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Communication, Safety Drift and Scale Law at a Systems Level

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Most of the time, the world works according to plan. Work routines contain low levels of variety or a small number of exceptions over time (Kluge, 2014). Occasionally, we encounter inconsistent or unusual situations. Inconsistency will trigger speech acts to seek clarification or may result in a state of confusion in the individual. Problems arise when acts of clarification are not initiated either because the individual can rationalise signals or can tolerate the state of confusion (and, therefore, does not feel a need for clarification). By finding ways to accommodate the current situation, we can defer taking appropriate action until it is too late. We also see, at an individual level, that messages can be incomplete or delivered in a non-standard format. Of interest, LOSA observations reveal that crew engage in repair behaviour when communicating with off-board agencies. They fill in gaps in understanding by guessing what a speaker said or fall back on previous experience to interpret statements. Despite the prevalence of uncertainty and repair, the system still functions.

Moving on to consider the implications of the Embraer 120 and the Dash 8-400 examples given above, what we are really looking at is communication across networks. The network comprises both individuals engaged in activity and artefacts designed to inform and constrain those individuals. In addition, as we move up the hierarchy, the distance between the point of design and the point of application grows both physically and temporally. I think that this presents a challenge. It is a cliche in aviation that the manufacturer’s documents are designed more to limit liability in the event of failure that to guarantee successful workplace performance. Whether this is true or not, the issue of information ergonomics and system scale effect is clearly a problem. The risk seems to be a function of the number of nodes in a communication network and the distance between initiators of communication and actors responding to that communication.


Communication is both the glue that binds teams and the mechanism that enables work to be done. It is a skill we all take for granted. This chapter has outlined the functions served by communication in the work process and also the properties of communication that allow it to fulfil its purpose. Within a systems context, communication serves as both control and feedback. Orders and instructions, commands and tasks are all direct action, whereas responses, acknowledgements and queries are forms of feedback. Unfortunately, the process is inherently fragile and requires effort if it is to function effectively. That said, humans are adept at filling in gaps in conversation based on the context of speech and deducing meaning. We repair flaws in communication. We will continue our examination in the next chapter where we will look at the role of the organisation in my hierarchical model.


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