From the article: … In aviation, this is called “get there itis.” A pilot is responsible for safety, but might cut corners if they’re also under pressure to get somewhere on time. An example is...
From the article:
This brings us back to the OceanGate accident of June 18, 2023. In this accident, the TITAN submersible imploded, killing everyone aboard. One of the crewmembers who died was Stockton Rush, who was both pilot of the vessel and CEO of OceanGate.
The report is a scathing indictment of Rush. In particular, it criticizes how he sacrificed safety for his business goals, ran an organization that lacked that the expertise required to engineer experimental submersibles, promoted a toxic workplace culture that suppressed signs of trouble instead of addressing them, and centralized all authority in himself.
However, one thing we can say about Rush was that he was maximally accountable. After all, he was both CEO and pilot. He believed so much that TITAN was safe that he literally put his life on the line. As Nassim Taleb would put it, he had skin in the game. And yet, despite this accountability, he still took irresponsible risks, which led to disaster.
By being the pilot, Rush personally accepted the risks. But his actual understanding of the risk, his model of risk, was fundamentally incorrect. It was wrong, dangerously so.
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While the CEO also being a pilot sounds like it should be a good thing for safety (skin in the game!), it also creates a problem that the resilience engineering folks refer to as a double bind. Yes, Rush had strong incentives to ensure he wasn’t taking stupid risks, because otherwise he might die. But he also had strong incentives to keep the business going, and those incentives were in direct conflict with the safety incentives. But double-binds are not just an issue for CEO-pilots, because anyone in the organization will feel pressure from above to make decisions in support of the business, which may cut against safety. Accountability doesn’t solve the problem of double-binds, it exacerbates them, by putting someone on the hook for delivering.
Once again, from the resilience engineering literature, one way to deal with this problem is through cross-checks. For example, see the paper Collaborative Cross-Checking to Enhance Resilience by Patterson, Woods, Cook, and Render. Instead of depending on a single individual (accountability), you take advantage of the different perspectives of multiple people (diversity).
You also need someone who is not under a double-bind who has the authority to say “this is unsafe”. That wasn’t possible at OceanGate, where the CEO was all-powerful, and anybody who spoke up was silenced or pushed out.
In aviation, this is called “get there itis.” A pilot is responsible for safety, but might cut corners if they’re also under pressure to get somewhere on time. An example is JFK Junior’s crash.
I suppose the opposite of a double-bind is “you had one job.”
From the article:
…
In aviation, this is called “get there itis.” A pilot is responsible for safety, but might cut corners if they’re also under pressure to get somewhere on time. An example is JFK Junior’s crash.
I suppose the opposite of a double-bind is “you had one job.”