The Emperor’s New Clothes: When is an incident not really an incident?

Posted by Alan Smith



I am sure we are all familiar with The Emperor's New Clothes, a short fable by Hans Christian Andersen about two weavers who promise an emperor a new suit of clothes that they say is invisible to those who are unfit for their positions, stupid or incompetent.

It reminds me of an experience a number of years ago, when I was teaching an Incident Investigation and Root Cause Analysis course at a gas production facility in Algeria. Midway through the morning the class was interrupted by the arrival of a senior manager from the leadership team, desperately keen to award five students from a particular asset with t-shirts proclaiming another 100,000 hour incident-free milestone at their facility.

Amidst the back patting and proud posing for photographs for the company magazine, I had time to reflect on my interaction with the same five students in the previous days, during which they had candidly exchanged numerous repeat “near misses” at the very same facility.

Surely there must be some mistake? How could this possibly be? But - alas - how could I be so foolish? Of course a near miss was not counted in the company milestone league table as an incident as these were not perceived by the leaders as “real” incidents.

This is undoubtedly a great concept for t-shirt manufacturers but less so for those whom they adorn.  Aspiring towards a zero-incident safety culture is both noble and commendable but is it really real?

Having led or overseen numerous high-profile, tragic and very “real” incidents over the years, both as a former detective superintendent and director of Matrix Risk Control, one absolute common denominator is that each “real” incident is always preceded by a pattern of “non-real” minor incidents or misdemeanours. Typically - and revealingly - the root causes of these non-incidents will be the very same as those which cause the spectacular real incident.  Another day towards that t-shirt is another opportunity lost…

Those who have watched, or who plan to watch, the latest blockbuster Deepwater Horizon, should perhaps reflect on the less well-publicised tale of The Emperor's New Clothes.

The Deepwater Horizon drilling rig was the jewel in the company's safety crown, having enjoyed an extraordinary seven-year period devoid of significant incidents – an organisational record.

But was this flawless record a force for good? The reality is that this was an asset where praise and accolades were creating a dangerous level of self-confidence and belief akin to the emperor himself. Who would dare to suggest that all might not be as it seemed?

As would unfold in the subsequent investigation, all was not as it indeed seemed on this drilling rig: those at the heart of management and operations simply never saw the disaster coming. Years of “incident-free” activity, coupled with an over-confident workforce, had conspired to create the illusion - indeed culture - of a completely safe working environment to the extent that any alarm, confusion, deviations or anomalies were simply explained away. The setting aside of data or signals that didn't conform to expectations became the norm, in favour of information that did.

Of course there had been many “real” incidents in the years, months and weeks preceding the tragic blowout but, equally tragically, these went unnoticed or were overlooked. Recognition, investigation and analysis of any one of these incidents could have revealed that all was not as it seemed.

So why were these seemingly clear indicators missed? Ignorance? Recklessness? Blindly aggressive production mentality? No. This was simply a symptom of a theory or condition known as “normalisation of deviance” or, as I would call it, “organisational rust”.

Research into this phenomenon reveals that over a passage of incident-free time those at the heart of obvious high-risk activity become systematically disillusioned, allowing risks to creep up unchecked. The subsequent disaster, when it strikes, is perversely not the product of a violation of the normal daily routine but is a direct result of the normalised daily routine.

So be cautious - nigh sceptical - of the boasts of the “million hours incident-free” organisation as these claims could be as invisible and unlikely as the emperor's new clothes.

At Matrix Risk Control we believe that a successful incident management system begins not with the dreaded phone call but with an honest recognition, investigation and analysis of those gold dust “non-incidents”.

The t-shirt will just have to wait…

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incidentincident investigationDeepwater Horizonroot cause analysishealth and safetyincident reportingnear missesrisk management