Avoid Institutionalized Incident Nonsense
How to get past the nonsense and look at problems differently.
By Robert Ross on 11/12/2019
We do things all the time that have better alternatives without giving a single thought to it. It might be the way we tie your shoes, brush our teeth, or manage SEV1 globally impacting incidents for millions of users. This is such a deeply rooted instinct that it displays itself in the animal kingdom as well.
There’s an old story called “The Five Monkeys” that details how a group of monkeys will eventually learn to not climb a ladder to where bananas are hoisted. As the story goes, 5 monkeys are placed in a cage, and one begins to climb the ladder for the bananas only to be sprayed with water, the other monkeys included. Temptation settles in, and another monkey attempts to climb the ladder for the same bananas only for everyone to be doused again. Eventually, the monkeys start pulling down and scolding any monkey that starts climbing the ladder to avoid their cold, wet fate.
Some time passes, and a trainer replaces one of the monkeys with a different monkey. This new (naive) monkey obviously makes an attempt for the delicious bananas but is met with screeching and is pulled down from the ladder. Soon, another monkey of the original five is replaced with a new monkey. The new monkey scrambles for delicious bananas and is, again, pulled down by the monkeys and screamed at. The difference this time, though, is that the first replacement monkey also pulls down the poor feller and screams at it. How peculiar, considering that monkey never actually was sprayed with water.
This test certainly has gone through the telephone multiple times, but the story still paints a great picture of how we do things all the time without ever considering why we do (or don’t) do them at all.
I find the above experiment fascinating on its own, but when you start to look at the world around you with this frame of mind, you’ll see it all the time. Just look at the TSA.
The TSA was formed swiftly after the September 11th terrorist attacks on November 19th, 2001, a mere 69 days. Only a few weeks later, Richard Reid attempted to light a shoe bomb on a flight from Paris to Miami. However, it wasn’t until August 2006 that the TSA mandated all passengers must remove shoes to screen for explosives after intelligence indicated it was a continued threat.
If you were born in the late 1990s, you likely don’t remember the September 11th attacks. Your perspective is formed with stories, history, and days of remembrance. If young adults travel now, they’ve been taking their shoes off every single time they go to board a plane; it’s just the way it is. No questions, do as everyone else does. This includes no liquids and taking our jackets off, which were both results of attempted terrorist attacks as well.
This aligns with the five monkeys experiment we started with because it can be hard to see why we must take our shoes off now if we weren’t there for the reasoning that caused it in the first place. It’s also the logical start point for “Because that’s the way we’ve always done it!” when these young adults have kids of their own, and the kids begrudgingly ask, “Why do I have to take my shoes off mom?” - Because it really is the way they’ve always done it.
Creating new norms is challenging, especially when millions of people are affected by the change. Organizations like the TSA are unlikely ever to have a meeting about removing the shoe policy on its own. Change of policies usually has catalysts, and in the event of the TSA, it might be a dire one. The reality is, the TSA is not there to keep us safe; they’re there to give us the illusion we’re safe. It’s a classic case of security theater.
There are signs everywhere. So much so, we almost don’t see some of them anymore. If you drive, however, you are required by law to follow some simple signs. But not all road signage was always simple. In fact, the signs we have today are the way they are because of confusion, and yes, incidents.
Stop signs, for example, are a distinct octagon that bears the word “Stop” in white over a hard to miss red background. But before 1954, this was not the case. The original stop sign (which appeared in Detroit, Michigan in 1915) had black letters that said “Stop” and white background. They were short, only about 3-4 feet above the ground and a perfect square at 24” by 24”.
Stop signs weren’t standardized until 1922, however, giving them some of the distinct characteristics we see today. This only happened because motorists would come across multiple versions of the sign and either not see them at all or get confused. The octagon change has been in use since we change to reflection and size in the following years. Stop signs reduced overall crashes and improved flow of traffic. While this sounds great, it’s peculiar that we still default to stop signs at intersections rather than a vastly superior alternative: The Roundabout.
The roundabout has been in use longer than stop signs, first making its appearance in the United States in the 1790s when they were used in Washington DC (If you’ve ever driven in DC, they are everywhere). However, they didn’t gain much traction in the US. In the 1960s, Britain made adjustments to their roundabouts in the laws regarding who yielded to whom. The improvements from the change resulted in a massive effort to expand the number of roundabouts in the UK. The British can expect to come across a roundabout roughly every 127 intersections. The current iteration of a roundabout (There’s been a few, with one version called a “rotary”) has some incredible stats. The Insurance Institute for Highway Safety (IIHS) and the Federal Highway Administration in the USA have found they usually reduce collisions by 37%, 75% reduction in injury collisions, 40% for pedestrian collisions, and a whopping 90% reduction in fatalities.
So why, when all of the stats show roundabouts to be safer than signals or stop signs, are they not more popular in the United States?
There are a few opinions from varying sources, but one that I found particularly interesting came from this article where Lee Rodegerdts says:
My guess is that the possible benefit of roundabouts wasn’t widely known, and we had a long history of using traffic signals.
Or put another way, “That’s the way we’ve always done it!”
Stop signs are another example of how safety might be sold to us as a piece of historical normality. How could we challenge the efficacy of THE stop sign? Society knows how to use them when they are on-boarded into a driver’s seat. The possibility of changing how we cross intersections at a national scale is very far from reality.
We’ve all had a complaint about our jobs and how we approach certain things. Hands may wave violently as a member of the old guard explains via a history lesson why the thing we’re challenging is justified. As you identify these false feelings of safety, you may have a new challenge: moving the mountains. Pioneering change requires traversing the deeply rooted forest of normality. You’ll feel like you’re trying to feed a cat its medicine as it’s head violently thrashes back and forth, avoiding what is right for them. But the valley of change can be a game-changer for you and your organization.
Next time you have an incident and you head into a postmortem meeting, try identifying what the organization does just because that’s the way you’ve always done it. Do you create 30 action items to generate the oh so warm feeling of safety? Are managers attending and steamrolling the conversation just so a number on a TV in the hallway reads “99.99” next to the uptime metric? Are people on their laptops working on something else while the meeting is in session? (No that never happens)
Change for the benefit of safety can be daunting and exhausting, especially at larger organizations. Start small, find friends to help you, and don’t give up.
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