A simple framework for preventing unwanted outcomes

MB
6 min readMay 28, 2020

--

Vernon’s bad synch

On his way to jail for a crime, he claims not to have committed, Veron Little, the protagonist in DBC Pierre’s satirical Vernon God Little, observes that the flashing lights from the police car precession synchronize every 43 blinks.

As his character is prone to doing, he relates this observation to a ‘learning’ he makes about life.

His learning here is that every now and then, the stars align, and everything does actually synch up. Sometimes for good, and sometimes for bad.

Unfortunately for Vernon, he’s in the middle of a very bad synch!

Vernon isn’t the only one to experience the bad synch though. As we all know, sometimes the stars align and everything goes your way, but often they go against you.

When they synch for good, embrace the experience and enjoy the ride. But when they synch for bad, it’s best to be at least somewhat prepared to prevent the worst from happening.

This simple framework will show you how.

Where I work we’re used to the bad synch. This happens when the barriers we’ve put in place to manage hazards, fail.

This often results in an incident that’s either safety-related, damage to equipment, or a financial loss.

This incident is known as a ‘swiss cheese moment’. Named so because all the holes in the cheese slices have aligned to allow a hazard or threat to pass through unchallenged.

As our working environment — much like our lives — is constantly surrounded by hazards, we’re constantly working to misalign the cheese slices by putting barriers in place.

These barriers can be things like procedures, safety devices, or training.

But try as we might — and we do try — we can’t always prevent the cheese slices aligning.

Often this is due to human error, but as the swiss cheese model shows, it typically needs to be a multiple-barrier failure to cause an incident.

It’s worth noting that an incident doesn’t always happen. Sometimes nothing happens despite the failures.

This is due more to luck than design. And sooner than later that luck will run out if the barriers remain in a failed state. This is because you have significantly increased the probability of an incident.

A key principle then is that the more barriers you have, the less likely you are to be on the receiving end of an unwanted outcome.

Sometimes things do just happen though. You’re in the wrong place at the wrong time and there’s nothing you can do about it. But often the problem is that you didn’t have adequate barriers in the first place. Or that you didn’t react to the warning signs and take action when the barriers failed.

This is Vernon’s bad synch.

The hapless Veron made a series of bad decisions and allowed the cheese slices to align. Now he’s on his way to court on trial for mass murder.

Whilst that’s unlikely to happen to you and me, there are plenty of other things that could.

To prevent this, or at least lessen the likelihood of a swiss cheese moment in your life, you need to learn some basics risk management skills.

One technique is Barrier Management.

There are two basic stages involved.

The first stage involves understanding the risks or threats you face so that you can put control measures (barriers) in place to prevent a bad event from happening.

The second stage involves the response measures you can take to prevent the outcome from worsening if the barriers fail.

That may sound complicated, but it’s really not.

Vernon’s bad synch illustrates how it works.

Vernon’s bad synch

Something unexpected happens at his high school. It’s a shooting.

Because he couldn’t — or wouldn’t — verify his whereabouts, Veron’s at risk (his threat) of becoming the prime suspect.

If he’s unable to control the threat, he’s going to be arrested (his bad event).

If the bad event happens, he’s going to have to limit the severity of the outcome (the consequence).

3 steps

On either side of the event are things you can do to manage the situation.

Vernon can prevent the event from happening by cooperating (his barriers) with the police.

And if his barriers fail and the bad event takes place, he can work with his lawyer (his response measure) to prevent the consequences worsening.

3 steps become 5 steps

Steps 2 & 4 represent your plan and your contingency plan.

Hopefully, you never have to use the response measures, but barriers do sometimes fail.

Veron’s barriers fail because he doesn’t cooperate with the police, skips bail, and then ends up on the run. Multiple failures!

Eventually, after some amusing events, they catch up with him and he’s now going on trial for the shootings. This is when he realizes that he’s in the middle of a very bad synch.

At this point, he’s only on step 4 and has a chance to prevent an unwanted outcome.

Unfortunately, poor Vernon doesn’t understand how barrier management works, so instead of using his response measures to limit the consequences, he makes everything a whole lot worse.

For the novel, it’s great that he doesn’t understand as it’s far more amusing. But for you and me, a basic understanding of the process can be very helpful.

You can use the process to help with many things you face daily.

Although it works best as a planning tool, used before you act, the principles work with emergent situations too (just as in Vernon’s case).

To use it, you need to think about the threats (or risks) you might face from choosing a certain course of action.

Then think about what you can do to stop the event from happening.

And finally what you’ll do to manage the situation if the event does occur.

As a basic example, here’s how I have used it.

A realistic bad event would be a fire in my family home.

The main threats I could foresee would be from things like bad wiring, appliances overheating, or damaged sockets and switches. That type of thing.

To prevent this from happening I put barriers in place.

I get approved electricians to do any electrical work. I make sure the sockets are not overloaded, and I switch things off and replace any damaged parts.

The consequences of a house fire could be the death of a family member if they couldn’t get out of the house.

So to prevent the consequences from occurring, or worsening, I use response measures.

I ensure I have adequate fire detection systems (smoke & heat alarms) and extinguishers in the house. I also make sure that my family knows what to do in the event of a fire, and how to get out quickly.

If only one barrier fails, whilst it’s still possible a fire could start, I’ve reduced the probability because of the other barriers I have in place.

Conversely, if all those barriers fail, I have increased the probability of a fire.

Hopefully, you never end up in Vernon’s predicament, but chances are you’ll be on the receiving end of some other unfortunate synchronization sooner or later.

To reduce the probability of this happening, put barriers in place — and the more the better.

If they do fail, don’t follow Vernon’s lead and make the situation worse. Instead, use your response measures to limit the consequences.

As you become more comfortable with the framework, you can assess how many barriers and responses are necessary for a given situation, and also make some assumptions about how strong these barriers are.

But even very basic understanding will help prevent an unwanted outcome. If only Vernon had known.

Originally published at http://www.alessonfromlyrics.com on May 28, 2020.

--

--

No responses yet