So how do we factor that into incident investigations? By accepting that, faced with the same facts, people will not necessarily behave in the same way. The world we live in is far more complex than that. Dekker (2011) observes: "Rational decision-making requires a massive amount of cognitive resources and plenty of time. It also requires a world that is, in principle, completely describable. Complexity denies the possibility of all of these. In complex systems (which our world increasingly consists of) humans could not or should not even behave like perfectly rational decision-makers. In a simple world, decision-makers can have perfect and exhaustive access to information for their decisions, as well as clearly defined preferences and goals about what they want to achieve. But in complex worlds, perfect rationality (that is, full knowledge of all relevant information, possible outcomes, and relevant goals) is out of reach ... In complex systems, decision-making calls for judgments under uncertainty, ambiguity and time pressure. In those settings, options that appear to work are better than perfect options that never get computed. Reasoning in complex systems is governed by people's local understanding, by their focus of attention, goals, and knowledge, rather than some (fundamentally unknowable) global ideal. People do not make decisions according to rational theory. What matters for them is that the decision (mostly) works in their situation." 0 F i Dekker (2011) goes on to explain that this perfectly normal reaction to the rules being imposed on us at a local level can accumulate at an organisational level with harmful consequences. He explains: "Local decisions that made sense at the time given the goals, knowledge and mindset of decision-makers, can cumulatively become a set of socially organized circumstances that make the system more likely to produce a harmful outcome. Locally sensible decisions about balancing safety and productivity -once made and successfully repeated -can eventually grow into unreflective, routine, taken-for-granted scripts that become part of the worldview that people all over the organization or system bring to their decision problems. Thus, the harmful outcome is not reducible to the acts or decisions by individuals in the system, but a routine by- product of the characteristics of the complex system itself." 1 F ii These inconvenient truths of the complex reality we face pose a challenge to the conventional wisdom around incident investigation which is typically concerned with uncovering "the truth" and, indeed, more so, "the root cause" of an incident. Consider the pioneering approach of James Reason in the "Swiss cheese" theory, a theory on which most modern incident investigation techniques are based.
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