How do we act?
Routine thinking is everyday thinking where thinking and action are intimately related but without necessarily the need for explicit and reflective justification of the reasons for decisions. Reflective practice is serious deliberative thinking and continuous learning required of a professional practical decision maker, such as medical practitioners and engineers responsible for the safety of others through a public duty of care.
Action changes an object. The change may or may not be intended. In other words some intended actions result in unintended consequences and these may well sometimes be major surprises. Performance is a sequence of changes and may or may not be the executing or carrying into effect or fulfilling a command, promise or undertaking. Performance may be the manner in which an object fulfils its intended purpose and it is in this sense that practice is performance to achieve a stated purpose.
Damage is change to an object, due to interactions with other objects, which reduces quality or fitness for purpose.
Robustness, redundancy, vulnerability, resilience, adaptability and risk are all attributes of a process that are not well understood
Robustness is strength in all possible modes of failure. Robust systems are sturdy, hardy, they endure and are tolerant of damage. An object is robust if it resists damage and, if damaged, resists the propagation of that damage. Redundancy is having additional connections over those that are strictly necessary and which may or may not have a role and do work. A critical object is one that can have decisive importance in a context. A critical state of an object is one in which abrupt change may occur. Progressive failure, cascading, propagating or unzipping occurs when, after some initial damage, further damage progresses dependant on previous damage and without extra inputs, through many limiting conditions and damage states of increasing scope, breadth and consequences. Vulnerability is susceptibility to initial damage
Not only can failures, accidents and disasters release significant amounts of uncontrolled energy from internal hazards, but they are also significant shocks to existing cultural beliefs and norms about hazards and how they should be managed. During the time up to a failure event discrepancies develop between the way the world is thought to operate and the actuality – this is the incubation period. Failure incubates as internal hazards go largely unrecognised. The final failure event is a trigger event that may be perceived as the cause of failure but is, in reality, the end of a process. During this process there may be rigidities of belief and perception, emerging dangers may be minimised, there may be concerns that occupy a lot of attention that turn out not to be critical, complaints may be disregarded, communications may be poor and regulations may be ignored.
Resilience is the ability to recover from damage – especially from surprises or unexpected events and shocks and particularly where they arise from the unintended consequences of decisions. Resilience is the capability of returning, after damage, to an original, or to a newly defined state for a newly defined purpose. It includes preparedness for change and specifically for identifying damage – particularly that which was unforeseen and the identifying of incubating hazards. It includes diversity, robustness, redundancy, adaptability, perseverance and the ability to ‘bounce-back’. Linear elastic strain energy is resilient because it is recoverable – there is theoretically no permanent change. Adaptability is a capability of being able to adjust to different conditions and still be fit for purpose. Systems that are highly interconnected – particularly if they are tightly coupled may not be robust, resilient or adaptable. Notice that these definitions do not involve risk.
Risk is the chance of an uncertain event at some time in the future.
Corollories 8 to 17 are drawn nd Principles 1 to 7 and they follow from how we address how to act to organise ourselves effectively. For example if we see the world in layers of interacting holons then subsidiarity (Corollary 8) is the idea that decisions should be as local as possible because that is where the problems are best understood. Likewise it is important to recognise emergence (Corollary 9) as those attributes that apply at only one or more layers as a result of interactions between holons at lower levels that do not exhibit these attributes. Connectivity (Corollary 10) is the basis for all relationships and patterns of relationships – all things are interconnected. Teamwork is critical so there is a much increased chance of success if stakeholder interests are aligned (Corollary 11). Since change is ubiquitous then everything is a process (Corollary 12). The processes may be loopy with feedback and feedforward (Corollary 13). The six important overall attributes of a process are why, how, who, what, where and when (Corollary 16) We maintain that to obtain desirable outcomes appropriate leadership and collaborative learning is crucial (Corollary 14) because there will be unexpected and unintended changes (Corollary 15) and so trade offs may be required when two or more output variables are negatively related (Corollary 17).
To translate the axioms and their corollaries into principles to use when making decisions and taking actions requires some principles. As well as be clear about fitness for purpose (P1) and duty of care (P2) the principles for action are to create models that integrate people, purposes, products and methods. To achive this models have to given firm foundations (getting the basics right), strong structures (getting physical and organisational structures right) and working well (smooth running). Structures need to be sufficiently discriminatory, consistent, cohesive and concordant. Content needs to be balanced, necessary and of requisite variety. Control of the processes is towards desirable outcomes such that risks are being managed and the lessons are being learned? Evidence has to be gathered both quantitatively and qualitatively such that timely decisions and interventions are made to keep processes on track towards purposeful outcomes.