Right on. Field staff judgment, like safety itself, is an emerging property. This makes it a lousy contributing factor and a hopeless "root cause" for an incident. Judgment emerges from the structures in place around the upstream risks; how well they function but--more importantly--how well they are integrated. Staff training, for instance, has to be kept aligned with the gap between the minimum qualifications to be hired, and the experience, skills and cultural understanding needed to do the work well. Change either the qualifications to get in the door, as you might to recruit from a broader staff pool, or change the work, as you might when you develop a new program, and the training has to shift to align with a gap that is now a different shape and in a different place. Same with the field support systems; they need to change when any other part of the system changes.
Right on. Field staff judgment, like safety itself, is an emerging property. This makes it a lousy contributing factor and a hopeless "root cause" for an incident. Judgment emerges from the structures in place around the upstream risks; how well they function but--more importantly--how well they are integrated. Staff training, for instance, has to be kept aligned with the gap between the minimum qualifications to be hired, and the experience, skills and cultural understanding needed to do the work well. Change either the qualifications to get in the door, as you might to recruit from a broader staff pool, or change the work, as you might when you develop a new program, and the training has to shift to align with a gap that is now a different shape and in a different place. Same with the field support systems; they need to change when any other part of the system changes.
well said!