I rarely use the 2005 Honda CRV. I drive the Honda to go places outside the 50 mile (safe) range of Electra, my all electric 2015 Nissan Leaf, or to haul yard waste to the landfill. The battery in the key to the Honda died a few weeks ago, so I replaced it. Unfortunately, this was the second time I had split the key open to change the battery and the two halves no longer snapped back together. My solution was to tape the two pieces of the key together with a big piece of packing tape. While doing this repair, I covered the hole at the top of the key that’s used to connect the key to the other keys on my key chain. So, I just kept the Honda key separate.
On Friday night, I forgot to plug in Electra to charge her up, so on Saturday morning, I parked downtown to charge her at the charging station, and I walked Bonnie (my rescue dog) while the car charged. I wanted to drive Electra to transport cats to PetSmart for adoption. (Electra normally rests in our garage and we have an electric door opener.) However, after arriving back home, my wife heard from our supervisor that she wanted five crates of cats and some boxes. That’s a lot to carry in Electra, so we decided to use the nameless Honda CRV instead. I picked up the single car key, and we went out the back door which I locked on the door knob. It crossed my mind to lock the deadbolt too, but I decided we would not be gone long, so the house would be safe enough. As my wife and I stepped down off the deck, it dawned on me that I did not pocket my other set of keys. I only had the car key. I asked my wife if she brought her keys. No, she said, she didn’t bring any keys, since she was not driving. Neither of us had the house key on us.
Systems theory is a useful way to consider how things sometimes go wrong in organizations. Organizations are designed to handle routine, everyday interactions. A retail store, for example, takes in stock, stores some of it, gets merchandise on the shelves, helps customers find what they want, then takes the customers’ cash before they carry their purchases out the door.
Most Saturday mornings are the same for my wife and I. I get up first and feed our dog and cats, and then take Bonnie for a walk. While we are walking (or sniffing as the case may be) my wife gets a shower. Bonnie and I return home and I shower, and then we lock Bonnie in her crate (which she likes) and take off in Electra to get breakfast, followed by a trip to the Big House (no, not the Allman Brothers’ Museum) where dozens of rescued cats are lodged. We then put the requested cats in the carrier and drive them to the Morrow PetSmart.
On most Saturdays, this routine is repeated without incident. Some days, something unusual happens, but we manage to adjust. For example, a cat we were supposed to transport is not at the Big House but is being fostered, or a selected cat is sick, or a cat is too shy to get into the carrier without a fight. We get in touch with our supervisor when things like this happen and create a plan that solves the problem. No big deal. But, if we transport cats enough times, multiple unusual events may occur on the same day that cause a more serious breakdown. Miscommunications are often a major factor that causes a cats that people want to adopt at PetSmart not being there or not arriving with their heslth records. Since we’ve been working for this group for years, the problems don’t often occur. We all understand each other and double check what we are doing as needed.
Generally speaking, well run organizations have contingency plans in place to handle nonroutine occurrences. My wife and I have a well hidden house key just in case we lock ourselves out. But, there may not be a contingency plan for every unusual or unexpected event, or the combinations of unexpected events may compound small issues making them big problems. If you do the same things repeatedly, unlikely events become likely to happen.
I suspect that, if I don’t fix my car key properly and reattach it on my key ring, I will walk out of the house without a housekey once or twice a year. Over the course of the next ten years, either my wife or I may get locked out and forget to return the key to its hiding place, so if these things happen and the potential problem is not discovered, one of those times when I take the Honda and forget my housekey, I’ll be locked out. Not a big deal unless something else happensvat the same time.
Many of the disasters that occur are the result of an unusual combination of events and miscommunications. When unusual things occur, we are likely to ignore them, assume things are normal, or misunderstand what’s happening. One poor perception or bad decision based on flawed information can foster other misperceptions and result in additional bad decisions. Snowball effect. Backup plans fail because they may not be the correct solutions in every circumstance that arises. In most of our jobs, the result of these unusual circumstances may not be a big deal. But in some organizations, the “output” can be a disaster. Navy ships may crash into foreign vessels, resulting in loss of life. Laboratories may release deadly diseases. Chemical companies may spill toxins into the environment. Cruise ships may feed passengers food that causes illnesses. Missiles could be launched accidentally. Systems theory suggests there are multiple causes contributing to these types of major accidents.
Our tendency is to try to find one individual who is responsible. We love to find a scapegoat. It is easier to blame one person than to examine the entire system. But, there is value in looking all of the parts of the system to see how the system handles stress.
Some aspects of a system are critical. They are the key links in the chain of events you want to happen. We have to pay a great deal of attention to these elements. If, for example, you are an event planner who is organizing a wedding, getting the minister to the church on time is critical. If the minister does not show up, the wedding may not happen. If the wrong date or time is sent out on the invitations there will be a major problem. If there is miscommunication with the caterer or photographer, the wedding won’t go smoothly. Yes, both the bride and groom need to show up. You, as an event planner, have to double and triple check critical elements and develop backup plans. You need to have the phone number for a last-minute minister if the designated one gets sick, you have to call to confirm the day/time with the church a few weeks beforehand to make sure the church did not get flooded in the last heavy rain, and you have to make sure there are no cold feet a few days before the wedding. Some minor problems occur in every wedding, so its best to try to get the wedding parties to think about enjoying themselves rather than anticipating the perfect wedding.
I hope I remember to bring my phone when I walk out the door without my house key. A lack of communication can cause many problems, but communication can also solve many problems before they have a big impact.