How Organisational Behaviour Undermines Learning and Adaptive Capacity

Drift and Pattern: Making Ethical Failure Visible

 

Sidney Dekker’s work on drift into failure shows how complex systems rarely break down due to a single mistake. Instead, failure develops gradually through a sequence of small, locally rational decisions made under pressure. Over time, organisations adapt to conflicting demands—efficiency, cost, performance—while drifting away from safe or sustainable operational limits. Each step appears logical in context. The risk remains largely invisible — until it is no longer containable (S. Dekker, 2011, 2025; S. Dekker and Pruchnicki, 2014; S. W. Dekker, 2013).

Research in safety science supports this. Periods of apparent success—such as low incidents and strong performance metrics—can hide increasing risks. Organisations may begin to suppress or filter bad news, perform “safety theatre,” or rely on measures that no longer reflect reality. During this incubation period, warning signals are ignored, normalised, or simply not noticed, as they conflict with prevailing beliefs about how the system is functioning.

What often goes unnoticed is how this drift appears in everyday organisational behaviour as it happens. Drift is not abstract. It is demonstrated through recurring patterns — such as how decisions are justified, how trade-offs are handled, how responsibility is assigned, and whether people remain connected to reality. These behaviours are visible and form what can be recognised as ethical antipatterns.

 

 

From Drift to Antipattern

 

Drift Mechanism (Dekker)	Ethical Antipattern (This Work)	What It Looks Like in Practice
Local rationality	Post-hoc Justification	Decisions feel right in the moment and are justified after the fact
Goal conflict	Hidden Trade-offs	Competing pressures are resolved quietly rather than explicitly
Safety theatre	Performative Ethics	Compliance is demonstrated, but reality is obscured
Suppression of bad news	Silence Under Pressure	Issues are not raised when they matter most
Success masking risk	Consequence Avoidance	Absence of incidents is taken as evidence of safety
Distance from reality	Gemba Evasion	Decisions made without direct exposure to customers or work
Distributed complexity	Displaced Accountability	Responsibility becomes unclear and fragmented
Model–reality mismatch	Forced Fit	Reality is reshaped to match the model or strategy

 

Drifting into failure is not random.

It follows patterns.

The question is whether those patterns are recognised early enough to change course.

 

 

Patterns

• Performative Ethics

Values are stated but not enacted → ethics as signalling

• Post-hoc Justification

Decisions made first, justified later → reasoning becomes narrative cover

• Hidden Trade-offs

Trade-offs avoided or obscured → tension suppressed, not resolved

• Displaced Accountability

Responsibility unclear or shifted → consequences fall elsewhere

• Silence Under Pressure

People withdraw voice → early warning system collapses

• Consequence Avoidance

Foreseeable impacts not examined → negligence conditions emerge

• Gemba Evasion (your new contribution)

Reality avoided because it may contradict intent → decisions made without exposure to lived experience

• Forced Fit

Reality reshaped to match the model → customer need replaced by organisational agenda

 

• Mechanism: How Antipatterns Create Fragility

Antipatterns → break SECI loops:

• Socialisation → avoided (no Gemba)
• Externalisation → distorted
• Combination → biased
• Internalisation → false learning

Result: Adaptive Capacity declines despite apparent activity

So ask: What are the ethical consequences of this decision — and who owns them?

• Ethics is not a failure of intent
• It is a failure of patterned behaviour under pressure

Organisations do not drift into unethical outcomes randomly.
They follow recognisable paths.

Ethics isn’t just about values. It is the pattern of decisions an organisation makes when under pressure. Ethical integrity shows itself through actions — not intentions. In complex environments, there is rarely a single “right” answer. What truly matters is whether decisions stay aligned with purpose, responsibility, and consequences.

Drifting into failure is not random — It follows patterns.

The question is whether those patterns are recognised early enough to change course.

 

Dekker, S. (2011). Drift into Failure: Ashgate Publishing Company.

Dekker, S. (2025). Safety Theater: How Success Can Mask Growing Safety Risks. Professional Safety, 70(10), 28–34.

Dekker, S., & Pruchnicki, S. (2014). Drifting into failure: theorising the dynamics of disaster incubation. Theoretical Issues in Ergonomics Science, 15(6), 534–544.

Dekker, S. W. (2013). Drifting into failure: Complexity theory and the management of risk. In Chaos and complexity theory for management: Nonlinear dynamics (pp. 241–253): IGI Global Scientific Publishing.