Closing the Loop

The risk-management method is about loop closure as much as it is about cyclic improvement. One of our more peculiar discoveries over the years has been that the most common single point of failure in all systems, inside the safety domain and out, are described as “loop closure failures.” This means, in plain terms, that almost all of them fail not by bad intentions, or because of ignorance, but because of a lack of stamina. Closure in the context of systems is not a fantastical term, but is really a specific one that means all systems intended to provide themselves a feedback loop must close that loop, or they will fail.

In terms of traditional safety this is shown everywhere you look, but probably most notably by the fact the same cause-effect conditions cause the vast majority of accidents. It shows practitioners of traditional safety are not learning from their aggregate data, because they have no objective mechanisms to educate them, and because they have no aggregate potential across entirely disparate data sources. They cannot, for example, warn that a site is at greater risk because the people on that site have training deficits, because they often do not know, until after the fact, what the site purpose is, who is there, or what they are doing. This reactive stance is a choice, which extends from allowing chaos instead of governance, and failing to manage. Yet, this is no surprise, since traditional safety is concerned with raw counts rather than analysis. That some people can actually provide safety via the traditional model is a shocking testament to individual insight.

When risk-management is embraced, the closure of its feedback loop is where the maximum value is generated, because it can educate, inform, and provide the grist for the decision-making mill that renders better decisions. The challenge is that so few people have been trained to close the loop for any system, to actually follow-through, that the risk-management model can face a distinct and immediate challenge that has nothing to do with its features or scope, and everything to do with how unprepared people seem to be to manage.

Management is almost a lost art, because it has been packaged and those packages ignore that solid management is an analytical process that helps make decisions. Management is not housekeeping, though housekeeping requires management; any more than management is a decision, though it generates them. Management is about perceiving opportunity based upon inputs, about steering resources to achieve outputs, and about ensuring that the decisions create more output than the required input.

Part of the real problem with closing the loop for managers today is bad information, which is often triggered by a reliance on statistical calculations and other formulae. The often repeated idea that business management graduates are awful managers is precisely because too many of them end up in a management position and the only tools they know are to use those formulaic approaches. They apply them correctly, without recognising the inputs are skewed by bad communication, misconceptions, and so on. The rule that stated garbage in equals garbage out is true, and management by statistic ensures failure.

To succeed requires to know the inputs, know the path they take, and to know when the outputs appear they must be returned to the cycle. Closing the loop for risk-management returns value beyond the investment many times over.