, it’s quite different, because it’s not something we can test by running an experiment. Instead, the idea that systems fail because somebody did something wrong (or didn’t do something right) is more like a lens or a frame, it’s a perspective, a way of making sense of the incident. It’s like how the fields of economics, psychology, and sociology act as different lenses for making sense of the world: a sociological explanation of a phenomenon (say, the First World War) will be different from an economic explanation, and we will get different insights from the different lenses.

An alternative lens for making sense of an incident is to ask the question “how did this incident happen, assuming that everybody did everything right?” In other words, assume that everybody whose actions contributed to the incident made the best possible decision based on the information they had, and the constraints and incentives that were imposed upon them.

Looking at the incident from this perspective will yield will very different kinds of insights, because it will generate different types of questions, such as:

• What information did people know in the moment?
• What were the constraints that people were operating under?

Now, I personally believe that the second perspective is strictly superior to the first, but I acknowledge that this is a judgment based on personal experience. However, even if you think the first perspective also has merit, if you truly want to maximize the amount of insight you get from a post-incident analysis, then I encourage you to try to the second perspective as well. Make the claim “Let’s assume everybody did everything right. How could this incident still have happened?” I guarantee, you’ll learn something new about your system that you didn’t know before.