ABSTRACT
Surprise is inherently challenging to any activity; it challenges resilient action, since by definition it cannot be anticipated, and for some types of surprises, monitoring is limited by both lack of knowledge about what to target and the absence of precursor events or organisational drift (Dekker, 2011; Snook, 2000) that might have provided even soft signals of future problems. It does, however, present opportunities both for responding and for learning. In this chapter we describe a critical incident involving information technology (IT) in a care delivery organisation. The incident was characterised by the co-occurrence of both situational and fundamental surprise (Lanir, 1986), and the responses to it are informative about both specific vulnerabilities and general adaptive capacities of the organisation. We studied this event to gain insight into three aspects of resilience: first, how adaptive capacity is used to meet challenges; second, to understand better what barriers to learning are active; and finally, to infer recommendations for practice. We conducted these analyses both shortly after the event, and then revisited them in discussions with key participants about three years later. We note that temporal
and cross-level factors played important roles in affecting the balance between situational and fundamental learning. Because the situational story (of component failure) developed first, it was difficult for the fundamental story of unknown, hidden hazards to supplant it. In addition, the story of the situational surprise was easily understood by all members of the organisation, but that of the fundamental surprise were difficult for many to grasp, including (especially) senior leadership, who tended to adopt an over-simplified (situational) view of the problem. Finally, over time, the fundamental surprise was virtually forgotten, and those members of the organisation who do remember it have (in effect) gone into self-imposed exile. Thus, although the organisation did learn and adapt effectively from this event, it has become progressively blind to the continuing threat of fundamental surprise in complex technology.
